THE JOINT COMMISSION PATIENT
BLOOD MANAGEMENT
PERFORMANCE MEASURES
TAC OCT. 2011
PBM-NQF
• Although not endorsed for use at the national
level by NQF at present, these measures are
an excellent tool for healthcare organizations
to evaluate the transfusion consent process,
blood utilization, blood administration
documentation and identify processes related
to elective surgery that may decrease the
need for blood and improve patient safety.
PBM-01
• Transfusion Consent
– Patients with a signed consent who received
information about the risks, benefits and
alternatives prior to the initial blood transfusion
or the initial transfusion was deemed a medical
emergency
Transfusion Consent Rationale PBM-01
• The rate of transfusion consent in US is
unknown
• Studies in other countries show that there is
poor documentation and room for
improvement
• Involving patients in healthcare decisions is a
national priority
Feedback on PBM-01
• Hospitals support this measure because
information about transfusion is not
consistently given to patients
• Information is provided by a variety of staff
• Staff need education about the risks, benefits
and alternatives
• Informed consent for blood transfusions is not
required by all states
• Consent process varies between hospitals
PBM-02
• RBC Transfusion Indication
– RBC units transfused with pre-transfusion
hemoglobin or hematocrit result and clinical
indication documented.
RBC Transfusion Indication Rationale
PBM-02
• Information about total blood use could be
used to determine benchmarks by diagnoses
or procedure
• Promotes a standardized process of
– Checking a lab result prior to each transfusion
– Documentation of a reason why blood was
transfused
Feedback on PBM-02
• Hospitals have different “acceptable”
pre-transfusion lab values
• Difficult to identify transfusions during
surgery
• Point of care testing not used in all
hospitals during surgery
Feedback on PBM-02, con’t
• Difficult to determine if documentation
of clinical indication was sufficient
• No standardized definition used for
“bleeding”
• Lack of national guidelines such as pretransfusion lab results not being required
prior to transfusion.
PBM-03
• Plasma Transfusion Indication
– Plasma units with pre-transfusion laboratory
testing and clinical indication documented.
Plasma Transfusion Indication
Rationale PBM-03
• No standardized method for hospitals to
determine which patients should receive
plasma
• Promotes a standardized process of:
– Checking a lab result prior to transfusion
– Documentation of a reason why plasma was
transfused
Feedback on PBM-03
• Reasons for giving plasma are unclear and
conflicting at times
• An INR >2 and “bleeding” should be the only
clinical indication
PBM-04
• Platelet Transfusion Indication
– Platelet doses transfused with pre-transfusion
platelet testing and clinical indication
documented.
Platelet Transfusion Indication
Rationale PBM-04
• There is no standardized method for hospitals
to determine which patients receive platelets
• Transfusion of platelets associated with
adverse events
• Promote a standardized process of
– Checking a lab result prior to transfusion
– Documentation of a reason why platelets were
transfused
Feedback on PBM-04
• There is concern that establishing a critical
value would trigger increased platelet use
• Hospitals are unclear about:
– Whether platelets are indicated when patients on
Plavix
– The definition of ‘thrombocytopenia’
PBM-05
• Blood Administration Documentation
– Transfusions of blood units with documentation
for all of the following:
• Patient identification, transfusion order and blood ID
number confirmed prior to the initiation of transfusion.
• Date and time of transfusion.
• Blood pressure, pulse and temperature recorded pre,
during and post transfusion.
Blood Administration Documentation
Rationale PBM-05
• Transfusion process is very complex and has
been identified as a high-risk area for error
• Standardizing the process will enable reliable
tracking of potential adverse events nationally
• Numerous errors are associated with incorrect
patient ID
• Administration data elements
– Patient ID verification, Tx order, Tx start date, Tx
start time, Vital sign monitoring, Blood ID number
Feedback on PBM-05
• Some data elements are difficult to collect
when blood products are transfused during
surgery
• The data element criteria are standards of
care and already being collected
• “Transfusion orders” are usually not required
during surgery.
PBM-06
• Preoperative Anemia Screening
– Patients have documentation of preoperative
anemia screening 14-45 days before Anesthesia
Start Date
Preoperative Anemia Screening
Rationale PBM-06
• Preoperative anemia is associated with
increased morbidity and mortality
• National audit found that 35% of patients
scheduled for joint replacement therapy had a
hgb <13 at preadmission testing.
• Formal protocols for early detection, eval and
management of high-blood loss surgeries has
been identified as an unmet need.
Feedback on PBM-06
• Information is not done or not available
• One barrier is who will manage care prior to
surgery
• Information about when the patient was
scheduled for surgery was not always in the
medical record
• Consider adding another measure to evaluate
if anemia screening was effective
PBM-07
• Preoperative Blood Type and Antibody Testing
– Patients with documentation of preoperative type
and screen or type and crossmatch completed
prior to Anesthesia Start Time.
Preoperative Blood Type & Screening
Rationale PBM-07
• This measure is supported by TJC National
Patient Safety Goals
• Patient safety is a national priority
• This issue affects the majority of hospitals and
other high-blood use procedures
Feedback on PBM-07
• This is a patient safety issue
• Hospitals should document whether blood is
available on pre-procedure checklist
• Some hospitals would like to see this measure
be required and completed sooner than
anesthesia start time
• Type and Screening NOT completed prior to
surgery happens frequently
Next Steps for PBM Measures
• Encourage use of the PBM measures at the local
level
• HHS is organizing further data collection efforts
• The seven blood measures have been added to
the measure reserve library. They can be used as
non-core measures until they are called upon for
national use. Historically, this occurs in alignment
with CMS
• Funding pending for retooling the specifications
for retrieval in electronic medical record
Appropriate Inventory Management
• AIM Module I
– 19 blood centers have completely
implemented (~400 hospitals participating)
• AIM Module I version 1.1-Hospital ADL
– Allows the participating hospitals to provide
electronic files to automate their Module I
data input
• 11hospitals participating using ADL
17
AIM-Module 1
• Create a community approach to blood
management to ensure patient transfusion
needs are met
• Determine how many days worth of inventory
are needed based on many criteria
• Benchmark and trend community inventories
against hospital usages using a national
database
Transparency Provides Trust –
A Partnership
Leukoreduced Red Cells : Detailed Graphical Display
Hospital name: DePaul Health Center
Graph type: Days Worth of Inventory Blood group: All
Blood Groups
Cluster: All selected categories - RBC Usage - Very
High
Cluster count: 10
Hospital
Average
Cluster
Average
Standard
Deviation
Hospital
Days
Jul 2010
4.68
7.11
2.84
4
6.92
Aug 2010
4.68
7.11
2.82
4
7.13
Sep 2010
4.68
7.11
2.48
4
7.12
Oct 2010
4.68
7.11
2.18
5
7.39
Nov 2010
4.68
7.11
2.64
5
7.35
Dec 2010
4.68
7.11
2.96
6
7.84
Jan 2011
4.68
7.11
2.95
5
7.2
Feb 2011
4.68
7.11
3.85
6
7.37
Cluster Days
Hospital name: DePaul Health Center
Graph type: Wastage as a Percentage of
Distributed Blood group: All Blood Groups
Cluster: All selected categories - RBC Usage Very High
Cluster count: 23
Hospital
Percentage
Cluster
Percentage
Hospital
Average
Cluster
Average
Standard
Deviation
Jul 2010
1.1
0.45
0.34
0.34
1.46
Aug 2010
0
0.37
0.34
0.34
1.71
Sep 2010
0
0.31
0.34
0.34
0.99
Oct 2010
0.23
0.32
0.34
0.34
1.23
Nov 2010
0.41
0.32
0.34
0.34
1.01
Dec 2010
0.52
0.57
0.34
0.34
2.32
Jan 2011
0.23
0.24
0.34
0.34
0.82
Feb 2011
0
0.16
0.34
0.34
0.58
Leukoreduced Red Cells : Detailed
Graphical Display
Hospital name: DePaul Health
Center
Graph type: Wastage as a Percentage
of Distributed Blood group: All
Blood Groups
Cluster: All selected categories - RBC
Usage - Very High
Cluster count: 23
Improper
Communication
Improper Handling
Breakage/Bag
Integrity
Patient Not Ready
Cancelled Order
Patient Expired
Equipment Failure
Failed Visual
Inspection
Outdated
Jul 2010
0
0
0.27
0
0.27
0
0.55
0
0
Aug 2010
0
0
0
0
0
0
0
0
0
Sep 2010
0
0
0
0
0
0
0
0
0
Oct 2010
0
0.23
0
0
0
0
0
0
0
Nov 2010
0.20
0
0
0.20
0
0
0
0
0
Dec 2010
0
0.52
0
0
0
0
0
0
0
Jan 2011
0
0.23
0
0
0
0
0
0
0
Feb 2011
0
0
0
0
0
0
0
0
0
Average
0.02
0.17
0.03
0.02
0.03
0
0.06
0
0
Cluster
0.01
0.05
0.01
0.01
0.00
0.00
0.00
0.26
0
Leukoreduced Red Cells : Detailed Graphical Display
Hospital name: DePaul Health Center
Graph type: Inventory Age at Receipt Blood group: All Blood Groups
Cluster: All selected categories - RBC Usage - Very High
Cluster count: 23
Leukoreduced Red Cells : Detailed Graphical
Display
Hospital name: DePaul Health Center
Graph type: Transfusions as a Percentage of
Received Blood group: All Blood Groups
Cluster: All selected categories - RBC Usage - Very
High
Cluster count: 8
Hospital
Percentage
Cluster
Percentage
Hospital
Average
Cluster
Average
Standard
Deviation
Jul 2010
89.32
89.22
94.84
91.41
33.97
Aug 2010
93.16
82.37
94.84
91.41
16.88
Sep 2010
96.5
99.14
94.84
91.41
6.86
Oct 2010
92.34
95.45
94.84
91.41
7.9
Nov 2010
96.31
90.78
94.84
91.41
8.42
Dec 2010
90.65
88.38
94.84
91.41
11.86
Jan 2011
93.35
90.88
94.84
91.41
7.27
Feb 2011
107.09
97.71
94.84
91.41
8.41
AIM Hospital Community
• Potential to have thousands of hospitals of all sizes
and services providing data to a true national data
base accessible to all participating hospitals
– User group of hospital transfusion committee
members discussing findings and seeking best
practices
– AIM uses the established blood utilization review
mechanism without the need for additional staff
38
Summary
• The PBM measures are general measures that
collect data on all patients that can be further
analyzed by diagnoses and/or procedure code,
age group or appropriateness as studies become
available
• The abstraction burden for PBM measures using
paper based records is labor intensive and would
capture only a percentage of the transfusions
• The lack of national guidelines for blood impacts
the ability to standardize clinical indications
Summary
• AIM provides blood centers a tool to assist hospitals
and physicians to better manage and use the
available blood supply while:
– Lowering the risk of transfusion complications
– Lowering the cost of blood, and
– Maintaining appropriate inventory levels to ensure
patient transfusion support
39
Resources
• http://www.jointcommission.org/patient_blood_
management_performance_measures_project/
• Expectations From The Joint Commission,
Jennifer Rhamy MBA, MA, MTTT(ASCP), HP
Executive Director
• Patient Blood Management Performance
Measure Project, Harriet Gammon, MSN, RN,
CPHQ
• AIM (Appropriate Inventory Management),
Kellie Kerr, America’s Blood Centers, Carrie
Hantack, MVRBC