2014/LSIF/PD/032 Building a Blood System Using Patient Blood Management

Transcription

1 204/LSIF/PD/032 Building a Blood System Using Patient Blood Management Submitted by: University of Auckland Policy Dialogue and Workshop on Attaining a Safe and Sustainable Blood Supply Chain Manila, Philippines 30 September October 204

2 BUILDING A BLOOD SYSTEM using PBM Kerry Gunn MBChB DA (UK) FANZCA Department of Anaesthesia and Perioperative Medicine Auckland City Hospital & University of Auckland

3 Auckland City Hospital, NZ 47,400 operations 0,290 low risk Issues 24,242 RBCs 608 plasma 7424 platelets Disclosures: Baxter Healthcare, Fresenius, Vifor, Smiths Medical

4 International Comparison Country Component Issues per 000 population (2009/0) Red Cells Platelets Fresh Frozen Plasma New Zealand Australia France * Denmark Ireland ** United Kingdom International data from International Forum on Inventory Management Vox Sanguinis (200) 98: e295 e363 Data based on issues from Blood Centres not the number of components transfused

5 Australian consensus guidelines

6 Lean Six Sigma Approach

7 The Audit Story, Key findings Process Capability of Hb PRIOR TO CHARTING (non precationary charting) Process Data LSL * Target * USL 80 Sample Mean Sample N 22 StDev (O v erall) USL O v erall C apability Z.Bench Z.LSL * Z.USL Ppk -0.3 C pm * The analysis looked at charting where the Hb was >80g/Ltr. For patients not undergoing procedures this was 64% There were 04 times (77%) in the two week period where units were charted and the patient ended with a HB >00 g/ltr O bserved Performance % < LSL * % > USL % Total Exp. O v erall Performance % < LSL * % > USL % Total Worksheet: All audit data.mtw; 26/07/200 RBC UNITS CHARTED vs Hb PRIOR TO CHARTING * 6 NUMBER OF RBC UNITS CHARTED MTP 3 Dec Panel variable: PRECATIONARY Worksheet: All audit data.mtw; 27/07/ Hb PRIOR TO CHARTING

8 Transfusing above 80Hb is not good practice Histogram of HB before post-op transfusion

9 Voice of the Customer Voice of the Customer Key issue Measurable Requirement Critical To Quality Junior doctor (prescriber) No recognised system Variance Needed guidelines Senior doctor (owner) Delegated responsibility, now disempowered Excess use Trust in clinical champion before releasing contol Blood service No responsibility for physician decision making Sales Rewarded for excess use Management Poor understanding of indications Cost Required savings, but provided resourses for change program Define Auckland Phase District Health Board

10 Red cells are bad sometimes Anaemia is bad almost always but don t transfuse to get there

11 2 Preop anaemia and reducing bleeding Post op Hb g/l Restricting red cells 8

12 Make the changes Decision Algorithms Patient Information Hand-outs Internal Checklists & Forms

13 Reducing RBC wastage and transfusion

14 Effective Blood Management st Pillar 2 nd Pillar 3 rd Pillar Optimise red cell mass Minimise blood loss & bleeding Harness & optimise physiological reserve of anaemia Multidisciplinary team approach

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16 What proportion of our patients are anaemic preoperatively? Red Cell Audit of NZ Hospitals NZBlood Sept 2008

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18 The place of decision trees in intraoperative transfusion? Johanson Vox Sanguinis 96-8

19 NZ Iron polymaltose use Total Consumption by Year - Tranexamic Acid Total Units

20 ADHB Red cell use RBC used / Patient screen tested 0.56 UCL= LCL= before phase I Phase II _ P= Jan-08 Aug-08 Mar-09 Oct-09 May-0 Dec-0 Jul- Feb-2 Sep - 2 Apr - 3

21 FFP use FFP Used / Patient screen tested UCL=0.083 LCL=0.080 before phase I Phase II _ P= Jan-08 Aug-08 Mar-09 Oct-09 May-0 Dec-0 Jul- Feb-2 Sep - 2 Apr - 3

22 Summary of savings: "Blood is a gift" Project to date and Year to date Full life Project Oct-0 to date # Units saved $ Cost saved Patient (Hrs LOS reduced) Nurse hours released Bed day cost Nurse cost Consumable cost Total savings RBC (Red Blood Cell),922 $3,9,028 47,688 8,942 $2,980,500 $300,96 $59,60 $6,460,054 FFP (Fresh Frozen Plasma) 4,387 $886,372 7,548 3,290 $,096,750 $0,730 $2,935 $2,5,786 Total 6,309 $4,005,399 65,236 2,232 $4,077,250 $4,645 $8,545 $8,575,840 o date YTD 204 Project Savings # Units saved $ Cost saved Patient (Hrs LOS Nurse hours reduced) released Bed day cost Nurse cost Consumable cost Total savings RBC (Red Blood Cell) 2,543 $674,480 0,72,907 $635,750 $64,86 $2,75 $,387,3 FFP (Fresh Frozen Plasma),092 $223,28 4, $273,000 $27,563 $5,460 $529,304 Total 3,635 $897,76 4,540 2,726 $908,750 $9,749 $8,75 $,96,435 P=0.496 P= UCL= LCL= before phase I Phase II RBC used / Patient screen tested cost Consumable cost Total savings FFP Used / Patient screen tested before phase I Phase II UCL=0.049 LCL= $300, $59,60 $6,460, $0,730 $2,935 $2,5, $4,645 $8,545 $8,575, Jan-08 Aug-08 Mar-09 Oct-09 May-0 Dec-0 Jul- Jan-08 Aug-08 cost Consumable cost Total savings 0.00 Mar-09 Oct-09 May-0 Dec-0 Jul- Feb-2 Sep - 2 Apr - 3 Nov - 3 $64,86 $2,75 $,387,3 $27,563 $5,460 $529, $9,749 $8,75 $,96, Absolute volume of RBC and FFP RBC before phase I FFP Phase II

23 Clinical Demand for Red Cells in NZ Red Cell Weekly Issues to Medical Facilities FY07-FY2 Growth largely consistent with population growth Reduction in demand for Red Cells of 3.7% over this period July August MAT

24 NZ use of red cells (NZBS sales)

25 The higher hanging fruit Reduce plasma waste Warfarin reversal guidelines Fractionated products Reduce red cell use IV Iron programs Electronic ordering/audit Smart fridges

26 Lessons learnt Our systems now promote reducing bleeding Collaborative approach using clinical champions have immediate effect DMAIC model aligns well with medicalscientific model. Change leads to large sustained reduction in blood use