Choosing Wisely YouTube video

Transcription

1 Julie Hendry

2 Choosing Wisely YouTube video

3 Introduce Choosing Wisely Canada Explain CSTM process to develop CWC recommendations Review the CSTM recommendations Choosing Wisely Canada s 10,000,000 Challenge Discuss examples and results of implementation of some CWC recommendations

4 A national campaign, led by the medical profession to: Help physicians and patients engage in conversations about unnecessary tests, treatments and procedures Help physicians and patients make smart and effective choices Ensure patients get care they need and avoid tests, treatments and procedures that could cause harm

5 1. To encourage physicians to engage in conversations with patients about the overuse of tests, treatments and medical procedures. 2. To empower patients to make informed choices, in consultation with their physicians, about getting the right care while limiting exposure to unnecessary tests, treatments and medical procedures. 3. To cultivate a culture of responsible stewardship of health care resources among physicians from those in medical schools to those in professional practice. 4. To engender public dialogue on the issue more is not always better, when it comes to medical tests, treatments and procedures. 5. To engage health system and non-medical stakeholders, at provincial/territorial and national levels, in the implementation of the Choosing Wisely Canada campaign.

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8 1. Which patients are seen and how frequently 2. Which patients are hospitalized 3. Which tests, procedures and surgical operations are administered 4. Which technologies are used 5. Which medications are prescribed Emanuel EJ. JAMA

9 I ve always done this The patient wants it $$ New tests are good I don t want to get sued Referring doctor wants it Better to do something than nothing

10 Ontario Family Physicians Agree/strongly agree that patients drive inappropriate use of services Agree/strongly agree patients will benefit from CW recommendations Agree/strongly agree that primary responsibility for ordering rests with physicians At least somewhat familiar with CW 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

11 Aware of CWC Believe 1/3 of care is unnecessary Patients drive overuse more than physicians Patients need more decision support Physician has primary responsibility 0% 20% 40% 60% 80% 100% Ipsos Reid (2015). Awareness and Attitudes towards Choosing Wisely Campaign. 11

12 Has a doctor ever recommended a test or treatment that you did not feel was necessary for your health? How did you respond (to what you thought was unnecessary treatment)? Yes No I asked my doctor why she or he felt the test or treatment was necessary 44% 24% I ignored my doctor's advice, but did not discuss it with him or her 31% 76% I took the test or treatment without discussing it with the doctor, even though I felt it was unnecessary 25% 12

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14 Choosing Wisely is now spreading worldwide. Choosing Wisely Canada annual meeting held recently in Toronto Two annual international round tables in Europe. Bringing 17 different countries together to discuss their Choosing Wisely campaigns and experience

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16 Physicians Societies develop lists Disseminate through multiple channels Patients Develop patient materials Disseminate broadly through multiple channels Media Coordinated approach toward media Multiple voices, a common message Stakeholders Work through health care stakeholder organizations to implement and support adoption 16

17 Societies free to determine process List items must be within society s purview List items must be frequent Must be evidence to support list items Process must be publicly available 17

18 Choosing Wisely Canada is working with various stakeholder groups to disseminate the patient materials widely. Choosing Wisely Canada is also working with medical schools to introduce new content into the undergraduate, postgraduate and continuing medical education curricula.

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20 a call to all membership for suggested list items. Membership : Submitted suggestions /lists Some groups worked together and submitted a long list Recommendation and scientific evidence for it

21 CSTM board voted on the accumulated list ranked the items according to their assessment of what was most important. worked together to refine the wording found additional references as required.

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23 On June 2 at 10:00am EDT, 49 new Choosing Wisely Canada recommendations will be released by 10 specialty societies including: Emergency Medicine Canadian Association of Emergency Physicians Hospital Medicine Canadian Society of Hospital Medicine Nuclear Medicine Canadian Association of Nuclear Medicine Paediatric Surgery Canadian Association of Paediatric Surgeons Psychiatry Canadian Academy of Child and Adolescent Psychiatry Canadian Academy of Geriatric Psychiatry Canadian Psychiatric Association Spine Canadian Spine Society Transfusion Medicine (releasing 5 additional items) Canadian Society for Transfusion Medicine Vascular Surgery Canadian Society for Vascular Surgery

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25 1-Don t transfuse blood if other nontransfusion therapies or observation would be just as effective. Blood transfusion should not be given if other safer non-transfusion alternatives are available. For example, patients with iron deficiency without hemodynamic instability should be given iron therapy.

26 2- Don t transfuse more than one Red cell unit at a time when transfusion is required in stable, nonbleeding patients. Indications for red blood transfusion depend on clinical assessment and the cause of the anemia. In a stable, non-bleeding patient, often a single unit of blood is adequate to relieve patient symptoms or to raise the hemoglobin to an acceptable level. Transfusions are associated with increased morbidity and mortality in high-risk hospitalized inpatients.

27 Transfusion decisions should be influenced by symptoms and hemoglobin concentration. Single unit red cell transfusions should be the standard for non-bleeding, hospitalized patients. Additional units should only be prescribed after re-assessment of the patient and their hemoglobin value.

28 3-Don t transfuse plasma to correct a mildly elevated (<1.8) international normalized ratio (INR) or activated partial thromboplastin time (aptt) before a procedure. A mildly elevated INR is not predictive of an increased risk of bleeding. Furthermore, transfusion of plasma has not been demonstrated to significantly change the INR value when the INR was only minimally elevated (<1.8).

29 4- Don t routinely transfuse platelets for patients with chemotherapy-induced thrombocytopenia if the platelet count is greater than 10 X 109/L in the absence of bleeding. A platelet count of 10 X 10 9 /L or greater usually provides adequate haemostasis. Platelet transfusions are associated with adverse events and risks.

30 Considerations in the decision to transfuse platelets include the cause of the thrombocytopenia, comorbid conditions, symptoms of bleeding, risk factors for bleeding, and the need to perform an invasive procedure.

31 5- Don t routinely use plasma or prothrombin complex concentrates for non-emergent reversal of vitamin K antagonists. Patients requiring non-emergent reversal of warfarin can often be treated with vitamin K or by discontinuing the warfarin therapy. Prothrombin complex concentrates should only be used for patients with serious bleeding or for those who need urgent surgery. Plasma should only be used in this setting if prothrombin complex concentrates are not available or are contraindicated.

32 6- Don t use immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines are demonstrated. Immunoglobulin (gammaglobulin) replacement does not improve outcomes unless there is impairment of antigenspecific IgG antibody responses to vaccine immunizations or natural infections. Isolated decreases in immunoglobulins (isotypes or subclasses), alone, do not indicate a need for immunoglobulin replacement therapy. Exceptions include genetically defined/suspected disorders. Measurement of IgG subclasses is not routinely useful in determining the need for immunoglobulin therapy. Selective IgA deficiency is not an indication for administration of immunoglobulin.

33 7- Don t order unnecessary pre-transfusion testing (type and screen) for all pre-operative patients. Pre-operative transfusion testing is not necessary for the vast majority of surgical patients (e.g., appendectomy, cholecystectomy, hysterectomy and hernia repair) as those patients usually do not require transfusion. Ordering pre-transfusion testing for patients who will likely not require transfusion will lead to unnecessary blood drawn from a patient and unnecessary testing performed. It may also lead to unnecessary delay in the surgical procedure waiting for the results. To guide you whether pre-transfusion testing is required for a certain surgical procedure, your hospital may have a maximum surgical blood ordering schedule or specific testing guidelines based on current surgical practices.

34 8- Don t routinely order perioperative autologous and directed blood collection. There is no role for routine perioperative autologous donation or directed donation except for selected patients (for example, patients with rare red blood cell antigen types). Medical evidence does not support the concept that autologous (blood donated by one s self) or directed blood (blood donated by a friend/family member) is safer than allogeneic blood. In fact, there is concern that the risks of directed donation may be greater (higher rates of positive test results for infectious diseases). Autologous transfusion has risks of bacterial contamination and clerical errors (wrong unit/patient transfused). As well, autologous blood donation before surgery can contribute to perioperative anemia and a greater need for transfusion.

35 9- Don t transfuse O negative blood except to O negative patients and in emergencies for female patients of child-bearing potential of unknown blood group. Males and females without childbearing potential can receive O Rh-positive red cells. O-negative red cell units are in chronic short supply, in some part due to over utilization for patients who are not O- negative. To ensure O-negative red cells are available for patients who truly need them, their use should be restricted to: (1) patients who are O-Rh-negative; (2) patients with unknown blood group requiring emergent transfusion who are female and of child-bearing age. Type specific red cells should be administered as soon as possible in all emergency situations.

36 10- Don t transfuse group AB plasma to non-group AB patients unless in emergency situations where the ABO group is unknown. The demand for AB plasma has increased. Group AB individuals comprise only 3% of Canadian blood donors. Those donors who are group AB are universal donors for plasma, thus are the most in-demand type for plasma transfusion. Type-specific plasma should be issued as soon as possible in emergency situations to preserve the AB plasma inventory for those patients where the blood group is unknown.

37 Other societies?

38 Canadian Society of Internal Medicine Third recommendation: Don t transfuse red blood cells for arbitrary hemoglobin or hematocrit thresholds in the absence of symptoms, active coronary disease, heart failure or stroke.

39 Canadian Hematology Society Fifth recommendation: Don t transfuse patients based solely on an arbitrary hemoglobin threshold.

40 Canadian Society of Palliative Care Physicians Fifth recommendation: Don t transfuse red blood cells for arbitrary hemoglobin or hematocrit thresholds in the absence of symptoms, or if no benefit was perceived from previous transfusions.

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42 Participating in the 10 Million Challenge involves doing the following: Get the starter kit Pick a focus and a goal for your project Register your project and CWC will create a profile describing your project on the CWC website Implement your change ideas Tell us how you did The 10 Million Challenge will officially launch on April 1, CWC is pre-registering right now. If you would like to be among the early registrants, download the starter kit or CWC to learn more.

43 Canadian Society for Transfusion Medicine Second recommendation: Don t transfuse more than one Red cell unit at a time when transfusion is required in stable, non-bleeding patients.

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47 Results Based on two months study 256 units transfused for stable patients. >180 units (70%) could have been avoided. = units unnecessary transfusions per year, 5% of total RBCs issued from blood bank at QEII.

48 Transfuse one red cell unit and then reassess based on the indication: hemoglobin level/ clinical symptoms. Policy approved By DMAC Fall Policy was enforced by blood transfusion services starting January 2013

49 Transfuse one red cell unit and then reassess based on the indication: hemoglobin level/ clinical symptoms. Did not include out patient clinic or Emergency room Did not include Hematology in-patients due to nursing workload concern. Did not indicate a hemoglobin cut off as there are no agreed upon National or Provincial guidelines

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51 Conclusions The policy was implemented in Jan 2013: -from Jan to Aug 2012 : RBCs were transfused -from Jan to Aug 2013 : RBCs were transfused -From Jan to Aug 2013: -20% decrease in red cell transfusions (2112 units of red cells) -10% increase in one unit transfusions -10% Decrease in number of patients transfused (335 patients). -Greater than $1,000,000 savings to provincial blood budget RBCs 2012 # of 2013# of 2012 % of One patients vs two units patients in 2012 patients vs % of patients One % 75.76% Two % 21% Total patients

52 Significant reduction of red blood cell transfusion requirements by changing from a double-unit to a single-unit transfusion policy in patients receiving intensive chemotherapy or stem cell transplantation Martin David Berger, Bernhard Gerber, Kornelius Arn, Oliver Senn, Urs Schanz, Georg Stussi Haematologica January : Conclusions Implementing a single-unit transfusion policy saves 25% of red blood cell units and, thereby, reduces the risks associated with allogeneic blood transfusions.

53 Hematology inpatients Concerns Large number of red cell transfusion Increase nursing workload Delay second unit transfusion Transfuse into the late evening.

54 Hematology inpatients In November 2013 and in collaboration with the Clinical hematologists BTS implemented a modified Red Cell Guidelines for elective non-bleeding General Hematology and Bone Marrow Transplant patients. If a non-bleeding patient has a hemoglobin 70-80g/L will receive ONE unit of red cells and have a repeat CBC on the following morning. If a non-bleeding patient has hemoglobin of< 70g/L will receive TWO units of red cells and have a repeat CBC on the following morning.

55 3 Month Audit of Hematology & Bone Marrow Transplant Pre & Post Red Cell Guidelines 16% Decrease # of red cell units transfused 87% Decrease # of post transfusion hemoglobin >100 g/l 81% Decrease # of patients receiving two red cell units in one episode 13% Decrease # of red cell units transfused per patient

56 Decrease number of patients transfused By around 300 patients per year. 10% of patients Decrease red cell transfusions by 1038 units in 2012/2013 By 2544 units in 2013/2014. For the year , the cost savings to the Nova Scotia blood budget was $519,000 and in the year of , the savings increased to $1,272,000.

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58 3-Don t transfuse plasma to correct a mildly elevated (<1.8) international normalized ratio (INR) or activated partial thromboplastin time (aptt) before a procedure. A mildly elevated INR is not predictive of an increased risk of bleeding. Furthermore, transfusion of plasma has not been demonstrated to significantly change the INR value when the INR was only minimally elevated (<1.8).

59 1-Don t transfuse blood if other nontransfusion therapies or observation would be just as effective. Blood transfusion should not be given if other safer non-transfusion alternatives are available. For example, patients with iron deficiency without hemodynamic instability should be given iron therapy.

60 The inappropriate use of blood products puts patients at unnecessary risk of serious adverse transfusion reactions such as Transfusion-related acute lung injury (TRALI) Transfusion-associated circulatory overload (TACO), Anaphylaxis Hemolysis Others.

61 7- Don t order unnecessary pre-transfusion testing (type and screen) for all pre-operative patients. Pre-operative transfusion testing is not necessary for the vast majority of surgical patients (e.g., appendectomy, cholecystectomy, hysterectomy and hernia repair) as those patients usually do not require transfusion. Ordering pre-transfusion testing for patients who will likely not require transfusion will lead to unnecessary blood drawn from a patient and unnecessary testing performed. It may also lead to unnecessary delay in the surgical procedure waiting for the results. To guide you whether pre-transfusion testing is required for a certain surgical procedure, your hospital may have a maximum surgical blood ordering schedule or specific testing guidelines based on current surgical practices.

62 ENGAGEMENT & EDUCATION QUALITY IMPROVEMENT HARD CODING o Leadership engagement o Physician education o Patient education Soft o QI projects o Measurement o Audit and feedback o Policy changes o EMR/CPOE integration o Order set changes Hard Individuals as the change unit Engagement-oriented Lower risk Organization as the change unit Rules-oriented Higher risk

63 Educational opportunities about the CSTM recommendations to health professionals and patients Developing and distributing promotional materials T-shirts, postcards, video Establish mechanisms to support the adoption of the Choosing Wisely Canada lists. Measure outcomes of implementing the recommendations

64 CWC Video Red Cell Utilization Coming Soon Choosing Wisely Toolkit from ORBCoN Dr. Yulia Lin

65 Educational opportunities For example: Blood Matters Nova Scotia November 2014 Newfoundland Transfusion Medicine symposium November 2014 CSTM Education Day, Prince George March 2015 The Canadian Blood Coordinating Programs Collaborative (CBCPC) meeting May 2015 University of Toronto Transfusion Medicine rounds September 2015 Saskatchewan Transfusion Medicine Symposium October 2015 Manitoba blood management rounds November 2015 Alberta Vein to Vein Workshop March 2016 CSTM Annual conference Vancouver 2016 Education to non TM audiences Any suggestions

66 Choosing Wisely YouTube video

67 Questions or Suggestions