Transfusion Audits

1. Transfusion Audits

2. Transfusion Audits: Overview • What is the impetus behind doing this? • What process are you using to do this? • What is the outcome for me? • What are St. Luke’s criteria for blood/blood product transfusion? • What inclusions/exclusions to these criteria will better fit this unique population of patients?

3. Impetus – Part One • Joint Commission’s Comprehensive Accreditation Manuel for Hospitals (CAMH) outlines elements of performance the medical staff needs to be actively involved in measuring, assessing, and improving: • includes use of blood and blood components • 2007 edition of CAMH introduced revised credentialing/privileging standards • to include the 6 areas of ACGME general competencies • Focused Professional Practice Evaluation • Ongoing Professional Practice Evaluation • requires the Medical Staff to conduct an ongoing evaluation of each physician’s practice Medical Staff is required to collect ongoing blood/component data on each physician

4. Impetus – Part Two • St. Luke’s Medical Staff has been working to restructure Peer Review since March 2007 • Focus is on creating a meaningful quality program for physicians • Peer Review Task Force meetings comprised of interested members of Medical Staff were held to discuss, combine, and and refine both national and St. Luke’s-specific “rules, rates, and reviews” and set standards/limits for new physician feedback reports • Blood component use not meeting appropriateness criteria excluding autologous units was approved during these meetings • Nationally this is a “rule” indicator w/ an excellence target of 1/year and acceptable target of 4/year • Task Force elected to change excellence target to 2/year and acceptable target to 4/year New physician feedback reports need to include this data

5. Impetus – Part Three St. Luke’s has a Transfusion Committee • Committee is necessary to maintain our College of American Pathology (CAP) and American Association of Blood Banks (AABB) certifications • Committee must demonstrate “… the transfusion service medical director actively participates in establishing criteria and in reviewing cases not meeting transfusion audit criteria” ¹ • Inpatient populations (surgical hips, AAA repairs, acute leukemia) have been audited against Committee-defined transfusion criteria for many years at St. Luke’s • findings reviewed, discussed at Committee • difficulty defining mechanism or appropriate way to share information and give feedback to the rest of Medical Staff ¹ Shulman, I., & Saxena, S. (2005). The Transfusion Services Committee-Responsibilities and Response to Adverse Transfusion Events. Hematology, 483-490. Committee now has a way to share results of transfusion audits w/ MDs

6. Outcome • Transfusion Committee’s blood appropriateness audit process is changing from population-based to physician-specific • charts will be audited against criteria by registered nurses in PI • documented rationale/reasons for transfusing outside of parameters is very welcome and appreciated • outliers validated by Committee chair • physicians will be sent letter and given opportunity to explain why transfusion was given • Committee will consider response and make final determination • physician will receive “rule violation” letter every time Committee determines transfusion was not warranted • Rule violations will flow into the new Physician Feedback reports to help meet new standards for Medical Staff credentialing Document why transfusion is being given if patient does not meet criteria

7. Current Transfusion Criteria (handout) • PACKED RED BLOOD CELLS • Acute blood loss with: • Life threatening physiologic changes (drop in systolic pressure, tachycardia, orthostatic changes) • Hemoglobin < 10 gm postop • Anemia: • Anemia with hemoglobin < 8 or hematocrit < 24 unless a history of coronary artery disease, chronic pulmonary disease, cerebrovascular disease, chemotherapy, radiation • Anemia requiring correction prior to anesthesia with hemoglobin < 8 or hematocrit < 24 • Neonatal transfusion (see Neonatal Transfusion Criteria)

8. Current Transfusion Criteria (handout) • Fresh Frozen Plasma • coagulation factor deficiency documented by coagulation abnormality • replacement during pheresis • Cryoprecipitate • treatment for von Willebrand’s disease, fibrinogen deficiency, factor XIII deficiency • fibrin glue – intraoperatively • Platelets • count < 5,000/cmm with or without bleeding • count < 20,000/cmm or < 50,000/cmm with a decreasing platelet count in a bleeding patient or in patients on chemotherapy • count < 75,000/cmm in a surgical patient unless patient is on cardiopulmonary bypass • stable premature (see Neonatal Transfusion Criteria)

9. New Process • Explain reasons why and how the data will be used • Share transfusion criteria • Seek input and ask for expertise in fine-tuning criteria specific to each unique patient population • Audit charts against criteria after department input • Share results w/ Transfusion Committee and Department • Individual identities will be kept confidential • Discuss practicality of keeping this indicator as a “rule” w/ targets of 2 and 4/year • Seek input on the ideal # of charts per physician to audit every month/quarter w/ the realization that this will need to eventually involve every member of the Medical Staff

10. We Want Your Input! • Transfusion auditors are looking for any input you would like to give to Transfusion criteria or this necessary audit process! • Feel free to contact PI Specialist Julie Sperling, RN at 381-3499