Best Practice Submission
Evidence Based Blood Product Utilization
Point of Contact: Emily Volk, MD, eevolk@baptisthealthsystem.com
Patrick Halinski, jphalins@baptisthealthsystem.com
Group Involved with the Project: Baptist Health System Blood and Tissue Committee
Submitted by Major Andrew R. Gregory
11 May 2012
Executive Summary: Blood product utilization is an area where adopting evidence-based
standards has resulted in a significant reduction in utilization without a decrease in patient
quality. Physician education programs combined with computerized decision support templates
show promise in reducing practice variation among providers. As more third party payers adopt
prospective global payment methods similar to CMS’s DRG system, proactive utilization
management of ancillary services such as laboratory, radiology and blood products will be
necessary to remain financially viable. Baptist Health System’s pilot program for evidencebased blood product utilization optimization demonstrates the great potential in establishing such
programs.
Objective of the Best Practice:
The primary purpose of a Blood and Tissue Committee (BTC) is to ensure safe, high quality,
evidenced- based and cost effective use of blood products and tissue at all BHS Hospitals. In
order to efficiently and effectively address the needs of our populations, the BHS Blood and
Tissue Committee is divided into two committees: Pediatric Blood and Tissue Committee and
Adult Blood and Tissue Committee. Each committee focuses on the unique needs of their
population to include implementing and maintaining safe transfusion practices, reducing the
number of transfusion errors and optimizing blood utilization. The committees also serve to
coordinate clinical services required in order to comply with regulatory and accreditation
requirements related to blood and tissue utilization. This multidisciplinary committee provides an
opportunity for teamwork and open communication between all BHS Hospitals. Open
communication and teamwork are key elements of a successful program.
Background:
BHS formed the Blood and Tissue Committee to oversee the utilization of blood products
within all five BHS hospitals to align practice patterns with current evidence-based medicine while
reducing costs and improving patient outcomes. A pilot study was begun in November of 2010.
Literature Review:
Blood product utilization is an area gaining more attention in the medical community. There
is a significant cost savings potential through reduction in blood product usage, both in quantity of
transfusions and in total volume transfused. Each transfusion procedure carries with it significant
risks to the patient. Thus, minimizing unnecessary procedures also leads to improved outcomes by
reducing the opportunities for these risks. As early as 1990 the National Institute of Health had
conducted conferences specifically related to developing a consensus of blood product utilization
standards. Richard Brown led a study that highlighted the great variability among providers practice
patterns for when to transfuse patients (Brown, 1992). In 1993 Morrison published results of a pilot
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program for provider education that resulted in a 75% reduction in total number of packed cells
transfused and a 60% decrease in the total number of patients transfused year over year at an
OB/GYN department in a Mississippi hospital. This reduction was attributed to a yearlong provider
education effort that was combined with a quality audit program (Morrison, 1993).
Nearly two decades later, Chang, et al. highlighted the continued variation in physician
practice patterns. The team used retroactive chart reviews to show that a computerized transfusion
decision support system could reduce this practice pattern variance. The study results suggest
computerization could lead as great as a 45% reduction in transfusions (Chang, 2011).
Faisal Masud led a team of doctors at the Methodist Hospitals in Houston to validate the
safety of blood utilization management. Through provider education the team was able to reduce
blood product utilization by 30.6% over a two-year period with no harm to the patients. In fact, the
study results suggested that the decrease in blood utilization led to a trending towards better overall
outcomes for the patients (Masud, 2011).
To achieve the best results for a hospital system, the techniques for utilization management
should be extended to other ancillary services and procedures. A more recent article by Elizabeth
Stuebing and Thomas Miner discusses the economic realities of healthcare and suggests that similar
utilization management practices will be effective in reducing over utilization of laboratory services
as well (Stuebing, 2011).
Implementation Methods:
In November 2010, BHS began a pilot study for evidence based blood utilization. The
program was multi-faceted with a committee established to identify evidence-based best practices for
blood transfusions and blood product utilizations. Order sets and guidelines were developed
including computerized physician order entry iForms where CPOE was available. The physician
order form for blood product usage was adopted by the Medical Executive Board and made
mandatory for all non-emergent and non-OR blood product orders throughout the Baptist Health
System.
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A large emphasis was placed on physician education and buy-in. In-person lectures were
given, including dinners where statistics and the evidence-based guidelines were presented. Posters
were made and distributed via doctors’ lounges and physician leadership committees. In-person and
online continuing medical education classes were provided for physicians and nurses at all five BHS
hospitals. An internal marketing campaign to physicians was conducted specifically to promote the
use of single unit red blood cells for transfusions, where appropriate, versus the traditional two unit
transfusions.
A mandatory documentation requirement of clinical indication of each transfusion was
initiated. This allowed for just-in-time interventions and education by a pathologist, medical
director and/or the blood bank to provide clinical consultative discussion with the ordering
physician when established criteria were not being followed. One additional key change was the
adoption of a critical value for hemoglobin at a level of 7g/dL, a change from the previous value of
8g/dL.
Results:
The success of this pilot program is clear. After on year, the Baptist Hospital system had
realized a reduction in blood product utilization of greater than 25% year over year. These
results have been sustained as the study has entered into its second year.
As the results are briefed back to the physician community there has been increased
acceptance by those physicians who initially were hesitant to adapt practice patterns to meet the
evidence-based guidelines. Despite the decreased utilization, there has been no decline in patient
outcomes.
Cost savings have been significant. Estimated savings over the next three years total more
than $21 million versus a continuation at the pre-study blood utilization rate. As CPOE becomes
available at each hospital, it is anticipated that even greater savings may be realized due to the
enhanced decision support systems available via computerized entry models.
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Conclusion:
Evidence-based management of blood product utilization is an overwhelming success,
providing significant cost savings with no negative impact on quality of care as measured by
patient outcomes. Switching to evidence-based utilization of products and services such as
blood, lab and x-ray services is the way forward for hospitals to maintain cost and utilization
control. In a healthcare world with increasing global payment models such as CMS’s DRG
reimbursement model, this transition will be required to maintain financial viability.
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References
Brown R., Brown R., Edwards J. & Nutz J. (1992). Variation in a medical faculty’s decisions to
transfuse: implications for modifying blood product utilization. Medical Care. 30(12): 10831096.
Chang C., Lin Y., Wu Y., & Yeh C. (2011). The effects of a computerized transfusion decision
support system on physician compliance and its appropriateness for fresh frozen plasma use in a
medical center. American Journal of Clinical Pathology. 135:417-422.
Masud F., Larson-Pollock K., Leveque C., & Vykoukal D. (2011). Establishing a culture of
blood management through education: a quality initiative study of postoperative blood use in
CABG patients at Methodist DeBakey Heart & Vascular Center. American Journal of Medical
Quality. 26(5): 349-356.
Morrison J., Sumrall D., Chevalier S., Robinson S., et al. (1993). The effect of provider
education on blood utilization practices. American Journal of Obstetrics and Gynecology.
169(5):1240-5.
Stuebing E., & Miner T. (2011). Surgical vampires and rising health care expenditures. Archives
of Surgery. 146(5):524-527
Tinmouth A., MacDougall L., Fergusson D., & Amin M. (2005). Reducing the amount of blood
transfusion: a systematic review of behavioral interventions to change physicians’ transfusion
practice. Archives of Internal Medicine. 165:845-852.
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