Blood Conservation Program Yields Millions of Dollars in Savings

在美国，每三秒钟就有一个人需要输血，这意味着每年输血近1700万种血液成分。然而，有证据表明，多达60%的红细胞输血可能是不必要的。2011年，服务于明尼苏达州和威斯康辛州西部的医疗服务系统艾琳娜健康(Allina Health)在整个系统的输血操作中存在很大差异，输血率比全国基准高出25%。为了改善高风险输血的结果，阿利纳健康公司(Allina Health)利用其数据开发了一项以证据为基础的血液保护计划，旨在降低成本，节约宝贵的血液资源。

A CASE FOR POLICING BLOOD USAGE

输血是一种常见的医疗干预手段，在美国，每年有将近1700万的血液成分被输入——但是，输血并非没有风险。¹Recent evidence indicates that a blood transfusion places patients at risk for immediate and long-term adverse outcomes, including myocardial infarction, stroke, renal failure, infection, and malignancy. Receiving a blood transfusion also increases a patient’s risk of death. Further, patients who receive blood transfusions during cardiac procedures or orthopedic surgeries may be at greater risk for adverse outcomes.^2,3

Allina Health, an integrated healthcare delivery system, is dedicated to the prevention and treatment of illness and enhancing the greater health of individuals, families, and communities throughout Minnesota and western Wisconsin. Despite the availability evidence- based guidelines for blood conservation, physicians have been slow to embrace them.

输血被认为是一种高风险的手术，其相关费用也很高，仅红细胞每年的费用估计就高达70亿美元。然而，有证据表明，多达60%的红细胞输血可能是不必要的。此外，在全国范围内输血的做法也有很大的差异，这与患者的特点有关。⁴阿利纳健康公司将血液保护计划的发展视为改善结果和降低与使用血液制品有关的成本的一种手段。

HIGH DEMAND FOR BLOOD PRODUCTS FUELS CONSERVATION

With 12 hospitals, more than 100,000 inpatient hospital admissions annually, 1.5 million hospital outpatient admissions, 343,000 emergency care visits, and more than 90,000 inpatient and outpatient surgical procedures performed annually, Allina Health uses a lot of blood products, Aware of this, senior clinical leaders at Allina Health began discussions in 2010 on how to determine necessity for, and reduce the unwarranted use of, blood products across the system.

Wanting to better understand the opportunity for improvement, Allina Health obtained a blood product utilization review by an external consult. As a result of the review, Allina Health discovered its transfusion rate was higher than supported by the evidence and there was wide variation in transfusion practices across the system. In total, blood transfusion rates at Allina Health were coming in 25 percent higher than national benchmarks.

The external benchmarking was useful in highlighting opportunities for improvement in utilization. However, the monthly reports Allina Health received did not have enough detail to be useful in targeting meaningful outcomes improvement. Allina Health needed a strategic work plan that would increase adherence to evidence-based guidelines, thus making better use of limited, costly blood resources in an effort to ensure patients were receiving the best possible care.

BLOOD CONSERVATION PROGRAM ENACTED SYSTEMWIDE

Due to Allina Health’s systemwide EHR with shared electronic transfusion order sets, the decision was made to implement changes systemwide, rather than hospital by hospital. To ensure appropriate utilization of limited, costly blood resources, and ensure it was providing patients with the best possible care, Allina Health launched a blood conservation program, establishing a transfusion care council to provide governance over the improvement process.

With the understanding that clinical expertise was needed to make lasting improvements, Allina Health identified key stakeholders for the transfusion care council, including physician representatives from pathology, cardiovascular surgery, and anesthesia. Representatives from nursing were also identified to champion the improvement efforts and promote buy-in.

Allina Health relies on the Health Catalyst^®Analytics Platform, including the Late-Binding™ Data Warehouse and broad suite of analytics applications, for its data and analytics. To make meaningful outcomes improvements, Allina Health needed detailed data regarding blood product utilization, beyond what the initial benchmarking could provide. Allina Health leveraged its analytics platform to create a comprehensive, interactive transfusion application with more robust metrics and details to support ongoing outcomes improvement. The interactive transfusion application enabled Allina Health to conduct comprehensive evaluation and monitoring of blood product utilization (see Figure 1).

交互式输血应用程序提供了血液制品利用的可视化，包括输血制品、订购供应商、输血指征(包括输血频率和时间、输血单位数、输血有效性等)。数据可按医院、单位或患者查看，并包括患者的年龄、诊断和任何并发症。此外，该应用程序还提供了对血液产品管理法规要求的遵从性的见解。

Through the use of the analytics application, Allina Health was able to complete a detailed review of blood product utilization. Armed with meaningful, actionable data, the transfusion care council better understood the opportunity for improvement, and began work to ensure complete adoption of The Society of Thoracic Surgeons blood conservation guidelines. Several high-impact improvements were implemented systemwide:

• Reduced the systemwide transfusion order set default unit from two units to one.
• Included tools and information in the EHR order sets, such as recent lab values and patient vital signs, that can be used to enhance decision making during order entry.
• Added requirement for an in-person evaluation of the patient’s condition, basing the decision to transfuse on patient symptoms in addition to lab results.
• Updated cardiac bypass protocols to use the patient’s blood to prime the heart-lung machine, as opposed to using donated blood.
• Implemented auto-transfusion, a process where patients receive their own blood which is collected from surgical sites is filtered for re-infusion, for surgical cardiac and orthopedic patients.
• Added a device to invasive monitoring lines to reduce the volume of blood obtained for lab draws.

The new blood transfusion guidelines are vastly different from what many medical and nursing professionals learn during training. As such, Allina Health understood that education would be a key driver for success. Comprehensive workshops were developed for medical and nursing staff. Learning videos were created to support the transfusion improvements and to provide ongoing education across the integrated system. Additionally, quality scorecards support ongoing systemwide evaluation of performance in comparison to internal and national benchmarks (see Figures 2 and 3).

阿利纳健康利用其分析平台促进结果的持续改进。世界杯厄瓜多尔vs塞内加尔波胆预测输血护理委员会可以很容易地审查为每次入院提取的关键参数，以确定病例进行额外审查，支持有效地识别潜在的护理改进。

RESULTS

After reducing the yearly cost of blood products by $3.2M, Allina Health has continued to improve its blood conservation program, achieving:

• Four-fold increase in the ratio of single vs. double unit red cell transfusions. (0.48 to 2.24).
• 血浆输血减少32%。

Additionally, the use of donated blood products in cardiac surgery has been further improved through a:

• Four-fold reduction in net prime volume of cardiopulmonary bypass circuit per case.
• 术后置胸管患者输血的相对减少率为33%。

“病人血液管理的目标不是输血越来越少。我们不需要分析。我们的目标是避免对病人不利的输血，这就是我们需要分析的地方。我们需要把输血和价值联系起来。通过我们的仪表盘，我们可以将输血与住院时间和再入院等结果联系起来。”

– Lauren Anthony, M.D
System Medical Director
Allina Health Laboratory

WHAT’S NEXT

Allina Health has begun work to correlate transfusions to outcomes, such as length of stay, readmission rates, and hospital-acquired infection rates. The goal of this work is to establish transfusion guidelines that optimize patient outcomes. Additionally, Allina Health plans to implement a system-level peer review process for transfusion practice, as well as include transfusion metrics as part of ongoing physician practice evaluations.

REFERENCES

1. American Red Cross. (2017).Blood facts and statistics.
2. 布朗，J. D.(2008)。The silent risks of blood transfusion.ResearchGate.
3. Sheehan, E., & Parvizi, J. (2010).Blood transfusions can increase the risk of infection in orthopedic patients.Orthopedics today.
4. Thomas j .(2016)。Blood transfusion best practices.Elite Learning.