Improve outcomes, reduce costs with a Patient Blood Management program

Welcome, everyone. We're going to wait just a few moments as attendees join us from our virtual lobby, and then we'll go ahead and get started. Thank you again. Welcome to those who have just joined us. We're waiting a few moments as additional attendees join us from our virtual lobby, and then we will go ahead and get started. Welcome to today's American College of Healthcare Executives webinar. Thank you for joining us today. I'm Shannon Heflin and I'm a program specialist for ACG. Before we get started, I would like to go over a few items so you know how to participate in today's event. Next slide please. Audio will be heard through your computer speakers. So please be sure that your volume is turned up. If for some reason you're having difficulty with the connection. Our recommendation is that you exit out of your browser and restart the zoom session. You will have the opportunity to submit questions to today's presenters by typing your questions into the Q&A box. You may send in your questions at any time during the presentation. We will collect these and address them during the Q&A session at the end of today's presentation. The link to the handout for today's webinar can be found at the bottom of the reminder email you received from EAC you today. It was sent to everyone about an hour ago. Today's event will offer each participant one hour of qualifying education credit credits or self-reported for this webinar. To receive your credit, visit my.echo.org and select my Education credit on the right hand side of the screen. Scroll down to the self-reported credit section and add your credit. Today's program is being recorded and will be available within the next week in the Corporate Partner Resources section of the AC cord. In addition, each of you will receive a follow up email from ACG tomorrow containing a link to the webinar recording and the handout I previously mentioned. We greatly value your feedback and hope you'll take a few minutes to give us your input, as it will include a link to the evaluation form for today's webinar as well. Next slide please. I'd like to take this opportunity to note that this webinar is made possible in part by the support of Quest Diagnostics, an ACG Premier corporate partner, and their commitment to X vision and mission to advance our members in health Care leadership excellence. You will find additional resources from Quest Diagnostics in the Corporate Partner section of ACG dawg. Next slide please. It is now my pleasure to introduce everyone to our speakers for today's program. Doctor Patricia Ford, MD, medical advisor, comprehensive patient blood management of acumen. Next slide please. And Tammy Germany MT, ACP executive director, health systems operation quest diagnostics. And now Tammy, I will turn everything over to you to begin the program. Thank you. Shannon. I'd like to just take a moment to introduce myself a little bit further. I am a medical technologist by career. I would tell you that my career journey has followed what I would call a traditional laboratory leader. Road path. And I started out as a generalist. I did spend a lot of time in the blood bank and absolutely developed a passion for transfusion medicine during my early stages of my career. I then became a supervisor at a small rural hospital, progressed into the reference lab business where I was managing physicians, office labs and STAT labs. And then prior to coming to quest, I had the privilege of working at a very large health system in Pennsylvania, where I was the clinical pathology operations director. As the Executive director for Health System operations here at Quest. I have the opportunity to work to drive the strategic direction for improving our services to our health system customers and improving patient outcomes, which is quite an honor to be a part of. Next slide please. So as our learning objectives for this webinar today, it's important that we understand the current state of our national blood utilization and cost. And I'll take a few moments here at the beginning to go through that. Then I'm going to turn it over to, Doctor Ford to talk about unlocking those meaningful strategies where we can implement patient blood management, reduce costs, and improve clinical outcomes. We're going to discuss how a health system may be able to reduce blood related costs as a part of that conversation. Next slide please. And you'll see here, the agenda that we're going to be following in our discussion. Next slide please. So before Doctor Ford shares her expertise on patient blood management, I'm going to begin by grounding us in the current state of blood utilization and its impact on patient outcomes and health care costs. Next slide. In the United States, we're transfusing 21 million blood components to approximately 8 million patients. Blood products in the USA contribute to about 6 to 7 billion in annual cost. Unfortunately, the cost of blood products similar to other supplies in the country has continued to increase, and over the past three years it's been rising at approximately 10 to 20% rate. And it's safe to say that is not going to slow down. Historically, there have been efforts to reduce utilization, including patient blood management. However, for the first time in 15 years, we are starting to see a rise. And in the U.S., in blood component utilization, especially red blood cells and platelets. Next slide please. There is more to understanding our current state. Is it me or is the slide not. No, it's it's mines based care. So. So sorry. I'll go. That's okay. It's stuck. Okay, so in a minute. So sorry. Tammy, if you have yours up, I can stop sharing. It's all good. We roll with the punches. Yeah, we do. I can let me do that. Let me know when you're ready and I will stop sharing. You will need to stop sharing. Yep. Thank you for doing that. Yep. Just what we talked about. Line got stuck. I know. Are you seeing my president? Absolutely. Perfect. Excellent, excellent. Okay, let's get to the right slide. Yep. All perfect. Thanks. You're welcome. So there is more to understanding our current state when it comes to managing blood supply. Blood products are an important and essential treatment for patients in the right situation. The Joint Commission Journal on Quality and Patient Safety in 2023 published a study on unnecessary blood transfusions. They noted that up to 40% of blood transfusions are actually unnecessary and avoidable. It listed red blood cell transfusions as one of the top five most overused hospital procedures. Taking this a step further, when we put on the lens of patient outcomes, blood products are not benign. There is an increased risk of adverse events associated with transfusions. As we lay on the unnecessary or avoidable transfusions with that potential adverse risk, we can have an overuse cost in our health system of about $1.9 billion and then an additional 6.1 billion in associated cost for adverse events. We also know that we're depleting the blood supply due to overuse and declining, donations. So how do we conserve this precious blood product and reduce adverse events by incorporating a comprehend and so patient blood management program. I'm about to turn over to the presentation to Doctor Ford so that she can share her experience and her expertise on improving patient outcomes by demonstrating how to reduce transfusion exposure, improving our operational efficiencies by preventing disruptions to our hospital operations, and mitigating the impact of the blood shortages. Lowering our hospital costs by reducing blood utilization and expenses. Reducing length of stay and readmissions with, anemia management programs, and even generating a new revenue stream by improving patient satisfaction, outpatient lab volumes and IV ion infusions. So please join me in welcoming Doctor Ford. Thank you. Tammy. So just to give a little bit of information on my background and my, interest in this field, I'm a general hematologist oncologist here at Pennsylvania Hospital, part of the University of Penn Health System, and I've been involved with patient blood management for about the last 20 years. I have a large Jehovah Witness following here. I say about 1200 Jehovah Witnesses each year for all different reason. And the really has given me the expertise and kind of managing, anemia, thrombocytopenia and then that led us to really expand that program into a patient blood management program here about the last 12 years. And we do that in conjunction with our transfusion utilization program. We also have been the one of the four leaders of doing transplants and Car-T in Jehovah Witnesses. Next slide. So let's talk a little bit about patient blood management and clinically how if you open up a patient blood management program in your system, how this can really help you drive. This is the standard of care. Next slide. So there's an urgent need to implement patient blood management. As we all know. There's a next slide a lot of reasons why we need to manage and preserve the patient's own blood both for safety and cost needs. Needs of some of the drivers. Next slide. So what is patient blood management. Well it really is a patient centered systematic and very much an evidence based approach to improving patient outcomes by really managing and preserving the patient's own blood while promoting patient safety and patient empowerment. Next slide. It's comprehensive. It's multidisciplinary. And this kind of looks at the center of patient blood management really is improving patient outcomes. But if we look around we'll start at the top right in terms of managing anemia. So in in this case what we want to do is really identify diagnose manage anemia early and then use red blood cells only when clinically appropriate. If you look at the next square you can see here patient centered. We want to bring the patient's back into the whole aspect of doing transfusion support by promoting their choice and autonomy, giving more discussions on alternative treatments, risk and benefits. And if you look to your top left, you can see then really we utilize blood conservation modalities so we don't lose so much blood. And also down the bottom we want to improve hemostats this really habit so that we identify and characterize any bleeding abnormality. So you can see in patient blood management this really does incorporate a lot of different strategies. Next slide. So what makes this a priority. Well first of all blood transfusion is not a benign transfusion. It is a liquid transplant. We're giving viable red cells. We're giving a viable, kind of travel or white cells when we do this transfusion. So we really I'm going to go through in a few slides here in a minute. Some of the things you may not have been, absolutely aware of in terms of patient safety, that happens when you have a blood transfusion. And what we've learned, if we can really limit transfusions and increase hemoglobin. So we really see a lot of decrease in red bleeding, hospital stay, hospital cost and mortality. If you look down the bottom just to give you an example of how patient blood management has really been adapted as a standard of care for many different societies. You can see down the bottom this is the Society of Anesthesiologists, ob gyn ARB, our critical care partners, Ash for the American Society of Hematology, and all of these have really embraced patient blood management, help established guidelines and standards of care for us. Next slide. So why should we address this? Why do we even care about blood transfusions? Well, let's take it first from the patient standpoint and clinical outcomes. Everyone's aware when you give a blood transfusion that there's the potential for disease transmission. And although the blood supply has never been safer, there is still that small potential, especially of unknown pathogens. We don't know what the next blood borne pathogen might be that's coming around the corner that we're not yet screening for immunosuppression. I have a slide on that coming up. One thing when you give red blood cells, you also even though we look at deplete, which means take away as many of the white blood cells that you're not giving the transfusion for, you still have viable donor leukocytes that go in and cause some issues in the recipient. As we all know, there's a decreased availability of blood. Donors are shortages, and this may get worse as we progress and our population ages. We may find that we have less donors. And you've been through periods in time where we've had a decrease in the blood supply. There's a significant cost outlined that beautifully. The amount of money that is spent, in terms of just mostly red cells, but also platelets in plasma. And there are patients who do not want a blood transfusion, some who will absolutely decline in my program, about 90% of patients. It is for religious reason, but 10% of our patients are refusing blood products based on fears of safety issues, or they've had a bad experience. So there's other patients who also would like, if there's safe alternatives, to have another option for them. Next slide. So this is just a little just to show you for a minute if you look at this is an electron micrograph of red blood cells. So what we get a unit of blood. What we want to do. If you look at day one day one means the first day we collected this from the donor. So that's day one. And that's what a red cell should look like. You can see those little, kind of by conclave, red cells all over. They're going to be able to be beautifully transverse through small vessels, do the job or give them for to transport oxygen into the tissues we want, but we can't give everybody the day one. We have to maintain our blood supply and we maintain our blood supply and your blood banks. And usually when you call for your unit or two, they need to give you the blood that is ready to out date the one that is closer to that day 35. And I think you can see look at the difference in those cells. They look spurred and they they're that's called storage disease of red cells. And they do not transverse through the micro vasculature as well. So if I have an opportunity to get you to make more of your own red cells, that is much safer, much healthier than potentially giving a red cell transfusion. Next slide. So PBM really aligns with your organizational priorities as you well know the patient blood management. If you look on the right these are things we're trying to do when we limit unnecessary transfusions. We know that we have improved length of stays. We have less hospital acquired infection. We have less cardiac and pulmonary complications, less clotting happens. Certainly you avoid the potential for any transfusion error or reaction if you're not giving an unnecessary transfusion. And then certainly you can see on your left how that then correlates with your cost savings and just your risk mitigation in general. Next slide. So let's focus a little bit first on anemia. So if you have a patient blood management program in your in your hospital what are they going to do. Who are the people you need in there. And how can they help. So we're going to focus first on anemia. Next slide. So as you can see anemia is a worldwide epidemic. So it's really thought that in the world at least this is the one of the largest preventable public health and health economic burdens. And transfusion has always been our default in the past, even here in the United States. One thing, if you look even at iron deficiency, we realize that that is under-recognized, undertreated and a real problem in our population. So really, this is an epidemic of just looking at anemia in and of itself and anemia, as you well know, is from many different reasons. Yes, it could be from bleeding, but it can just be a nutrient deficiency. The most common is iron deficiency. As patients age, they get anemia because of their chronic illnesses or because they have underlying kidney disease. So there's lots of reasons why people can be anemic. Next slide. And this is part of what your patient blood management team is going to do. They're going to make sure that they identify. I just met this morning with my PBM team. And we're developing a pathway to make sure as a for instance, that we're going to catch all those patients going through elective orthopedic procedures, who are anemic, to get them over quickly to our anemia clinic to optimize and improve that before they go to surgery. So this focuses a little bit on iron deficiency, one of our most common reasons for anemia and iron deficiency is so unrecognized, we realize about one third of women are iron deficient and do not know that from heavy menstrual cycles. They're not going all around getting their blood count checked and their iron levels checked, and they just assume that the fatigue, the insomnia, the restless leg syndrome are all just part of just being tired in general. So this is a real problem leading to both gender and racial disparity in care gender. Because the majority of iron deficiency is in women, very rare in men. And then racial disparities is much higher in women of color. And the little picture of the boy over there is although I'm talking about adults, this is a real important focus on maternal fetal health is to correct anemia, iron deficiency in particular, because we know there's increase in maternal fetal outcomes if women are iron deficient and are also anemic. So this is a big thing. That was one of the major focuses at our last. Ashe was looking at iron deficiency in our pregnant women. Next slide. So we know this looks significant, but we need to recognize that what's recognized this is modifiable. This is something we can really correct. And even when you look at now we're going to switch. Let's look at our surgical patients. This is very prevalent 20 to 40% of our patients are entering surgery suboptimal. They have not had their anemia manage diagnose and treat it. And as we've looked at this, what we find is if you enter into an elective procedure anemic, there's a 50% chance you could need a blood transfusion. We can fix that in the anemia clinic and really lessen that. So again, this just like people know what their glucose is, what their cholesterol is. We're trying to get blood health for the general public to also be something that they ask their physicians, what's my hemoglobin? And have our surgeons look at a hemoglobin A 12 and above as normal for a woman, 13 and above normal for a male. If it's less, you're anemic. And maybe that should be corrected before surgery to avoid the things on the right. Increased risk of infection, transfusion, kidney injury. Longer hospital stays if you are anemic. Next slide. And this just kind of also highlights a little bit the prevalence how commonly people enter into the surgical suite anemic. And you can see the big one is Gyn. That kind of makes sense. Our Gyn patients often are bleeding from their tumors or from their fibroids and enter in iron deficient. A lot of our GI, diseases also have had some bleeding component to it. So these are just giving you a little bit of idea of the percentage of patients that are actually there's a missed opportunity here to correct their anemia. Next slide. And this is exactly what your patient blood management team will do. They'll set up an anemia clinic. They'll they'll have this part, of your surgical team's evaluation here. This is just looking at one area which is gyn surgery here. And you can see when they looked at this study here, if they entered an anemic before going through their surgery, look at the increase you saw in all of those unwanted events. Mortality, respiratory complication, acute kidney injury, wounded faction, sepsis, clotting and of course, an increased risk of transfusions that was avoidable. Next slide. So 50 to 70% of females presenting for grand surgery are anemic. So again an area of opportunity for us. Well next slide. So preoperative anemia management. Our program goals here is really to set up a screening process. It's just part of our preoperative evaluation. Now in our elective patients that are undergoing surgery. And then they're sent over to our anemia clinic where we diagnose them, figure out what the issue is, why are they anemic, and then actually optimize that hemoglobin by given most of the time, I.V. iron erythropoietin in our outpatient, infusion areas. So this is really something that is now considered a standard of care is to identify and effectively treat anemia in your elective surgical patients. Next slide. So switching a little bit what else will your patient's blood management team do for you. So we've talked about correcting anemia. Let's also now move on to minimizing bleeding and blood loss. So part of the reasons why people can get anemic is from blood loss. Next slide. So our patient blood management program has lots of different strategies we use here. One is they'll identify preventing and treating patients who are at risk of bleeding. And this involves a lot of different strategies. So in the surgical arena with our anesthesiology team and our surgeons of course they're going to apply a particular surgical technique. But there's also extra things they may do in high blood loss procedures in terms of cell salvage as as one possibility, the use of prophylactic anti fibrin analytics to help the patients clot and not use so much blood. So the goal is to enter with the same hemoglobin you're going to exit or close to after surgery. So it's very goal directed. If there is bleeding that occurs it should be point of care testing and immediate testing that is done that can guide the surgeon. There, rather than just saying we want to enact a massive transfusion protocol being a little bit more specific to control that bleeding. What products do do I use? So again today it just happened. We did our transfusion analysis on the last three months, and we saw that a lot of the waste of products were in our massive, hemorrhage protocols. So that's something we're going to focus on before our next quarter. Next slide. So this lab guided bleeding management a part of your patient blood management. So we really want to make sure that we are utilizing the appropriate blood product for whatever the, clinical issue is not just throwing all the blood products out there or treating based on a number. Next slide. I androgenic blood loss. So this is a big one too. What we realized is when you're in the hospital, what happens is everybody at 6 to 7 a.m. in the morning, phlebotomy comes around and draws blood. If you look at the amount of blood that is actually drawn, in the hospital, just on your general regular floors, as I'm following my Jehovah's Witness patients, I will see a decline in hemoglobin A 1 or 2g, just from phlebotomy. So there's no other bleeding that is occurring in these patients in the intensive care unit. My patient blood management team there, we have a lot of setup done a lot of education with our nurses there so that there is no wasted blood. They have different connections they make on to the central line so that there is no central line wastage or minimal central line wastage, which really preserves the patient's own blood. Remember, that was part of our definition of patient blood management. Preserving the patient's own blood. And what we can find is this anemia that's secondary to phlebotomy. Blood loss can account for up to 40% of the red cells in the ICU. If you enter into the ICU with a hemoglobin of ten and you're doing multiple phlebotomy, there's a lot of blood wastage that is occurring. And you have a hemoglobin of seven. All of a sudden you're going to get a transfusion or not from the patient bleeding anywhere other than bleeding into the lines, bleeding because a phlebotomist. Next slide. The next aspect is just this whole tolerance of anemia. So part of what we do, a big part of what we do in our patient blood management program is education. And my program involves it is a multidisciplinary team. I have 17 different members on there from nursing. So they can help us with the education to quality improvement, to blood bankers, to the hospitalist, to the residents, all our members of our team here. Next slide. And part of what we do in terms of our education is really focus on the overuse and unnecessary transfusions as you see down the bottom, the Joint Commission actually had a national summit on overuse to identify five areas. They wanted to focus on that they felt our overuse without medical need. And you can see down the bottom was blood transfusion was right there. As Tammy mentioned, we the estimate can be that we give 30 to 40% of blood products unnecessary early just based on a number, no clinical need. Next slide. So how do we combat that? Well, we combat that by recognizing the fact that this is one of the most over utilized treatments in the United States. And we really can decrease significantly our blood transfusions. Even when I put in some basic transfusion guidelines quite a number of years ago, and we have a now an even more kind of, now that we have epic system, there's a stop there, a simple stop for the residents. We will never stop you from ordering blood, but it'll say, hey, if your hemoglobin in is, below seven, you don't need to give us a reason. If it's above seven, we just need to click a reason why you're giving that blood transfusion. And what happened was a 10% reduction automatically. Just a stop to make people really think. Do I need to give this blood transfusion? What is the reason as well as a broad hospital education. And we decreased by 10% within the first six months when we looked at that simple stop gap that the patient blood management team put into place. Next slide. So what do you what this slide is really showing you here is looking now at cardiac surgery for patients that are on bypass. And what we found is there's a variation in transfer rates here. The physician prevalence, as I mentioned, to just transfuse two units based on a number. As soon as it's under whatever number they decide in their head, under eight, under seven. And one big thing our PBM program did as others have done, is one unit of blood, unless it's a hemorrhage or there's a reason one in a blood bank clinically assess don't do that. Knee jerk we were all taught is, you know, students and interns two years if you need to be transfused, just order to order one unit clinically assessed before you order your second one. And also don't base it just on a hemoglobin trigger or cardiovascular surgeon. Now this is just over the top. But our cardiovascular surgeon would not allow a blood transfusion to be given by any of his fellows unless they personally called him day or night. Guess what happened? Nobody was getting transfused. They are not going to wake him up in the middle of the night. They really thought about it when they needed it. They called him, but it was amazing. Just that attending level kind of support or leadership that was so important and amazing. The reduction in transfusions that occurred. Next slide. And that's part of what your patient blood management team will do. They're going to look at metrics and they're going to give feedback to your providers. In terms of the transfusions are they in and out of guidelines. Can they do better. Who's an overuse. So this I just want to talk a little bit about anemia versus transfusion again. And this whole tolerance of anemia and what we call restrictive transfusion. Really lowering that transfusion trigger and giving it only when you need. So this slide was just looking at percentage of complications on your on your left. As you can see of serious pulmonary renal wounds. And were they anemic. Only with your red did they have. And transfusions only with your green. Or did they have both anemia and transfusion which is always your top there in terms of the purple. So it's just highlighting worse complications for anemia, worse complications with transfusion and worse yet if both occur. Next slide. So we know that this this is one of the physicians here. Anemia is bad. Transfusions work but both together are really super bad. Next slide. So what is the evidence we have in Tammy I'll have you just kind of flick through a couple of these because and then I think there's four of them there about four. And then I'll stop there is lots of evidence out there about restricting transfusion threshold. And this is evidence base. This is what we go when we go to providers to give them information. We just don't we can't just tell them don't do blood transfusion. What's the evidence. They're all worried we're going to have a poor outcome if we don't transfuse our patients. So it all kind of started. The first one is kind of hidden up in the top there, but that was, through the New England Journal of Medicine. It was done in, in the intensive care unit patients. And essentially they randomized them to a liberal versus a restrictive transfusion on their daily rounds. If your hemoglobin was ten or under, you got a unit of blood. That's liberal. If your hemoglobin was seven, you got a transfusion that was restrictive. And they looked at lots of different outcomes mortality, complications, etc. no difference from a 7 to 10, no difference. And then as Tammy was going through there, the study was repeated in pediatrics, orthopedics, cardiac patients always the same result liberal versus restrictive. That's where I had mentioned my hemoglobin level is seven. That's where I came up with it from evidence based literature. I know people wanted a number. I was arguing, I want to know number, but I just wanted them to transfuse based on clinical need. But I needed to set some kind of guidance. So we did a seven. And that's pretty widely accepted through ARB and other organizations. Next slide. And sorry Tammy I know that's a lot of them. There you go. Perfect. So less is more. Certainly in terms of transfusion and we want to really make it so that a single unit transfusion policy is put in place. That is your standard of care. And this is just highlighting here. When you look at the number of, down the bottom left, when you look at the number of red cells that are transfused, the more you give, the more complications you're going to have. When they compared, I did a little study looking at my Jehovah Witness population. Remember, they will not accept transfusions, based on religious convictions versus, patients, so will accept transfusion. And we just went through, by ICD codes and other things we looked at to get matched cohort. My patients like this day is always one day shorter, not transfusing. So why I'm not really sure I even understand why, although I can tell you that when you transfusion, it tends to be sometimes at the end of the hospital stay if there's any complication that keeps you longer. So always my patients come up matched cohorts, one day shorter. And my patients that are Joe witnesses enter with hemoglobin that are higher. They're exiting out to rehab after their orthopedic procedures are able to exercise a lot better when they hemoglobin A ten rather than a hemoglobin A 7 or 8. And these older patients who are somewhat deconditioned a lot of them anyway coming in next slide. So your patient blood management program, as we've kind of highlighted here should be multidisciplinary. You'll figure out who your stakeholders are. But we always started out when I came to this house, I started out by meeting with our, all of our chiefs and our executive and our leadership to really get buy in for this. And then together, we identified what do we want from this program? Well, we want data analysis. We want metrics. We want benchmarks. We want to improve, clinically map quality improvement. We want to change management. This is going to happen through education and awareness and feedback to individuals. So I continuously expand my PBM committee. And again, as I may have mentioned, I've now convened it, combined it. I used to sit on the transfusion or whatever you call it, your hospital transfusion utilization committee, and then they would sit some of them on my patient blood management. And we realized no one committee we take blood from when it enters into the hospital, you're maintaining safety and inventory all the way until we're done. Transfusion managing risk. So we're one committee now taking all of that together. Next slide. So establishing an effective PBM program really essentially you have to decide in your hospital what you want to do. But in general I think this applies to to most PBM programs. Is that you you're going to be doing a lot of education. You're going to be doing a lot of metric analysis that are clinically meaningful, you know, decreasing transfusions, making sure you're patients, you're addressing anemia. What's your length of stay, all the metrics you want to look at. And then you're going to give feedback and look for areas of opportunity. You're going to establish guidelines and documents and pathways. So you have this decision support trees in there for all of your providers here. Your PBM program is then go to figure out mitigation strategies. I've just run through a few of the ones that I have utilized that I think have really been helpful in our program. And then you're going to, you know, have your mission statement, your purpose, and establish your structure and your governance. And then we report yearly not only to all the chiefs, but we report annually to our quality, improvement, committee. To show the work that we've done and the metrics and the framework and guidelines that we've established that year. Next slide. So what's the impact? And you might have to click through. Thank you. So the impact here is that in a lot of studies this is looking at once they instituted a patient blood management program based on the pillars we've been through and some of the strategies, what they looked at here in these 17 studies were they decreased by 39%. Patients who were transfused, they saw shorter hospital stays, fewer complications, increased survival and cost reduction. If you look on your right. So I know it's a busy slide, but they'll be providing you with all these slides. If you want to look at this in a little bit more detail. Next slide. So what are our key takeaways that we want to really highlight for you here. What we've kind of talked a lot about the importance of patient blood management as a standard of care. And that this is an if there's an ever increasing scarce resource blood products, hopefully you're going to see significant cost savings and hopefully you're going to see improved clinical outcomes. When you look at what are the big drivers, why do hospitals want to do this? And they actually have looked at some of the drivers here. And the the big driver was patient outcome improving patient outcome was number one. Second was cost savings which we've highlighted. Third was preventing blood shortages. And fourth was patients decreasing, complications and improving patient safety. And lastly was shorter hospital stays. So that were the were the big drivers as to why a hospital or a health system really was ready to embark on the next step of establishing patient blood management as their standard of care. So I think that may take us to the last part here. It will be ready for a Q and A, and I think we left about 20 minutes appropriately for some wrap up and then questions. Awesome. Thank you so much Doctor Ford. As a reminder, to submit a written question or comment, please type your question into the Q&A box. But please note that we'll try to get through as many questions as possible, but if for some reason we don't get to your question, or you have a question that pops up after the webinar, you can contact, Quest Diagnostics, on the following, slide here. For any additional details regarding the webinar or the content we just presented. So our first question I will direct to you, Doctor Ford, can you explain how a blood management program, not only helps with patients, but also assists with the operations and financial standpoint of a health system. So, we look at that, through the, mostly through our blood transfusion, part of our, our patient blood management. So we have a quarterly report that they would normally do just to look at, you know, risk, side effects, etc.. But we've added on to that, the number of units, not just ways to which they will report the number of units being used per service line. And it was surprising to me, the biggest service line I know that's going to be surgery in our hospital. It's Highmark. So I realized, whoa, my partners needed to step it up over here. So then we look at individual physician feedback, and what we do is we look at the amount of blood products we're decreasing with each strategy, which leads to the cost. And it's hard to get, as people may know, on this part, to get the actual cost of a unit of blood. There's so many different components to testing and providing it and the nursing, etc. but it just stands to reason, as we're decreasing the number of units that we're using that that leads to cost. Effectiveness. So we do look at that in, in that way, the certainly our administrators are looking at their budget and you know, how much money they may actually see decrease. Excellent. Thank you so much. And then if an organization already has a blood management program in place, in your opinion, what are so what are some of the better ways to, to optimize that, that you found, in your journey with your organization? I think the, you know, even the last couple of years, what I found was my committee was not as comprehensive as I needed it to be. So I added on more nurses to to really, look at that aspect of education. And the nurses are wonderful. Just in terms of helping the, the new interns and the new residents in terms of their awarding of transfusions. And then I realized I need to have on there the stakeholders that are giving who are the providers nowadays that are actually because that's shifted, who's actually ordering, the, the blood products and it's the hospitalist. So I, I made sure that we added, as one of our members and we were meeting their needs. The hospitalist and a lot of Pas is a nurse. Practitioners are doing the ordering, so it's not really the attendings. So initially when I first started, I had like attendings on the committee, and I realized I don't need them as much as I they can be reported up to. I need the people actually ordering the transfusions. So that was a big shift. And then the second shift for me, as I mentioned, was really combining this patient blood management and transfusion utilization program together. And that has unbelievably helped us set, our kind of new things that we want to our mitigation, strategies we want to look at in the future. Really helpful because as a human, I would not have known about the amount of bloods and the problems with the massive transfusion protocol. For instance, without the transfusion specialist being on there, I would not know all the blood that may be, you know, wasted in the operating room because it's not brought back in a safe manner, etc.. So I think combining the two programs, adding on the actual providers, onto my committee was the most helpful. And then bringing on recently I brought in someone with I from it. I realized, oh, I want to put all these subjects in, I want to do all this, and who's going to look at all these metrics? So that is one thing that is, I would say, an ongoing challenge. Who is going to look at all these metrics? We can get the feedback and we can educate. But that's not really part of what we do. We somebody really needs to come in and be able to pull this information out to really get you don't know where your problems are until you actually see all your data. So I would say that is an ongoing challenge, that and you can't ask a busy provider or anybody else to do that. So I think that that is still I think something is really needed. And Tammy, do you have any insight into, into, the best way to organize or optimize blood management as well that you've seen in your line of work? So I appreciate the question. Actually, I think Doctor Ford hit on something that was really important. It's the monitoring of the metrics long term. One is grabbing the information. Right. How do you get that data into a form that is usable, that can give you insight first and then second? You have to have somebody who's dedicated to truly evaluating the data, taking solutions that are identified from that data. So I agree with that one. That one was a challenge for me. Excellent. Thank you so much. And then again I will direct this question to Doctor Ford. And Tammy you're welcome to pop in if you have an answer as well. How does blood how does patient blood management impact patient outcomes. As well as recovery times. Yep. So what we find is I'll take the first part which is the patient outcomes. So it really all relates to the two things, not exposing patients to the unnecessary risk of transfusions. If you have an alternative, the alternative being increased that hemoglobin. So if you know, if your for instance, we just looked at the amount of and you can't go by blood loss. What I'm going to say this because your estimate of blood loss your surgical surgeons are great. Always 50 to 156. But how much does your hemoglobin decline per surgical procedure? So if you enter in the hospital with a hemoglobin of 12 and you have a massive revision of, an infected hip or something in your lowest nadir, hemoglobin is then eight, you know, you have a four gram drop there, so you can't go by the EBL. You have to take what that hemoglobin is. So what we failed is we got to address that. And we are decreasing unnecessary, transfusions by getting the hemoglobin up to a level where we'll avoid transfusions. It won't go down to hemoglobin 6 or 7. And then also in terms of outcomes kind of avoiding the transfusions, improving the anemia from all of we said less infections, less hospital stay, less complications. And then I think I think I forget the was there. A second part of that question was patient outcomes outcomes and recovery time. That's why recovery time. So the recovery time well I was able to look at length of stay which was less. And our patients who had their hemoglobin higher and we're not being transfused. Recovery time is a rough one. Now others have looked at this especially in orthopedic procedures, and they kind of measured it, in rehab by how many steps they could make and some other parameters. And they reported out in this large series, it was one of those liberal restrictive patients did much better with higher hemoglobin. In terms of recovery time and rehab. Wonderful. Excellent answer. Thank you so much. Our next question is, if an organization has tried to implement a program such as this, but some have found out that the providers, have not always complied with the suggested guidelines. What do you recommend or what is your advice on how to help increase the compliance for these? Feedback. And done in a very non-threatening way. This is tricky. None of us like to be criticized. So it is done in a very non-threatening way, and we usually start by presenting the data first to the chairs of the department to say, I'm just getting a for instance, when we just did, here's your ten surgeons in this particular field. You have one outlier, everybody. And he's not doing he or she is not doing any more complicated procedures, no higher risk than your other doctors. Look at the outlier here they are transfusing, you know, four times more than all your other providers. How can we present this in a way, doctors are very competitive, and I like to be the outlier, the one that looks like they're not doing things as well. So it's an individual feedback at all times. It's done by the chair and then it just a presentation in general. But you're right, that is tricky. But you need the data. So you need to know what are the service lines and who is actually providing. Because right away you'll get the the, counter was, oh, I'm not running that blood on the attending. That's not by my residents or my or my peers are nurse practitioners. And the that feedback has to be I understand, but you're responsible. You're the attending. You provide the oversight, you lead. You got to then provide some education to your team. They're doing what they think you want them to do because they're providers also for another attending. And they're not transfusing. So, you know, you really it is finesse in terms of doing. But having buy in from leadership. Our chairs fabulous. Really helpful. I was going to add that to that statement, Doctor Ford, because to me some of that is by example. And what is the expectation from above? Yeah, right. Getting those key stakeholders involved early on certainly helps with that. Excellent. Thank you both. How can blood how can patient blood management help improve overall quality improvement initiatives? We'll start with you. Doctor Ford. So we did, win an award at one point for some of the things we're doing. And I'll do a real simple one. It's an easy one. Decreasing phlebotomy is in the hospital. Out. Who has had blood draw. That hurts. And then you can't get a vein. So now I've got to take it 4 or 5 times. So just educating our interns or residents and our, nurses in terms of do you really need to have a daily phlebotomy done on these patients that are in for a stable medical issue when you need it, you need it. So the decrease of phlebotomy led to patient satisfaction. Also with another one we did was and I'll mention is informed consent. So what I when I look at all the different risk factors involved in giving blood products, we all learned in medical school for the last time, one of the risk of, blood products. And we learn transfusion risk and and transfusion reactions. We did learn about storage, disease, immunosuppression, everything else. That is a bigger risk. The FDA, the biggest cause of mortality is, you know, lung associated traveling a related acute look, nobody's informed of patient lives. So what we did was we went out and we gave a little survey. We gave a survey to patients. They've already been through their informed consent process. Very basic questions. Were you offered alternatives? Do you understand. And they felt it was just miserable. Our informed consent process. Then we flipped it over. We gave to our providers that were ordering a transfusion, some basic transfusion questions that you should know. And a medical school lost a level and they failed. So we're failing in terms of doing education, we need to update education on appropriate use of blood products, and we need to do a better job of informing patients. You actually have an alternative to blood transfusion and you need to be aware. So that's the whole concept of blood health. I think you're going to see that rolled out that just started this last year to inform the public about blood health, for them to be an advocate for themselves and know what their hemoglobin is. And as for alternatives. So I think and hope you're going to see that catch on. And just like this, like I mentioned, they're going to ask for their blood sugar and cholesterol. They're going to start asking for their hemoglobin and going into surgery. What is it and what are my alternatives to transfusions. And that'll lead to better patient satisfaction, better patient outcomes, greater numbers. Yes Sammy. Anything you want to add to that? I thought you were right on point. I was just acknowledging that you gave some great examples of actual data driven outcomes, right? Yep. Wonderful. Thank you so much. I see this question popping up a number of times in the Q&A box. So I will go ahead and, ask this one. So you showed many evidence based studies throughout the, the presentation, that showed the impact and outcomes of the PBM program. What are some of the outcomes that you're seeing at your organization? And, and the community, with utilizing this patient blood management program? Doctor Ford so we have well, I'll give me as an example first. So did know anybody was looking at my a while back look at a my transfusion. Use in any way. But they went back and they compared it to when I first started in the hospital. And then how much do I transfuse now? And there was a 90% reduction. Now, I did not do that on purpose. That just led to my better understanding, my better awareness, and to just practice changing. So I personally decreased 90%. And there's no change in my clinical outcome in my patients. When we look at the hospital, we've had this program up and running for so long now we are pretty tight. It is sometimes hard for us to find opportunities to even restrict blood use more. But again, as I mentioned, that 10% reduction as soon as we had a little transfusion card and gave a little feedback and put that little stop sign, and we've continuously just done better and better with metrics and feedback. Beautiful. Thank you so much. This question comes from another individual. Well, we'll keep on to you, doctor, for they were curious about, how many people are on your, PBM team. And which department does it report up to? Is it nursing blood bank or something else? So currently, we have 17 members and they encompass, members from the blood utilization program. So there's about five there that have carried over. The chair of pathology is on there. Our lead in blood bank, our lead in laboratory services. So that was everyone who was there from pathology came over. There's about five. And then I have Jehovah Witness representative myself. And then I have, key providers from ObGyn, hospitalist, the residency program, emergency room surgery, very important. And the emergency department. So those are those then I have nursing educators, I have members from Quality Improvement, I have members from it. So I've kind of expanded this each year as we each year we kind of look at our committee roster, re-invite people and then see who are we missing in order to do things. Today during my PBM that people get excited about this. So we have one of our APS from the, actually from the orthopedic service who has sat down here and signed up every year. She loves it. She developed, she's orthopedic. She developed a GI pathway for me. That shows how to, you know, limit blood transfusions and how to care for those who declined. She ran with that and had a poster presentation at her, actually at one of the, societies. So people just get excited. They don't have to have knowledge. Nurses is what I always say to people will guide you through this, and we just make sure that we have everybody engaged and an opportunity to work on different projects that they may or may not have an expertise in. And then that person brings on 4 or 5 people from the committee. So people are always working on different projects right now. They're kind of looking at electronic, blood consents throughout every department, in every aspect, because we found that was a real problem. When they identified 30 people, they didn't have informed consent for blood, within the health system and electronic, I think we saw that. So there's so many different ways this committee can go, just so many different things that can be involved in transfusion that you don't even think of. So you'll figure out in your hospital what your big departments are. We have the largest obstetrical departments is why that's critical for us to have a have a member from ObGyn there all the time. And the residency program we added on the last about two years ago, it was very helpful. Right. See 17 members at the moment, wide variety and team members and and what they do at your organization. Excellent. Thank you so much. And we report we report up to the chief of medicine. Perfect. Yeah. No, no the next person I report up and then we just had our co CEO joined us. So she came in and joined the not join the committee but came in to monitor and see what we were up there. She's new to our hospital. So we want to make sure that that gets up to her also in terms of what our needs are, and kind of, you know, what we're doing. Yeah. So continuously evolving and growing is what it sounds like. Yeah. Perfect. This will be our last question. With the threat of blood shortages, how has your organization been coming to the challenge as far as, your experience with blood products that expire? So this I relied on my, blood utilization partners who did a phenomenal job. So I'm just thinking of the last couple things we did the last few years have made a big impact on wastage of blood products, because I wouldn't have known about that. How would I ever know about that as a hematologist oncologist? So they actually were wasting a lot of that outdated platelet products because they're only good for five days. So they were wasting a lot of platelets, just outdated. And so what they developed was a system to transport them to another hospital within our health system, before they expired. So they took that wastage down 95% because savings there with platelets. We were working and continue to work on the wastage in our massive, transfusion protocols. We've already done that in ob gyn. It was amazing. It was nursing that helped us there. So what we found was I think during a Covid situation, there's so many people going on there. Cold for the blood products. Blood by just sends them. They send them her packs. You know here's your platelets plasma red cells. No one's keeping track. No one was keeping track of what should have gone in next, what was currently in the room, etc. so we had the nurse who was already, or the recording nurse in the could really be more vocal verbal rather. Hey, we're supposed to be now giving two units a cryo. We're supposed to be given this. And look what I have here. You're sure you will be on a call for the next? So that nurse became really engaged and educated and made a giant impact on the wastage. From that, the operating room nurses helped us with the, the products that weren't returned quick enough or in the proper, you know, pulled container they were supposed to be. So having the circulating operating room nurse really focus on the blood products in, his or her room and keeping an eye on them and making sure they were properly being stored and returned in a fast manner. So really, it was nursing for all those that stepped up and really helped the most. Wonderful. Thank you so much, Doctor Ford. This concludes today's American College of Healthcare Executives webinar, Business Unusual Unlocking Strategic Ways to Manage Blood Supply and Improve Patient Care. I'd like to thank Tammy and Doctor Ford for sharing their knowledge and expertise with us today on how health systems can reduce costs and improve clinical outcomes by utilizing patient blood management strategies and optimizing blood use. And once again, I'd like to thank Cuesta Diagnostics for their continued support of ACG and its members. And in closing, EC wants to thank each of you and your organizations for what you do every day to provide quality health care to our communities across the nation. As a final reminder, watch out for the follow up email tomorrow with links to the session evaluation form, handout, and webinar recording. Today's program is copyrighted in 2024 by the American College of Healthcare Executives. All rights reserved. Thank you for joining us today, and please enjoy the rest of your day. Thank you. Thank you.