In 2011, Downers Grove, Ill.-based Advocate Health Care established a blood management program to reduce use, improve patient safety and save costs. In the first year of the program, Advocate reduced blood use by 22 percent at its level 1 trauma centers and by 29 percent at its level II trauma centers. This reduced utilization cut blood product costs by 21 percent, representing a savings of more than $3.4 million in the first year alone. Here, Beth Halperin, manager of transfusion safety, and Rishi Sikka, MD, vice president of clinical transformation, share the health system's journey to greater efficiency and safety through the blood management program.
Impetus for change
Advocate began to look at its blood use when its blood bank staff suggested blood was being overused, and that this presented a risk for patient safety. Advocate had Strategic Healthcare Group benchmark its current blood use and determined that an evidence-based approach to blood management could improve patient outcomes and efficiency.
Advocate employed several strategies to engage its physicians around the blood management initiative, including education, a bottom-up approach and an internal marketing campaign. Advocate had Timothy J. Hannon, MD, CMO and founder of Strategic Healthcare Group and former medical director of the St. Vincent Indianapolis Hospital blood management program, talk with physicians about the latest evidence on blood transfusions. "A national and respected thought leader, Dr. Hannon, met extensively with medical staff and conducted grand rounds throughout the system," Dr. Sikka says. "It wasn't just one hit, but multiple interactions at the same site over the course of many months."
Advocate also gathered its physician champions to lead the blood management initiative, developing guidelines and implementing them in electronic order sets. This bottom-up approach was critical for gaining buy-in and for the overall success of the program, according to Ms. Halperin and Dr. Sikka. "Engage your front-line physician and clinician thought leaders early on, and focus on quality and the safety of care," Dr. Sikka suggests. "Their engagement and ownership of [the initiative] was essential."
To spread the message about blood transfusion guidelines and help standardize practice, Advocate created an internal marketing campaign around two important practice changes:
1. Transfusing when the patient's blood hemoglobin concentration reaches 7 grams per deciliter instead of 10.
2. Transfusing one unit instead of two whenever possible.
In the past, physicians would transfuse when a patient's hemoglobin level was 10 g/dL. However, evidence has shown that patients can safely wait for a transfusion until their level is 7 g/dL, according to Dr. Sikka. In addition, traditional medical practice encouraged physicians to transfuse in even numbers, and to transfuse two units instead of one. "It was an old adage reinforced over the years, [...] though nobody could tell you why," he says.
Ms. Halperin worked with Advocate's public relations and communications team to spread these evidence-based guidelines to physicians and front-line staff with the slogan "Seven is the new 10. One is the new two." on sticker buttons and posters. In addition, CMO Lee Sacks, MD, sent a personal email to medical staff about the blood management initiative and a physician spokesperson made a video that was emailed to medical staff. This marketing campaign was supported with additional educational lectures by Dr. Hannon and program resources from the SHG Blood Management Portal. "We tried to aim for message saturation across the organization for why we're doing this and what the patient safety focus was," Ms. Halperin says.
Physician-designed order sets
In consultation with SHG, Advocate's physicians designed the order sets for blood transfusions, which ensured they fit into their daily workflow and fit with clinicians' thought processes, according to Ms. Halperin and Dr. Sikka. "We tried to build things in the way physicians think about clinical problems in the order sets," Ms. Halperin says. "If you look at the names of the order sets, they reflect how physicians think about [blood transfusions]."
Expanding blood management program
Advocate began the blood management program in its trauma centers and then expanded it to all of its hospitals. Now, the system is doing pilot projects at one of its sites to further conserve blood and improve patient safety. For example, orthopedic physicians are determining how to prevent excessive blood loss during hip and major joint replacement surgery. "There's already a lot of interest in extending the projects to other sites," Ms. Halperin says. "We anticipate, especially with orthopedics, doing a lot more of those projects across the system."