1. 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

2. 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 TarragoChildren’s Hospital Minnesota David RichNationwide Children’s Hospital David KaelberMetrohealth, Case Western Marissa Tucci CHU Sainte-Justine Research Center

3. 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.

4. 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

5. 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?

6. Red blood cell transfusions alter immune function Increased infection Suppressed immune function Altered cytokine profile Depletion of WBC.

7. 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

8. 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

9. Clinical Decision Support and Computerized Physician Order Entry (CPOE) Augments Adherence to Evidence Based Guidelines. Improved adherence to evidence based guidelines CPOE with decision support Medication safety Utilization of radiography RBC utilization in pediatric/adult patients Kawamoto BMJ 2005

10. Study Design

11. Decision Support Window

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

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

14. In the PICU, CPOE Decreased Blood Transfusions Per Patient Day

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

16. Overall transfusions per patient day

17. The relative risk of transfusion in the study population versus control

18. 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.

19. CRIT Website CRIT.stanford.edu Meeting updates Progress on data collection Download CDS tool Background data

20. Implementation InstitutionEMR Vendor ImplementedInvestigatingData Analysis Children’s Hospital Orange County Children’s Hospital of Michigan Children’s Hospital Boston Lucile Packard Children’s HospitalCerner 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

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