CPOE Reducing Inappropriate Transfusions (CRIT) Collaborative

CPOE Reducing Inappropriate Transfusions (CRIT) Collaborative “The most cost effective opportunity to improve patient outcomes in the next quarter century will likely come, not from discovering new therapies but from discovering how to effectively deliver therapies that are known to be effective” Sean Berenholtz 2003

Introduction of Collaborative Participants CONTACT

INSTITUTION

Richard Chang, Geetha Puthenveetil Suresh Srinivasan

Children’s Hospital Orange County

Marvin Harper, Jenifer Lightdale

Children’s Hospital Boston

Eloa Adams, Chris Longhurst

Lucile Packard Children’s Hospital

Munirah Curtis, Sara Boblick Smith

University of Illinois at Chicago

Calvin Popovich

All Children’s Hospital, Florida

Phil Spinella

Washington University, St Louis

Rod Tarrago

Children’s Hospital Minnesota

David Rich

Nationwide Children’s Hospital

David Kaelber

Metrohealth, Case Western

Marissa Tucci

CHU Sainte-Justine Research Center

Children’s Hospital of Michigan

Collaborative Goals • Introduce a tool to reduce unnecessary blood transfusions in hospitalized children across multiple institutions. • Test the hypothesis that CPOE tethered to CDS can improve and hasten the adoption of evidence based guidelines across multiple institutions. • Set the framework for future collaborations using effective decision support tools.

Collaborative Benefits • Quality Improvement – Improve transfusion utilization – Significant cost savings – Demonstrate the value of CPOE – Idea sharing – Networking

• Academic – Provide the framework to conduct hypothesis driven studies/RCT’s across multiple institutions – Provide the framework for future collaborations and research projects

Red Blood Cell Transfusions Carry Both Benefits and Risks Benefit

Risk

What are the standard transfusion practices?

When is it appropriate to transfuse?

When do the benefits outweigh the risk?

Red blood cell transfusions alter immune function

Altered cytokine profile

Depletion of WBC.

Suppressed immune function

Increased infection

Transfusion Practices are Highly Variable Among Hospital Based Pediatricians

2002-Transfusion practices among pediatric intensivist are highly variable

2007- A conservative transfusion strategy (7g/dl) is safe to use in stable critically ill children.

2011- Evidence is universally incorporated into best practice.

Laverdiere PCCM 2002

Barriers to Transforming Data Into Practice Lack of physician awareness

Lack of agreement between providers

Lack of ability to implement guidelines Cabana, JAMA 1999 Berenholtz, Current Opinion in Critical Care 2003

Clinical Decision Support and Computerized Physician Order Entry (CPOE) Augments Adherence to Evidence Based Guidelines. Improved adherence to evidence based guidelines

RBC utilization in pediatric/adult patients

Utilization of radiography

CPOE with decision support

Medication safety

Kawamoto BMJ 2005

Study Design

Decision Support Window

In the Acute Care Wards, CPOE Decision Support Decreased Average Pre-transfusion Hemoglobin 8

***

Avg. Pre-transfusion Hgb mg/dl

7

6

5

4

3

2

1

0 Control

Post-Intervention

In the PICU, CPOE Decision Support Decreased Average Pre-transfusion Hemoglobin 10

***

9

Avg. Pre-transfuion Hgb mg/dl

8 7 6 5 4

3 2 1 0 Control

Post-intervention

In the PICU, CPOE Decreased Blood Transfusions Per Patient Day

On the Acute Care Wards, CPOE Decreased Blood Transfusions 460 fewer blood transfusions 100 fewer patient exposures

Overall transfusions per patient day 0.09 0.08

Transfusions per patient day

0.07

*

0.06 0.05 0.04 0.03 0.02 0.01 0 Control

Post-intervention

The relative risk of transfusion in the study population versus control

Implementation of a Decision Support Algorithm in Association With CPOE Can: Accelerate adoption of evidence-based guidelines into clinical best practice

Decrease overall RBC transfusions in the PICU and pediatric acute care wards without increasing overall hospital mortality or PICU length of stay 460 fewer RBCT delivered to children at LPCH during the study period. The estimated direct cost savings for the blood alone was more than $160,000.00. After accounting for additional indirect costs surrounding blood transfusions, the overall savings is significantly greater.

CRIT Website Meeting updates

Background data

CRIT.stanford.edu

Download CDS tool

Progress on data collection

Implementation Institution

EMR Vendor

Children’s Hospital Orange County

Children’s Hospital of Michigan Children’s Hospital Boston Lucile Packard Children’s Hospital Cerner University of Illinois at Chicago All Children’s Hospital, Florida Washington University, St Louis Children’s Hospital Minnesota Nationwide Children’s Hospital Metrohealth, Case Western CHU Sainte-Justine Research Center

Implemented Investigating Data Analysis

Next meeting Monday October 24th 10:00 AM Spread the word!