In the United States alone, blood transfusions represent billions of dollars of healthcare costs with approximately twenty one million units of blood components transfused each year.1, 2 Obtaining compensation for components and transfusions continues to be a struggle as reimbursement rates are declining.3, 4 Moreover, pay for performance issues and the cost associated with poor outcomes related to the transfusion can be financially crippling. Patient blood management (PBM) is an evidence based approach designed to improve costs for healthcare organizations, stewardship of blood components, and outcomes for all patients in which the use of blood components might be considered. PBM programs are complex and multifaceted, as patients in this population frequently transition care through numerous settings and healthcare professionals. Together, PBM teams aim toward establishing organizational guidelines and resources to assist healthcare professionals in providing best practice methodologies that fit each patient’s unique needs. However, despite arduous efforts, complexities in healthcare can hinder a patient’s journey through the health care continuum and lead to serious adverse outcomes. Therefore, implementing strategic initiatives targeting the challenges surrounding transitional care is imperative for an effective and comprehensive PBM program.
Studies show that ineffective care transition can lead to increases in adverse events, readmission rates, and costs.5 The transfusion patient population is no exception. Patients who receive transfusions require movement between healthcare providers and settings as their conditions and needs change during the course of their treatment plan resulting in numerous opportunities for communication errors, missed diagnoses, etc. While there is no argument that blood saves lives, it is now widely known that blood transfusions do not come without serious risk to the patient. In combined fiscal years 2010-2014, regarding transfusions, transfusion related acute lung injury (TRALI) caused the highest number of reported fatalities (41%).6 Transfusion associated circulatory overload (TACO) and hemolytic transfusion reactions (HTR) due to non-ABO and ABO incompatibilities accounted for 22% and 21% of fatalities respectively.6 Astonishingly, researchers state up to 55% of TRALI incidences are missed/not diagnosed, indicating that the FDA reports are likely to be highly underreported.7 This may very well be the result of challenges with transitions of care. For example, studies show that delayed TRALI is common, often times occurring 6-72 hours after a transfusion in up to 25% of critically ill patients. What’s more, nearly 50% of all blood transfusions occur in the perioperative arena, and of these patients who experience TACO, approximately 70% will do so outside of the surgical setting. 8,9,10 The transfusing healthcare provider may no longer be the provider caring for and monitoring the patient. In fact, the receiving nurse may not even be aware the patient had a transfusion. Many healthcare personnel are simply not thinking of potential transfusion reactions 6-72 hours post transfusion.
The risks do not end with TRALI and TACO though. Consider PBM in the realm of trauma patients or patients with chronic anemia and its underlying etiologies. Some patients require numerous trips to outpatient settings for iron or erythropoietin therapy, transfusions, etc. Others are transferred to step down units or extended rehab facilities before returning home. As a result, PBM programs must encompass much more than blood utilization. Therefore, typical current PBM interventions include a much needed team approach, and the transfusion safety committee (TSC), with the lead of the transfusion safety officer (TSO), attempts to take the reins on this monstrous endeavor, monitoring inappropriate ordering, miscommunication between lab and nursing, supply shortages, inappropriate labeling of samples, misidentification of patient (two person bedside ID), etc.11 The TSO is typically a registered nurse or a laboratory scientist ( Med Tech), often without formal TSO training and often without a full time equivalent (FTE), whose role is to liaison between nursing, MDs, administration, etc. in the attempt to coordinate PBM initiatives. The TSO is charged with the responsibility for improving the process of transfusion care both inside and outside the laboratory, and his/her role overall is dedicated to the quality of the blood component and the patient’s outcomes. However, it is unrealistic to expect the TSO to be an expert in all areas of care. While oversight of the entire program is essential, a specialty expert(s) for varying services, who is also an expert in change management, patient care, education, and research is needed to implement the overarching initiatives deep into the crevices of the varying service areas. He/she needs an expert in various areas to oversee needed change initiatives specific to improving outcomes for blood management patients in given specialty populations, such as renal, cancer, perioperative, trauma, obstetric, etc. The clinical nurse specialist (CNS) is academically and experientially prepared to do just that; therefore, strategically networking and incorporating the expertise of CNSs into the PBM program can greatly improve outcomes.
The CNS is “an advanced practice registered nurse (APRNs) with graduate degrees, at the master’s and/or doctoral level in a specialty.” “They are leaders of a team in acute care and other facilities to improve the quality and safety of care, developers of programs to prevent avoidable complications, coaches of those with chronic diseases to prevent hospital readmissions, and researchers seeking evidence-based interventions to improve the outcomes of care”12. CNSs have demonstrated effectiveness in their ability to improve transition of care, reduce hospital acquired conditions by guiding interdisciplinary clinical teams with evidence based interventions, educating and mentoring nurses, improving access to community-based care, and developing programs to increase availability of effective care for those with chronic illness as well as for preventative care. 13-29 When utilized to their fullest extent of education and training, as recommended by the Institute of Medicine in their report on the Future of Nursing, CNSs have great influence in directing successful transition of care initiatives.30
In 2012 the Joint Commission (JC) began a three-year initiative to improve transition of care. This initiative included “defining methods for achieving improvement in the effectiveness of the transition of patients between health care organizations, which provide for the continuation of safe, quality care for patients in all settings.”5 JC defines “transitions of care” as the “…movement of patients between healthcare practitioners, settings, and home as their condition and care needs change”, and identifies issues related to poor transition of care such as communication, education, and accountability breakdowns. The introduction of evidence based care transition models such as the one illustrated in figure 2 are encouraged as a solution to the problem.32 The National Guidelines Clearinghouse expounds on evidence based transition of care models with emphasis on scope of diseases/patient conditions such as cardiovascular, orthopedics, endocrine, etc.31 Patients at risk for needing a transfusion can fall into any of these groups; therefore, the CNS should assist the TSO to bridge these initiatives, cross them over, and imbed them into an organization’s PBM program.
“Of the AABB member facilities responding to the 2013 AABB Blood Collection, Utilization, and Patient Blood Management Survey, more than half report implementing aspects of patient blood management into their transfusion practice, with more than 1/3 (37.8%) having a PBM program and nearly 1/4 having implemented five or more PBM interventions”, such as independent electronic medical records (EMR), and/or Centers for Medicare/Medicaid (CMS) and insurance regulations.33, 34 Interestingly, of those who did report having some form of a PBM program, only 27% reported nursing staff involvement. Additionally, only 42% and 39.6% of physicians and nurses are provided transfusion training/education, respectively.34Further inconsistencies such as recommended utilization of guidelines, computerized physician order entry (CPOE) systems, anemia management programs, or even the utilization of a TSO demonstrates how lack of practice consensus, communication barriers, and struggles with care transitions are major issues.
The literature abounds with recommendations supporting improvement in care coordination. In fact, the Joint Commission requires organizations to govern interventions aimed at improving the clinical process related to blood management. An article from the American Society of Hematology summarizes the requirements well: “Regulatory agencies and accrediting organizations require healthcare institutions to review blood transfusion practices and adverse outcomes, but do not specifically require that an institution assign a committee to accomplish that function. The Code of Federal Regulations (CFR) requires a hospital to develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QA/PI) program that reflects the complexity of the hospital’s organization and services, involves all hospital departments and services (including those services furnished under contract or arrangement), focuses provider efforts to improve health outcomes, and prevents adverse events including medical errors. Failure to do so jeopardizes payments from the Centers for Medicare and Medicaid Services program (CMS, formerly the Health Care Financing Administration).”35 While monetary stewardship is an important program driver, patient outcomes are always of utmost importance, and the CNS can play an integral role in expediting the aforementioned goals into fruition:
Suggested initial steps to incorporate the skill sets/expertise of the CNS in a PBM program
- Utilize CNSs to the full scope of the education and training
- Include service specific CNSs in the TSC (or at least one CNS to represent all CNSs for a given organization)/Use a CNS as a TSO
- Incorporate population specific transition care models into your organization and bridge them with the PBM program
- Set up care transition metrics for varying patient populations related to PBM
In summary, as healthcare providers work diligently toward improving patient care in a myriad of specialties and subspecialties, it can be difficult to merge initiatives. While the need for improvement in the transitioning of care for the patient blood management programs is easy to see, pulling together the interventions to ensure it occurs in an efficient, effective, and sustainable manner can be difficult. The CNS can be an invaluable resource in bridging these concepts, advancing the practice of nursing and patient outcomes, while collaborating with physicians and administrators to ensure organization and system wide goals are met.
Author: Carolyn Clancy MSN, RN, CN
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