Clinical Use of Blood The AIM II Trial

Sue CottonBlood Stocks Management Scheme

27/01/12

Dynamic Blood, East Midlands RTC Conference.

Presentation

Setting the SceneInventory ManagementAIM II what is it?Trial of AIM IIBenefits of AIM IISummary

Setting the Scene

Blood transfusion is an essential part of modern health care.Goodwill of voluntary donorsSupply must meet demandDemand is difficult to predictIt would be great to have detailed intelligence on where blood goes

How can we find out how blood is being used at the moment?

Only by time consuming retrospective studies or prospective auditOr by asking transfusion teams for information

Blood Stocks Management Scheme

Intelligence on blood inventory management gathered from across the blood supply chain.Stock and wastage levels of red cells Wastage levels of plateletsBenchmarkingTransparency of data Significant improvements in inventory management

Appropriate Inventory Management(AIM) Overview

Phase I (Module1)BSMS source code provided by NHSBTCollaboration between NHSBT/ America s Blood Centers (ABC)American name: AIM I (Appropriate Inventory Management Module I)

Phase II (Module 2)Allows for vein to vein monitoring of blood components from donation to the patient at the hospitalBlood utilisation management requires patient level transfusion data in order to determine meaningful and appropriate use

Goals for AIM

Create an inclusive approach to blood management by aligning supply with demand to ensure patient transfusion needs are metAssist hospitals in complying with metric driven standardsAIM is used to reduce the overall cost of blood by tracking Key Performance Indicators (KPIs):

Reduce unnecessary transfusion by providing reports with national (and international) benchmarking to reveal evidence based best practice

Red Cell Demand in England & N Wales

2.22 1.93

-4.36%

2.02

-5.88%

2.14

-1.40%

2.17

-0.90%

2.19

-1.21%

1.87

-2.88%

1.60

1.70

1.80

1.90

2.00

2.10

2.20

2.30

2000\01 2001\02 2002\03 2003\04 2004\05 2005\06 2006/07

Mill

ion

red

cel

l un

its

1.83

-2.4%

2007/08 2008/09

1.02%

1.86 1.87

0.3%

2009/10

-1.4%

2010/11

1.84

0.0%

2.4% -0.6% 0.8% -1.4% 0.5%

212

216

220

224

228

232

2001

/02

2002

/03

2003

/04

2004

/05

2005

/06

2006

/07

2007

/08

Issu

es 0

00

236

244

2008

/09

3.7%

2009

/10

4.0%

Platelet Demand in England & N. Wales

2010

/11

240

3.7%

AIM: Distr ibution of Transfused Patients by Age Group, Gender

Global Red Cell Utilization Rates: 2008-09

Source: D Devine et al.: International Forum/Inventory Management, Vox Sanguinis 2009

Analysis and reports

PAS coded data related to transfusion episode (ICD 10

diagnosis code, OPCS4 procedure code)

Data mining software extracts relevant data (no patient identifiable features)

Datawarehouse hosted by ABC (in trial)

PAS data related to length of stay, consultant,

specialty

LIMS data related to transfusion episode

Hospitals extract data around the transfusion episode from hospital databases and send to a data warehouse. Data can be used to generate reports for both blood providers and blood users.

AIM II The need for data

Dictionary of data elementsrequired provided to hospital.

Transfusion yes or no?Patient ID (encrypted)

Date of admission and dischargeYear of birth

GenderHealthcare Resource Group (HRG)

Date and time of transfusionTransfused component

Pre transfusion lab test resultDonation number and product code

Expiry date

Mortality FlagOrdering physician

Directorate

Trial of AIM II in England

Evaluate the AIM II system functionality, assessing the feasibility of using system to collect information on blood usageTrial in collaboration with 4 hospitalsPresent overview of system to hospital teams to enable them to understand the resources and IT capability required.Work with hospitals to establish data extraction routines Hospitals send data to data warehouseBenchmarking reports provided to hospitals

AIM II -Benchmarking

Benchmarking based upon clinical categories the user chooses

Randomized clinical tr ial designed to test the hypothesis that higher blood transfusion threshold improves functional recovery and reduces morbidity and mortality.

Outcome of this tr ial targets a more conservative 8.0g/dL transfusion tr igger .

Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair (FOCUS) Tr ial

Comparison of use of red cells in primary hip replacement

0

10

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Hospital 1 Hospital 2 Hospital 3 Hospital 4

Per

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tag

e o

f p

atie

nts

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nsf

use

d

This hospital has:a pre op anaemia

management pathwayuses IV tranexamic

acid to cover surgery has a strict post op

transfusion trigger

Figure 1. Observed Variation in Hospital-Specific Transfusion Rates for Primary Isolated CABG Surgery With Cardiopulmonary Bypass During 2008 (N = 798 Sites)

Bennett-Guerrero, E. et al. JAMA 2010;304:1568-1575

Blood and blood component use in coronary artery bypass surgery

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100

Hospital 1 Hospital 2 Hospital 3 Hospital 4

Per

cen

tag

e tr

ansf

use

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pat

ien

ts Red cells

FFP

platelets

This hospital has: Pre op anaemia management

pathwayUses IV tranexamic acidUses TEG to guide coagulopathy

treatmentHas strict post operative

transfusion trigger

Controversies in RBC Transfusion in the Critically Ill, Paul C. Hebert, et al April, 2007 (Abstract)

Transfusion Requirements in Cr itically Ill (TRICC)

Outcome:in the absence of bleeding, this group

recommended 7.0g/dL as the hemoglobin trigger for best patient outcome.

Red cell transfusion on ICU

0%

10%

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60%

70%

80%

90%

100%

Hospital 1 Hospital 2 Hospital 3 Hospital 4

Per

cen

tag

e tr

ansf

use

d

Hb>10

Hb 9-10

Hb 8-9

Hb 7-8

Hb < 7

This hospital has a strict transfusion trigger of Hb < 7g/dl

Which patients are receiving platelets in my hospital? (By HRG chapter)

0

10

20

30

40

50

60

Nervo

us System

Eyes a

nd Perio

rbita

Mouth H

ead Neck a

nd Ears

Respira

tory

System

Cardia

c Surg

ery a

nd Prim

ary C

ardiac C

...

Digestive S

ystem

Hepato

biliary

and Pancre

atic S

ystem

Musculoskeletal S

ystem

Skin, Bre

ast and B

urns

Endocrine a

nd Metabolic

System

Urinary

Tract

and Male

Reproductiv

e S...

Female Repro

ductive S

yste

m and Assis

t..

Obstetrics

Diseases of C

hildhood

and N

eonates

Vascular

System

Radiolo

gy and N

uclear Medicine

Haem

atology, C

hemoth

erap

y, Rad

iothe...

Undefined G

roups

Multiple

Traum

a, Emerg

ency Medicine a

..

Immunology, In

fectious D

iseases a

nd ot...

Critical C

are and H

igh Cost D

rugs

Per

cen

tag

e tr

ansf

use

d

Platelet use in haematology patients: stable patients with myelodysplasia

0%

10%

20%

30%

40%

50%

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70%

80%

90%

100%

Hospital 1 Hospital 2 Hospital 3 Hospital 4

Per

cen

tag

e p

atie

nts

tr

ansf

use

d

Plts >20

Plts 10-20

Plts <10

This hospital has a strict transfusion trigger of < 10 x 109/l for plateletsIt is possible to drill down to identify the cases where transfusion occurred with a platelet count above this

Examples of Future analysis

Percentage of transfusion of non-apheresis platelets to children under 16 yearsPercentage of children born after 1996 given standard FFPPost cardiac surgery outcome related to age of bloodUse of FFP to reverse warfarinTotal number of units (and donor exposures) transfused to individual patientsComparison of use for the same procedure by consultant

Future developments:Recording the clinical reason for blood use

The tool would become much more powerful if there could be a field in LIMS with a coded reason for clinical useThe code would come from a standardised menu and would be selected by the person requesting the transfusion (ideally by electronic order comms)Currently there is an assumption that the HRG is the reason for transfusion this is less accurate for medical reasons for transfusion

Potential Benefits of AIM IIBetter understanding of where and why blood and blood components are being used.

Hospitals and physicians will have benchmarking data to support appropriate use initiatives.

Hospitals wanting to utilise benchmarking have been hindered by limited data or lack of comparative data.At individual hospital level will be able to establish baseline performance and how it compares to regional / national / international peersStarting point for interhospital collaborations to identify best practice that could be implemented in other hospitals.

Potential Benefits of AIM II

NHSBT will benefit as knowledge of clinical use will inform strategic planning

Ensure sufficiency of supplyMaintain appropriate inventory levels to ensure supply meets demandInformation to evaluate safety decisionsSupport emergency planning

Summary

AIM II has the potential to assist hospitals and physicians together with NHSBT to better manage and use the available blood supply.Potential for local, regional, national and international benchmarking

Further development will depend on the outcome of the current trial

Acknowledgements

Trial hospitals AIM II Project TeamAmericas Blood Centers

Thank you for listening