ADDENDA Mar 23, 2005

6. A transfusion medicine physician in Florida is attempting to develop an alternative/supplement to retrospective transfusion review that is based on identifying transfusion events that fall outside of a defined audit "trigger". To this end, his hospital has used historical internal data to develop benchmarks by medical specialty and DRG regarding both the frequency of patients receiving transfusion within that DRG and the number of components received by the patients who require transfusion. They are now starting to monitor deviations from their internal benchmarks to see if they can detect changes in utilization that may require investigation and explanation. They are also looking at individual physician usage against the internal benchmark as well, although meaningful data is more difficult since a single patient could skew a physician's profile for a DRG. He is interested in whether anyone else is utilizing a similar approach, and what their experience might be. They are also looking for "external" benchmarks from demographically comparable facilities that we might be able to compare themselves against, in addition to the internal benchmarks that they have established. He wonders if anyone has developed similar benchmarks that they might be willing to share?

ADDENDA Mar 29, 2005

7. A colleague in New Mexico reports that her institution does 100% prospective review for transfusion of RBCs, Platelets, Plasma, Cryoprecipitate, Factors 7, 8 & 9, WinRho and AT3. They have very good compliance and rarely have to question an order as the physicians have become accustomed to the criteria (and sometimes know how to skirt the criteria). Her medical technologists look up the appropriate lab data whenever they receive an order for transfusion. If additional information is needed they call the patient care area, getting a pathologist involved as necessary. She has graciously provided their prospective review criteria.

ADDENDA Apr 6, 2005

8. A general pathologist who practices in a small community hospital (100+ beds) reports that he has been trying to set up a meaningful system of blood usage review for many years. He believes that establishing review criteria is not the problem, but that the actual review process in many institutions is flawed because physicians who order blood transfusions are often not the individuals who report why the blood orders were written. He comments that until a review system digs down to the level of whether a physician him/herself actually provided the reasons for why a blood product was ordered, there will be room for miscommunication and misdirection, etc. For example, his hospital developed a computerized blood order system that does not transmit a blood order unless an 'approved' indication was selected. This resulted in doctors yelling at the unit secretaries that they didn't care what 'reason' (interesting choice of words) was used, "just get the blood". The unit secretaries started entering into the computer whatever they or the nurse thought was a fitting indication for the blood order. Initially, the laboratory had no idea this was happening. Now the laboratory is trying to get support from a peer review committee for a new system that utilizes a retrospective checklist that the physician must complete in order for the medical record to be considered complete (which already has a system of enforcement with teeth in place). Although this is retrospective (e.g. "yes, I did conduct informed consent, here are the indications, and there was improvement in the patient's condition"), it does bring the matter directly in front of the physician 100% of the time and educates him/her on what the approved indications are. They must choose whether to be honest or not, knowing that there may be a review of the medical record later. A similar system could be used up front if they had an electronic medical record in which the physician had to enter the order him/herself, but currently they do not.

ADDENDA October 12, 2008

9. A colleague who works at a blood collection center in Colorado would like to know what other collection centers and/or transfusion services are doing to establish benchmarks to assess the necessity of high-volume component orders for specific patients, especially when such orders impact on the availability of blood products for other patients . For example, recently, at the inquiring colleague's blood collection center they had a situation where a patient’s physician was requesting an extremely high number of apheresis platelets from the Blood Center’s inventory. These orders made it nearly impossible for the blood collection center to fill orders for other hospitals (and therefore for other patients) and no tool or benchmark was currently in place to assist the distribution department in knowing whether this high-volume order should trigger blood collection center medical staff to investigate the medical necessity of the order. The inquiring colleague is trying to learn whether any other facilities have guidelines in place whereby a medical director of a blood collection center will call an ordering physician to discuss whether a high-volume set of orders is medically necessary.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator