CPOE Reducing Inappropriate
Transfusions (CRIT) Collaborative
“The most cost effective opportunity to improve
patient outcomes in the next quarter century will likely
come, not from discovering new therapies but from
discovering how to effectively deliver therapies that
are known to be effective”
Sean Berenholtz 2003
Introduction of Collaborative
Participants
CONTACT
INSTITUTION
Richard Chang, Geetha Puthenveetil
Suresh Srinivasan
Children’s Hospital Orange County
Marvin Harper, Jenifer Lightdale
Children’s Hospital Boston
Eloa Adams, Chris Longhurst
Lucile Packard Children’s Hospital
Munirah Curtis, Sara Boblick Smith
University of Illinois at Chicago
Calvin Popovich
All Children’s Hospital, Florida
Phil Spinella
Washington University, St Louis
Rod Tarrago
Children’s Hospital Minnesota
David Rich
Nationwide Children’s Hospital
David Kaelber
Metrohealth, Case Western
Marissa Tucci
CHU Sainte-Justine Research Center
Children’s Hospital of Michigan
Collaborative Goals
• Introduce a tool to reduce unnecessary blood
transfusions in hospitalized children across
multiple institutions.
• Test the hypothesis that CPOE tethered to CDS
can improve and hasten the adoption of
evidence based guidelines across multiple
institutions.
• Set the framework for future collaborations
using effective decision support tools.
Collaborative Benefits
• Quality Improvement
– Improve transfusion
utilization
– Significant cost savings
– Demonstrate the value
of CPOE
– Idea sharing
– Networking
• Academic
– Provide the framework
to conduct hypothesis
driven studies/RCT’s
across multiple
institutions
– Provide the framework
for future collaborations
and research projects
Red Blood Cell Transfusions Carry Both
Benefits and Risks
Benefit
Risk
What are the standard
transfusion practices?
When is it appropriate
to transfuse?
When do the benefits
outweigh the risk?
Red blood cell transfusions alter immune
function
Altered
cytokine
profile
Depletion
of WBC.
Suppressed
immune
function
Increased infection
Transfusion Practices are Highly Variable Among
Hospital Based Pediatricians
2002-Transfusion practices among
pediatric intensivist are highly
variable
2007- A conservative transfusion
strategy (7g/dl) is safe to use in
stable critically ill children.
2011- Evidence is universally
incorporated into best practice.
Laverdiere PCCM 2002
Barriers to Transforming Data Into
Practice
Lack of physician
awareness
Lack of agreement
between providers
Lack of ability to
implement
guidelines
Cabana, JAMA 1999
Berenholtz, Current Opinion in Critical Care 2003
Clinical Decision Support and Computerized Physician
Order Entry (CPOE) Augments Adherence to Evidence
Based Guidelines.
Improved adherence
to evidence based
guidelines
RBC utilization in
pediatric/adult
patients
Utilization of
radiography
CPOE with decision
support
Medication safety
Kawamoto BMJ 2005
Study Design
Decision Support Window
In the Acute Care Wards, CPOE Decision Support Decreased
Average Pre-transfusion Hemoglobin
8
***
Avg. Pre-transfusion Hgb mg/dl
7
6
5
4
3
2
1
0
Control
Post-Intervention
In the PICU, CPOE Decision Support Decreased
Average Pre-transfusion Hemoglobin
10
***
9
Avg. Pre-transfuion Hgb mg/dl
8
7
6
5
4
3
2
1
0
Control
Post-intervention
In the PICU, CPOE Decreased Blood Transfusions
Per Patient Day
On the Acute Care Wards, CPOE Decreased
Blood Transfusions
460 fewer blood transfusions
100 fewer patient exposures
Overall transfusions per patient day
0.09
0.08
Transfusions per patient day
0.07
*
0.06
0.05
0.04
0.03
0.02
0.01
0
Control
Post-intervention
The relative risk of transfusion in the
study population versus control
Implementation of a Decision Support Algorithm
in Association With CPOE Can:
Accelerate adoption of evidence-based guidelines into
clinical best practice
Decrease overall RBC transfusions in the PICU and pediatric
acute care wards without increasing overall hospital mortality
or PICU length of stay
460 fewer RBCT delivered to children at LPCH during the study
period. The estimated direct cost savings for the blood alone
was more than $160,000.00. After accounting for additional
indirect costs surrounding blood transfusions, the overall
savings is significantly greater.
CRIT Website
Meeting
updates
Background
data
CRIT.stanford.edu
Download
CDS tool
Progress on
data
collection
Implementation
Institution
EMR
Vendor
Children’s Hospital Orange
County
Children’s Hospital of Michigan
Children’s Hospital Boston
Lucile Packard Children’s Hospital Cerner
University of Illinois at Chicago
All Children’s Hospital, Florida
Washington University, St Louis
Children’s Hospital Minnesota
Nationwide Children’s Hospital
Metrohealth, Case Western
CHU Sainte-Justine Research
Center
Implemented Investigating Data
Analysis
Next meeting
Monday October 24th 10:00 AM
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