New Blood Products order set and guidelines beginning Oct 15th
Background
In the spring GHS began a review of its blood and blood products guidelines and
use. We found that our guidelines were not consistent with the recent literature and
national recommendations. Our guidelines at that time recommended blood transfusion at
a Hgb of 8 or lower. Despite, this approximately 40% of our blood was given to patients
with a Hgb greater than 8. In total almost 80% of the blood given within GHS was given
for a Hgb greater than 7. Over the last several years the literature has shown that use of
blood products increases morbidity, mortality, length of stay and cost. Therefore we want
to limit transfusions to only those patients who truly need it and will benefit from it. Our
goal is not to eliminate transfusions but simply to make sure that patients get the
right blood product for the right indication.
Action
Because this was a significant change to our current practice a multidisaplinary
group of physicians was brought together to review our old guidelines and develop new
ones that reflected the current literature. This group included:
Dr. Alex Saker – Hematology- Oncology
Dr. Richard Loyd - Hematology - Oncology
Dr. Althea Mcphail – Blood Bank
Dr. Romeo Massoud – Trauma Surgery
Dr. Jim Majors – General Surgery
Dr. Bill McGann- Critical Care / Pulmonary
Dr. Marty Austin – Hospitalists
Dr. Chris Hosfeld – Anesthesia
Dr. Dinesh Chatoth – Nephrology
Dr. Fred Chi – Orthopedics
Dr. Howard Sohnen – OB/Gyn
Dr. Scott Schorr – Gastroenterology
Dr. Searle Videlefsky – Cardiology
Dr. Carlton Buchanan – Emergency Medicine
The group agreed that it would be best to start with some already accepted
guidelines and modify those to fit the needs of GHS. We began by taking the guidelines
used at St. Vincent Hospital Indianapolis who has had a longstanding blood management
program. At the request of the group several additional indications for transfusion were
added to the order set. The new GHS order set was then taken to and approved by the
Medical Performance Improvement Committee and subsequently the Medical Executive
Committee.
Education
The Physician group was provided with a variety of articles regarding the effects
of blood and blood products. I will be happy to share them with anyone who would like
them for review. Also Dr. Tim Hannon Director of the Blood Management Program at St.
Vincent Hospital will be giving 3 lectures on Blood Management on Thursday Oct 11th.
In order to accommodate varying schedules, he will be lecturing at 8 am, 12 noon and 6
pm. He is an expert in Blood Management and can answer any questions you have. I
hope that you can attend one of these meetings.
Implementation
We will begin using the order set on Oct 15th. As of Nov 1st we will begin
collecting data on its use.
Possible questions you might have
As a physician what is expected of me? When you order blood, instead of simply
writing “Transfuse 2 units PRBC” you will be asked to use the “Blood Component Order
form”. On it you will be asked to give the indication for transfusion.
What if I forget to use the form? Will my patient still get the blood they need? Yes
we will not delay the transfusion as needed. You will be called by the nurse who will ask
you for the indication and will complete the form as a verbal order.
What if I refuse to fill out the form or don’t have an appropriate indication for
transfusion? This is a new process and a different way of doing things. Therefore from
Nov 1st thru Jan 1st will be an educational period. During that time the Committee will
simply send education letters to the involved MD. After Jan 1st those cases will be
referred to the Dept Chiefs for follow up and response.
Why another form to fill out? Don’t we have enough forms already! Changing
longstanding practice patterns is a challenge. We could have spent significant amounts of
time and energy trying to educate everyone on the new guidelines. Despite this it is my
experience that we would have had little success and would have had little impact on our
current practice patterns. The group of physicians involved felt that the annoyance of
another form was far outweighed by the educational benefit of having the new guidelines
on the order set.
What if my indication isn’t listed on the order set? It would have been impossible to
list all of the rare indications for transfusion. Instead we placed “other” as an option and
ask that you simply write in the indication. These will be reviewed by the Blood
Management committee for appropriateness and if felt to be inappropriate will be
forwarded to the Chief of the Department.
What areas of the hospital does this apply to? Currently it will only apply to
inpatient and OR. It will not apply to outpatients and outpatient surgery. It also only
applies to adults.
This is a new process that we think will lead to better outcomes for our patients.
Fewer infections, shorter lengths of stay and lower costs. Like anything else it will be a
work in progress and I ask that you bear with us as we institute it. If you have any
questions or concerns regarding this order set and policy please feel free to contact me.
K. Carlton Buchanan Jr. MD
Interim, Chief Medical Officer