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

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.

Meeting Agenda Introduction of New members. Overview of past Collaborative meetings. Discuss and establish timeline for our QI project.

Introduction of Collaborative Participants CONTACTINSTITUTION Richard Chang, Geetha Puthenveetil Children’s Hospital Orange County Suresh SrinivasanChildren’s Hospital of Michigan Marvin Harper, Jenifer LightdaleChildren’s Hospital Boston Eloa Adams, Chris LonghurstLucile Packard Children’s Hospital Munirah Curtis, Sara Boblick SmithUniversity of Illinois at Chicago Calvin PopovichAll Children’s Hospital, Florida Phil Spinella Washington University, St Louis Rod Tarrago, Judy ZeirChildren’s Hospital Minnesota David RichNationwide Children’s Hospital David KaelberMetrohealth, Case Western Marissa Tucci CHU Sainte-Justine Research Center

Introduction of Collaborative New Participants CONTACTINSTITUTION Colin Banas, Sean McKenna Children’s Hospital of RIchmond Lejla Music-AplencMercy Children’s Hospital Nabil HassanHelen DeVos Children’s Hospital Cynthia KaelbsRady Children’s Hospital Amy ManekerAkron Children’s Hospital Adam CampbellShriners Hospitals Irwin Gross Eastern Maine Medical Center Robert MoserCatholic Health East Brian HobermanKaiser Northern California Melissa Frei-JonesUTHSC Santa Rosa Children’s Hospital

Red Blood Cell Transfusions Carry Both Benefits and Risks BenefitRisk Increased blood stream infections ? Oxygen deliveryMortality Cost Improve intravascular volume Improve oxygen delivery What are the standard transfusion practices? When is it appropriate to transfuse? When do the benefits outweigh the risk? First Meeting- September 2011

Barriers to Transforming Data Into Practice Lack of physician awareness Lack of ability to implement guidelines Lack of agreement between providers Cabana, JAMA 1999 Berenholtz, Current Opinion in Critical Care 2003

Decision Support Window

September- CPOE Decreases Blood Transfusions 460 fewer blood transfusions 100 fewer patient exposures

BLOOD NET Support/Perform Multidisciplinary Blood Related Research in Critically Ill Children – Development Encourage/Motivate/stimulate ideas Study Design/Methods Identify Funding Sources – Completion Site recruitment – Analysis Data Analysis and Manuscript preparation October Phill Spinella

11 Impact of a PRUDENT © Red Blood Cell Strategy In Children Undergoing HSCT November Jenifer Lightdale

The CRIT QI project What would be the best project design for our groups initiative? Pure QI initiative? Randomized control trial? How about both? -Jenifer Lightdale and Hongyu at Boston Children’s.

All centers “go live” with rule around the same date, running in the background. Cohort randomized to early start date Data anlayzed in three phases lasting 4 months each Initiation phase, mid phase, late phase Cohort randomized to late start date (4 months after early start date) Data analyzed in three phases lasting 4 months each Initiation phase, mid phase, late phase Begin Data Collection Primary- Transfusions/pt day Secondary- Pre transfusion Hgb, Alert frequency Data Collection Proposed CRIT QI project design InitiationMiddle Late InitiationMiddle Late Early Cohort Late Cohort

Pathway to completion Approval from Transfusion Committees Local IRB approval Implement the decision support tool In the background Randomization of institutions Go Live- Data collection

InstitutionCommittee Approval IRBImplementationRandomized Analysis Children’s Hospital Orange County Children’s Hospital of Michigan Children’s Hospital Boston University of Illinois at Chicago All Children’s Hospital, Florida Mercy Children’s Hospital Children’s Hospital Minnesota Nationwide Children’s Hospital MetroHealth, Case Western Chldren’s Hospital of Richmond Rady Children’s Hospital Helen DeVos Children’s Hospital Akron Children’s Hospital Eastern Maine Medical Center Shriners Hospitals UTHSC Santa Rosa Children’s Hospital

Next meeting Monday Monday February 20 th 9:00 AM Spread the word!