1. blood transfusion guidelines
100% compliance of
blood transfusion guidelines
Prof. dr. Robert Slappendel, anesthesiologist
Manager Quality and Safety, Amphia Hospital
Tias Nimbas Business School, Tilburg University

2. Conflicts of interest All work is paid by Amphia Hospital
no payments by blood banks or pharmaceutical industries.

3. Who wants to be a millionaire?

4. What’s the price of one unit of blood?
Answer:
€ 50,=
€ 200,=
€ 800,=

5. Price of blood (2009)

6. Costs of blood Direct costs Indirect costs Donor Blood bank Collection
Storage in hospital
Research
Cross matching
Infections
Extra hospital stay
€200
€ 800

7. After this session all hospitals using over 7800 units of blood can save 1 million euro a year

8. Difference in transfusion rates Risks of blood
Topics to discuss
Difference in transfusion rates
Risks of blood
The battle of the blood bank
Transfusion triggers
100% compliance to blood transfusion guidelines
Results
Final conclusion

9. Variability of Transfusion Rates (2003)NL
 1. van der Poel, C.L. and M.P. Janssen, Final Report - The collection, testing and use of blood and blood products in Europe in : Strasbourg.
2. van der Poel, C.L. and M.P. Janssen, Final Report - The collection, testing and use of blood and blood products in Europe in : Strasbourg.
3. *Rouger P., Blood Transfusion in Europe: The White Book 2005, European Network of Transfusion Medicine Societies
Public Data from National Blood Authority, Australia

10. Gombotz H, Rehak P, Shander A, Hofmann A
Gombotz H, Rehak P, Shander A, Hofmann A. Blood use in elective surgery: the Austrian benchmark study. Transfusion 2007;47: 10

11. Potential for Reduction
Variability of Transfusion Rates for Matched Patients - Prospective Austrian Benchmark Study
Potential for Reduction

12. 97.4% of all transfusions could have been predicted by:
Level of anemia prior to surgery
Volume of perioperative blood loss
Transfusion trigger 12

13. Blood loss per surgeon (THP)

14. Take your surgeons apart!

15. Conclusion
There are differences between
countries
hospitals
doctors

16. Message:
Get the data out of your own hospital and show it to your colleagues!

17. Topics to discuss Difference in transfusion rates Risks of blood
The battle of the blood bank
Transfusion triggers
100% compliance to blood transfusion guidelines
Results
Final conclusion

19.  $40.1 billion more charges for txed pts!
Retrospective cohort study of all hospitalisations in the US in 2004 (n=38.66 million) to assess in-hospital outcomes associated with blood transfusion.
5.8% (2.33 million) transfused
After adjustment for age, gender, comorbidities, admission type or DRG transfusion associated with:
1.7 increased odds of death (P<0.0001)
1.9 increased odds of infection (P<0.0001)
2.5 days longer LOS
$17,194 higher charges (P<0.0001)
using Nationwide Inpatient Sample database
 $40.1 billion more charges for txed pts!

20. Agreement Allogenic transfusions?
Mortality
Morbidity
Hospital stay
Infection rates
Wound disturbances

21. Topics to discuss Difference in transfusion rates Risks of blood
The battle of the blood bank
Transfusion triggers
100% compliance to blood transfusion guidelines
Results
Final conclusion

22. Blood Safety Measures – Another Cost Driver
Source: America‘s Blood Centers, 2004

23. Current topic: Age of transfused red blood cells
Reduced levels of 2,3 diphosphoglycerate
Increased oxygen affinity
Shape change
Reduced deformability
Decreased viability
Reduced tissue oxygenation

24. Acknowledgement: Gavin Murphy

25. Topics to discuss Difference in transfusion rates Risks of blood
The battle of the blood bank
Transfusion triggers
100% compliance to blood transfusion guidelines
Results
Final conclusion

26. New national guideline blood transfusions 2011
New national guideline blood transfusions pages medical specialist > 200 residents

27. 100% compliance???
Doctors???????

28. IHI Tool
100% compliance to guideline

29. IHI Tool
Ordering of blood

30. Normal ordering of blood (non acute bleeding patient)
Hemoglobin level
Doctor thinks….
Orders the amount of packed cells!

31. Amphia ordering (non bleeding patient)
Age
Hemoglobin level
Time after surgery (> of <4 hrs)
Cardial or pulmonary problems
Determines the number of packed cells!
Physical barrier:
If the doctor wants anything else than this guideline he has to motivate and call the lab

32. Topics to discuss Difference in transfusion rates Risks of blood
The battle of the blood bank
Transfusion triggers
100% compliance to blood transfusion guidelines
Results
Final conclusion

33. Results:

34. Basic Principle Dutch Guideline
Hb-value is the main trigger for transfusion
No Hemoglobin value, no blood
< 4mmol/l all patients need to be transfused
< 5mmol/l might be better for patients > 60y
< 6mmol/l might be better for patients with a history of cardiac disease

35. Blood transfusions checklist approaches 100% compliance
Year
2010
2011
2012
2013
Number of
red cells
11453
11836
9928
9003
money € € € €
Difference € € €
Inclusive Indirect costs
€1.6 million
Difference %
16.1%
23.9%

36. Blood supply in the Netherlands

37. Number of transfusions /hospital admissions per 1000 inhabitants
Number of transfusions /hospital admissions per 1000 inhabitants. (Netherlands)
Number
Hospital admissions
transfusions
year

38. Benchmark Europa Netherlands 2012
Belgie 47,6 Nederland 32,9
Netherlands 2012
Nederland 2012
Survey 2010 European Directorate for the Quality of Medicines and Health Care

39. Topics to discuss Difference in transfusion rates Risks of blood
The battle of the blood bank
Transfusion triggers
100% compliance to blood transfusion guidelines
Results
Final conclusion

40. 5 drivers to change! Side effects Efficiency, Risks Quality and
Blood supply
Donors
Costs
Risks
Side effects
Efficiency,
Quality and
Patient Safety

41. Request for checklist: robslappendel@hotmail.com