Forum Focus — It’s not just a numbers game: Implementing a patient blood management program

Patient blood management (PBM) is an evidence-based, multidisciplinary approach to optimizing the care of patients who might need transfusion. According to the AABB, an international, not-for-profit association representing individuals and institutions involved in transfusion medicine and cellular therapies, PBM can reduce complications, save lives, and reduce expenditures.[1] AABB recently issued a list of five recommendations to decrease overuse of blood and improve patient care as part of the American Board of Internal Medicine Foundation’s Choosing Wisely campaign.

Hospitals, as part of their mission to serve as good stewards of limited resources, have begun to develop PBM programs and protocols for efficient and consistent practice across the organization. The American Hospital Association, under the direction of its Committee on Clinical Leadership, developed “Appropriate Use of Medical Resources,” a white paper released in November 2013 that identifies five areas where hospitals, in partnership with their clinical staff and patients, should look to reduce non-beneficial care. To help hospitals and their communities address these recommended areas, the AHA will release toolkits throughout the year targeting each of the five procedures/interventions. The first, appropriate blood management in inpatient services was developed with AABB and released in April.[2]

One of the members of the Committee on Clinical Leadership, Dr. David Perlstein, Chief Medical Officer and Senior Vice President of SBH Health System in the Bronx, New York, shared his hospital’s experience in developing a patient blood management program. Joining him was the PBM physician champion, Dr. Robert Karpinos, Chair of Anesthesiology, and the Medical Director of Perioperative Services. SBH Health System includes a 461-bed community teaching hospital and Level I Trauma Center serving a diverse population in an economically disadvantaged area, with a payer mix largely skewed to Medicaid. With nearly 100,000 emergency room visits and nearly 3,000 staff, SBH Health System has been a cornerstone of their community for over a century, incorporated in April 1866 as America’s first chronic disease hospital and the inspiration for many to follow.

Getting Started

The SBH Health System PBM program grew from a strong patient-centered culture that focuses on putting the patient first and empowering every employee to take an active role in making patient care better. In looking for ways to provide better care and improve the patient experience while remaining good stewards of their limited resources, blood management seemed a worthwhile pursuit. Patient blood management allowed SBH Health to decrease patient risk, improve quality of care and outcomes, respect patient autonomy, and involve patients in the care process. In addition, if done right, the PBM program had the potential to reduce blood use and save resources.

According to Dr. Perlstein, education was the major driver for PBM adoption. Dr. Karpinos agreed that physician buy-in was a matter of education and awareness. The initial development rested largely in the hands of the PBM physician champion, Dr. Karpinos. He began the journey by reaching out to the Society for the Advancement of Blood Management (SABM) to learn more about becoming a certified center of excellence. Dr. Karpinos then met with critical stakeholders and department chairs to make the case for PBM. Using that feedback and enthusiasm to develop a steering committee, Drs. Perlstein and Karpinos brought the concept to the hospital leadership committee. The combination of a patient-centered culture and largely clinically-trained leadership team supporting the effort created a place for the steering committee within the transfusion committee. Deliberate in their choices, Drs. Perlstein and Karpinos brought leaders from Informatics, Care Transitions, Internal Medicine, Outpatient medicine, and other key departments to the steering committee early on to help champion the PBM effort. In addition, support from the nursing community was essential.

As an initial task, the steering committee looked at blood usage patterns across the hospital and armed with a clear call for reducing unnecessary utilization, launched an educational program with nationally recognized guest speakers sharing the clinical evidence for PBM, the advantages and disadvantages of using blood and blood products, and the potential risks for patients. While in hindsight Dr. Karpinos would have brought the steering committee together sooner to speed the transition, he is pleased with the response across the organization. As they move toward full implementation following the year-long groundwork and education efforts, SBH Health System expects they will need additional resources for data analysis to track results and staff to coordinate the program.

PBM is a comprehensive blood management program, so moving beyond transfusion rates was important to SBH. As part of their comprehensive approach, SBH Health System is making changes to their anemia management protocols; changing standards from two units of blood to one unit, for example. The anemia and transfusion protocol revisions are being reviewed for approval by the medical staff in preparation for full PBM program implementation. By including the directors of medicine and medical informatics on the steering committee, there is broad support to drive the changes.

Surprises

Dr. Perlstein was most surprised by the rapidity with which the clinicians and staff accepted and were excited about a PBM program. Neither Dr, Perlstein nor Dr. Karpinos expected the multi-disciplinary support across the hospital as well as the buy-in from more senior physicians who would be changing lifelong practice patterns to new protocols. Both credit the clinical evidence and educational campaign for making the PBM case clear and compelling to the full spectrum of clinical staff.

Additionally, although it was not the intent, a PBM program also allows them to provide services to a sizeable population in their community sensitive to the use of blood and blood products. While PBM was undertaken as a quality improvement to the delivery of care, once the program is fully implemented, SBH will be able to address the needs of this population as well.

Lessons Learned

Dr. Perlstein says the biggest lesson he learned is to look for opportunities and not shy away from them because of concerns over culture. Building cultural change takes time, but that shouldn’t preclude efforts like PBM which can help enhance the patient-centered approach. He also cautioned that creating a program like PBM is not a destination, it is a journey and it is important to do your homework before starting out. The key, he says, is to have a plan, approach it slowly and methodically. He also advises gauging the challenges early to address potential pitfalls.

Dr. Karpinos agrees with the slow, methodical approach noting there are many resources available for beginning a PBM program. The Joint Commission has proposed guidelines for transfusion therapy, and their home state of New York has issued transfusion therapy guidelines. He advises those interested in PBM to learn as much as possible from these resources, such as the toolkit available from AHA[3], and build a system that enhances your organization’s strengths and mitigates its weaknesses.

Finally, Dr. Karpinos advises those looking to start a program to “just do it:” get educated, do the research, do the background work, and don’t be afraid of changing the culture. Although it will take time, the results thus far are very rewarding.

References

[1] Patient Blood Management. AABB. Accessed 6/1/14 at http://www.aabb.org/pbm/Pages/default.aspx.

[2] Appropriate Use of Medical Resources. Physician Leadership Forum. Accessed 6/1/14 at http://www.ahaphysicianforum.org/resources/appropriate-use/index.shtml.

[3] www.aha.org/PBM