Effectiveness of a real-time clinical decision support system for computerized physician order entry of plasma orders

Information technology improves the quality of transfusion practice in China

BACKGROUND AND OBJECTIVES

Transfusion services in China must establish a quality management system, and regular inspection of quality indicators is an important component of quality management. Although the positive role of information technology in reducing human errors has been widely reported, its role in improving transfusion quality indicators still requires further study. This study explores the role of information technology in improving the quality of transfusion practice.

MATERIALS AND METHODS

We developed an optimized blood transfusion management information system and then analysed the changes in four quality indicators before and after using the system to clarify the role of information technology in improving the quality of transfusion practice.

RESULTS

After using the optimized system, the completeness rate for transfusion request forms increased from 81.5% to 99.3%; an unqualified doctor's signature was the most common incomplete content (0.45%). The appropriate transfusion rate increased from 87% to 99.4%, and red blood cell and frozen plasma utilization in most surgical departments decreased. Although the reporting rate for adverse transfusion reactions increased from 0.22% to 0.49%, these increases might be partly due to changes in transfusion regulations. The adequacy rate of transfusion medical records increased from 74.8% to 90.4%. Overall, the inadequacy of informed consent for transfusion, pre-transfusion laboratory tests and documentation of the transfusion process were reduced from 6.4%, 6.2% and 12.6% to 1.7%, 2.0% and 5.9%, respectively.

CONCLUSION

Information technology can play an important role in improving the quality of transfusion practice, as part of a programme of medical education, regular audit and other measures.

Plasma Transfusion Practice in Adult Surgical Patients: Systematic Review of the Literature

Background

Plasma transfusions are most commonly used therapeutically for bleeding or prophylactically in non-bleeding patients prior to invasive procedures or surgery. Although plasma transfusions generally seem to decline, plasma usage for indications that lack evidence of efficacy prevail.

Summary

There is wide international, interinstitutional, and interindividual variance regarding the compliance with guidelines based on published references, supported by appropriate testing. There is furthermore a profound lack of evidence from randomized controlled trials comparing the effect of plasma transfusion with that of other therapeutic interventions for most indications, including massive bleeding. The expected benefit of a plasma transfusion needs to be balanced carefully against the associated risk of adverse events. In light of the heterogeneous nature of bleeding conditions and their rapid evolvement over time, fibrinogen and factor concentrate therapy, directed at specific phases of coagulation identified by alternative laboratory assays, may offer advantages over conventional blood product ratio-driven resuscitation. However, their outcome benefit has not been demonstrated in well-powered prospective trials. This systematic review will detail the current evidence base for plasma transfusion in adult surgical patients.

Use of fresh-frozen plasma in 2012 at the Fondazione Ca' Granda Hospital of Milan: assessment of appropriateness using record linkage techniques applied to data routinely recorded in various hospital information systems

BACKGROUND

The Quality Unit of a research and teaching hospital in Milan assessed the increased clinical use of fresh-frozen plasma in patients treated during 2012 in order to evaluate the appropriateness of this use.

MATERIALS AND METHODS

For each patient in the study, a pathology profile was generated by means of record linkage techniques involving data collected through different information systems. Patients' information was combined using the patient identifier key generating pathology profiles exported to an Excel file. The profiles were reviewed by two haematologists who identified 101 potentially inappropriate treatments for which the medical records had to be reviewed manually.

RESULTS

In 2012, 490 patients were transfused and for 473 cases the automatic record linkage provided a complete profile. The information relating to the remaining patients did not match, mainly because the patients underwent outpatient procedures for which clinical information is not automatically recorded. In the overall audit only 13 treatments were judged inappropriate.

DISCUSSION

Our study supports the view that record linkage techniques applied to data routinely recorded in different hospital information systems could be potentially extended to support clinical audits, enabling the generation of automated patient profiles that can be easily evaluated, relegating manual checks on medical records to doubtful cases only. Moreover, the method applied in this study allows the analysis of a full set of cases instead of sample surveys, increasing the robustness of the audit results.

Changes in plasma unit distributions to hospitals over a 10-year period

BACKGROUND

There are many influences on a hospital's demand for plasma. Pharmaceuticals are now being administered for many indications instead of plasma, although trauma resuscitation now emphasizes increased and early intervention with plasma. This multinational study evaluated changes in blood center plasma unit distributions over a 10-year period.

STUDY DESIGN AND METHODS

Data on the total number and the ABO groups of plasma unit distributions were obtained from nine American blood collectors (ABCs) and nine national or provincial blood services (NPBS) from 2007 through 2016. Plasma distributions to trauma hospitals by five ABCs and four NPBS were also analyzed.

RESULTS

The overall number of plasma unit distributions from ABCs decreased by 23.1% from 2007 to 2016, but the relative proportion of distributed AB plasma units increased during the same period. The NPBS (excluding the Japanese Red Cross [JRC]) also had a 35.4% decrease in the overall number of plasma unit distributions with an increase in the relative proportion of AB plasma distributions between 2007 and 2016. The JRC, however, reported an increase in the overall number of plasma distributions by 13.5% in 2016 compared to 2007. The proportion of low-titer A plasma distributions increased to 1.6% of total plasma distributions by ABCs in 2016. There was a trend of distributing increasing proportions of group AB plasma units to trauma hospitals over the 10-year period.

CONCLUSION

Although the number of plasma unit distributions has decreased at many blood collectors over time, the proportion of AB units has increased at both ABCs and NPBS.

Implementing a Health System-wide Patient Blood Management Program with a Clinical Community Approach

BACKGROUND

Patient blood management programs are gaining popularity as quality improvement and patient safety initiatives, but methods for implementing such programs across multihospital health systems are not well understood. Having recently incorporated a patient blood management program across our health system using a clinical community approach, we describe our methods and results.

METHODS

We formed the Johns Hopkins Health System blood management clinical community to reduce transfusion overuse across five hospitals. This physician-led, multidisciplinary, collaborative, quality-improvement team (the clinical community) worked to implement best practices for patient blood management, which we describe in detail. Changes in blood utilization and blood acquisition costs were compared for the pre- and post-patient blood management time periods.

RESULTS

Across the health system, multiunit erythrocyte transfusion orders decreased from 39.7 to 20.2% (by 49%; P < 0.0001). The percentage of patients transfused decreased for erythrocytes from 11.3 to 10.4%, for plasma from 2.9 to 2.2%, and for platelets from 3.1 to 2.7%, (P < 0.0001 for all three). The number of units transfused per 1,000 patients decreased for erythrocytes from 455 to 365 (by 19.8%; P < 0.0001), for plasma from 175 to 107 (by 38.9%; P = 0.0002), and for platelets from 167 to 141 (by 15.6%; P = 0.04). Blood acquisition cost savings were $2,120,273/yr, an approximate 400% return on investment for our patient blood management efforts.

CONCLUSIONS

Implementing a health system-wide patient blood management program by using a clinical community approach substantially reduced blood utilization and blood acquisition costs.

Real-Time Clinical Decision Support Decreases Inappropriate Plasma Transfusion

OBJECTIVES

To curtail inappropriate plasma transfusions, we instituted clinical decision support as an alert upon order entry if the patient's recent international normalized ratio (INR) was 1.7 or less.

METHODS

The alert was suppressed for massive transfusion and within operative or apheresis settings. The plasma order was automatically removed upon alert acceptance while clinical exception reasons allowed for continued transfusion. Alert impact was studied comparing a 7-month control period with a 4-month intervention period.

RESULTS

Monthly plasma utilization decreased 17.4%, from a mean ± SD of 3.40 ± 0.48 to 2.82 ± 0.6 plasma units per hundred patient days (95% confidence interval [CI] of difference, -0.1 to 1.3). Plasma transfused below an INR of 1.7 or less decreased from 47.6% to 41.6% (P = .0002; odds ratio, 0.78; 95% CI, 0.69-0.89). The alert recommendation was accepted 33% of the time while clinical exceptions were chosen in the remaining cases (active bleeding, 31%; other clinical indication, 33%; and apheresis, 2%). Alert acceptance rate varied significantly among different provider specialties.

CONCLUSIONS

Clinical decision support can help curtail inappropriate plasma use but needs to be part of a comprehensive strategy including audit and feedback for comprehensive, long-term changes.

Personalization and Patient Involvement in Decision Support Systems: Current Trends

OBJECTIVES

This survey aims at highlighting the latest trends (2012-2014) on the development, use, and evaluation of Information and Communication Technologies (ICT) based decision support systems (DSSs) in medicine, with a particular focus on patient-centered and personalized care.

METHODS

We considered papers published on scientific journals, by querying PubMed and Web of ScienceTM. Included studies focused on the implementation or evaluation of ICT-based tools used in clinical practice. A separate search was performed on computerized physician order entry systems (CPOEs), since they are increasingly embedding patient-tailored decision support.

RESULTS

We found 73 papers on DSSs (53 on specific ICT tools) and 72 papers on CPOEs. Although decision support through the delivery of recommendations is frequent (28/53 papers), our review highlighted also DSSs only based on efficient information presentation (25/53). Patient participation in making decisions is still limited (9/53), and mostly focused on risk communication. The most represented medical area is cancer (12%). Policy makers are beginning to be included among stakeholders (6/73), but integration with hospital information systems is still low. Concerning knowledge representation/management issues, we identified a trend towards building inference engines on top of standard data models. Most of the tools (57%) underwent a formal assessment study, even if half of them aimed at evaluating usability and not effectiveness.

CONCLUSIONS

Overall, we have noticed interesting evolutions of medical DSSs to improve communication with the patient, consider the economic and organizational impact, and use standard models for knowledge representation. However, systems focusing on patient-centered care still do not seem to be available at large.

Massive Transfusion Protocol: Communication Ordering Practice Survey (MTP COPS)

OBJECTIVES

We sought to assess ordering practices and quality of communication during massive transfusion at US level I trauma centers.

METHODS

An anonymous, web-based survey was distributed to blood banks supporting US level I trauma centers. Information gathered in the survey included demographics, utilization of and perceived level of support for computerized physician order entry (CPOE), frequency of order confusion, and nonprotocol ordering. Responses were analyzed using descriptive statistics.

RESULTS

Responses were received from 43 of 121 centers (35.5% response rate), with the majority completed by blood bank physicians (67.4%) and blood bank supervisors (25.6%). Allowable pathways for massive transfusion protocol (MTP) ordering included CPOE (48.8%), verbal/telephone (86.1%), and written (44.2%). The preferred method of MTP activation was verbal/telephone (86.1%). Initial activation of MTP was well communicated (97.6% agreement), but confusion associated with ongoing needs was reported to occur at least sometimes by 32.6%.

CONCLUSIONS

Although CPOE-based MTP ordering is offered by nearly half of US level I trauma centers, verbal/telephone ordering is by far the preferred mechanism. Our survey identifies confusion surrounding blood component needs during MTP resuscitation as an opportunity for practice improvement.

Is there a "magic" hemoglobin number? Clinical decision support promoting restrictive blood transfusion practices

Blood transfusion has been identified as one of the most frequently performed therapeutic procedures, with a significant percentage of transfusions identified to be inappropriate. Recent key clinical trials in adults have provided Level 1 evidence to support restrictive red blood cell (RBC) transfusion practices. However, some advocates have attempted to identify a "correct" Hb threshold for RBC transfusion; whereas others assert that management of anemia, including transfusion decisions, must take into account clinical patient variables, rather than simply one diagnostic laboratory test. The heterogeneity of guidelines for blood transfusion by a number of medical societies reflects this controversy. Clinical decision support (CDS) uses a Hb threshold number in a smart Best Practices Alert (BPA) upon physician order, to trigger a concurrent utilization self-review for whether blood transfusion therapy is appropriate. This review summarizes Level 1 evidence in seven key clinical trials in adults that support restrictive transfusion practices, along strategies made possible by CDS that have demonstrated value in improving blood utilization by promoting restrictive transfusion practices.

Pathologists as Stewards of Laboratory Information

Just as electronic health records are transforming the practice of medicine and health care information management, practicing in the era of the electronic health record offers opportunities, if not imperatives, for pathologists to take on new and “transformative” professional and leadership roles for the organizations they serve. Experience indicates that clinicians will perceive pathologists and laboratories as responsible for all aspects of laboratory testing and information management, including order entry and results reporting, even though such functions may fall beyond the control of the laboratory. As described and expanded upon in the previous 4 articles of this series, the use of electronic health records dictates changes in how clinicians interact with laboratory information. In this environment, pathologists are uniquely positioned to act as the stewards for laboratory information in electronic health records and throughout health care organizations.

Cytokines and clinical predictors in distinguishing pulmonary transfusion reactions

BACKGROUND

Pulmonary transfusion reactions are important complications of blood transfusion, yet differentiating these clinical syndromes is diagnostically challenging. We hypothesized that biologic markers of inflammation could be used in conjunction with clinical predictors to distinguish transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), and possible TRALI.

STUDY DESIGN AND METHODS

In a nested case-control study performed at the University of California at San Francisco and Mayo Clinic, Rochester, we evaluated clinical data and blood samples drawn before and after transfusion in patients with TRALI (n = 70), possible TRALI (n = 48), TACO (n = 29), and controls (n = 147). Cytokines measured included granulocyte-macrophage-colony-stimulating factor, interleukin (IL)-6, IL-8, IL-10, and tumor necrosis factor-α. Logistic regression and receiver operating characteristics curve analyses were used to determine the accuracy of clinical predictors and laboratory markers in differentiating TACO, TRALI, and possible TRALI.

RESULTS

Before and after transfusion, IL-6 and IL-8 were elevated in patients with TRALI and possible TRALI relative to controls, and IL-10 was elevated in patients with TACO and possible TRALI relative to that of TRALI and controls. For all pulmonary transfusion reactions, the combination of clinical variables and cytokine measurements displayed optimal diagnostic performance, and the model comparing TACO and TRALI correctly classified 92% of cases relative to expert panel diagnoses.

CONCLUSIONS

Before transfusion, there is evidence of systemic inflammation in patients who develop TRALI and possible TRALI but not TACO. A predictive model incorporating readily available clinical and cytokine data effectively differentiated transfusion-related respiratory complications such as TRALI and TACO.

Efficacy of education followed by computerized provider order entry with clinician decision support to reduce red blood cell utilization

BACKGROUND

Two necessary components of a patient blood management program are education regarding evidence-based transfusion guidelines and computerized provider order entry (CPOE) with clinician decision support (CDS). This study examines changes in red blood cell (RBC) utilization associated with each of these two interventions.

STUDY DESIGN AND METHODS

We reviewed 5 years of blood utilization data (2009-2013) for 70,118 surgical patients from 10 different specialty services at a tertiary care academic medical center. Three distinct periods were compared: 1) before blood management, 2) education alone, and 3) education plus CPOE. Changes in RBC unit utilization were assessed over the three periods stratified by surgical service. Cost savings were estimated based on RBC acquisition costs.

RESULTS

For all surgical services combined, RBC utilization decreased by 16.4% with education alone (p = 0.001) and then changed very little (2.5% increase) after subsequent addition of CPOE (p = 0.64). When we compared the period of education plus CPOE to the pre-blood management period, the overall decrease was 14.3% (p = 0.008; 2102 fewer RBC units/year, or a cost avoidance of $462,440/year). Services with the highest massive transfusion rates (≥10 RBC units) exhibited the least reduction in RBC utilization.

CONCLUSIONS

Adding CPOE with CDS after a successful education effort to promote evidence-based transfusion practice did not further reduce RBC utilization. These findings suggest that education is an important and effective component of a patient blood management program and that CPOE algorithms may serve to maintain compliance with evidence-based transfusion guidelines.

The next chapter in patient blood management: real-time clinical decision support

OBJECTIVES

Blood transfusion was identified by the American Medical Association as one of the top five most frequently overused therapies. Utilization review has been required by accreditation agencies, but retrospective review has been ineffective due to labor-intense resources applied to only a sampling of transfusion events. Electronic medical records have allowed clinical decision support (CDS) to occur via a best practices alert at the critical decision point concurrently with physician order entry.

METHODS

We review emerging strategies for improving blood utilization.

RESULTS

Implementation of CDS at our institution decreased the percentage of transfusions in patients with a hemoglobin level of more than 8 g/dL from 60% to less than 30%. Annual RBC transfusions were reduced by 24%, despite concurrent increases in patient discharge volumes and case mix complexity. This resulted in acquisition costs savings (direct blood product purchase costs) of $6.4 million over 4 years.

CONCLUSIONS

We have been able to significantly reduce inappropriate blood transfusions and related costs through an educational initiative coupled with real-time CDS. In deriving increased value out of health care, CDS can be applied to a number of overuse measures in laboratory testing, radiology, and therapy such as antibiotics, as outlined by the American Board of Internal Medicine's Choosing Wisely campaign.

Can automated alerts within computerized physician order entry improve compliance with laboratory practice guidelines for ordering Pap tests?

BACKGROUND

The electronic health record (EHR) provides opportunity to improve health and enhance appropriate test utilization through decision support. Electronic alerts in the order entry system can guide test use. Few published reports have assessed the impact of automated alerts on compliance of Pap ordering with published screening guidelines.

METHODS

Programming rules for Pap test ordering were developed within the EHR (Epic, Madison, WI) of the University of California, Davis Health System using American College of Obstetrics and Gynecology's 2009 guidelines and implemented in primary care clinics in 2010. Alerts discouraged Pap orders in women <21 and >71 years and displayed when an order was initiated. Providers were not prevented from placing an order. Results were measured during four calendar periods: (1) pre-alert (baseline) (July 2010 to June 2011), (2) post alert (alerts on) (July 2011 to December 2011), (3) inadvertent alert turn-off ("glitch") (January 2012 to December 2012), (5) post-glitch (alerts re-instated) (1/2013-7/2013). Metrics used to measure alert impact were between time and period seasonally adjusted relative frequency ratios.

RESULTS

Alerts were most effective in the <21 year old age group. During the baseline period 2.7 Pap tests were order in patients less than age 21 for every 100 Paps in those 21-71 years of age. This relative frequency decreased to 1.7 in the post-alert period and 1.4 during the glitch, with an even greater decline to 0.8 post-glitch when alerts were reinstated. Less impact was observed in the >70 year old group where the baseline relative frequency was 2.4 and declined to 2.1 post-alert, remained stable at 2.0 during the glitch period, and declined again to 1.7 post-glitch when alerts were reinstated. This likely reflects inclusion of women with a history of abnormal Pap tests for whom continued Pap testing is indicated, as well as reluctance by providers and patients to accept discontinuation of Pap testing for women with a history of normal Pap results. In both age groups, decreases in ordering were greatest when the alerts were functioning, indicating that the alerts had an effect beyond the influences of the environment.

CONCLUSIONS

Discouraging alerts can impact ordering of Pap tests and improve compliance with established guidelines, thus avoiding unnecessary follow-up tests that can create potential patient harm and unnecessary expense. Alerts represent a potential model to address utilization of other lab tests. Longer study intervals are necessary to determine if provider compliance is maintained.

Trends in RBC ordering and use after implementing adaptive alerts in the electronic computerized physician order entry system

OBJECTIVES

To reduce unnecessary RBC transfusions, the computerized physician order entry (CPOE) system was programmed to require prescribers to select an indication for transfusion. An alert appeared if the patient's hemoglobin (Hb) level was above the threshold determined by the selected indication (adaptive alerts).

METHODS

Data on RBC orders from the 4 months before the adaptive alerts were implemented were compared with the 10 months after implementation.

RESULTS

Significantly fewer alerts were generated after the implementation, and the rate at which the alerts were heeded also increased. There was a trend toward fewer RBC units transfused after adaptive alert implementation. A large number of RBCs were ordered using a nonspecific transfusion indication, although many of these patients had antecedent Hb values close to the threshold.

CONCLUSIONS

Electronically generated alerts can reduce but are insufficient to eliminate non-evidence-based transfusions. Analysis of the alerts suggests areas for CPOE improvement.