Evidence-based blood utilization has been a focus for several years at Mountain States Health Alliance (MSHA), a 14-hospital system based in Tennessee that also serves Southwest Virginia, Southeastern Kentucky and Western North Carolina.
“I was looking at blood utilization,” said Andrew Fletcher, MD, who led the Mountain States lab utilization initiative. “You don’t know where to go so when I first saw Choosing Wisely, it was the instruction book. It’s kind of a road map with recommendations and evidence.”
Mountain States already had the institutional focus on improving evidence-based care through its Physician Council for Clinical Excellence (PCCE).
“Mountain States identified physicians in each hospital who were interested in looking at gaps in practice and clinical evidence, and figuring out how to close those gaps,” said Morris H. Seligman, MD, Executive Vice President and Chief Medical Officer for Mountain States Health Alliance. “These folks become the guardians of adoption and meet once a month to discuss efforts to reduce low-value care throughout the system.”
In 2014 and 2015, an interdisciplinary team – with buy-in from the PCCE— looked to implement the AABB (American Association of Blood Banks’) Choosing Wisely recommendation that suggests best practice is adhering to a restrictive transfusion strategy in hospitalized, stable patients. They introduced an extra step within the order-entry system to require physicians ordering more than one unit of blood to input a specific reason for the extra units. This enabled Mountain States to track physician ordering and provide rapid feedback to the medical staff on compliance with the guidelines.
After one year of the project implementation, Mountain States saw a sustained reduction of about 20 percent in blood utilization throughout the entire health system. The data was published in the September edition of Tennessee Medicine’s e-journal.
The next project Mountain States worked to implement built on this success and focused on reducing CT scans for pulmonary embolism. Another interdisciplinary team formed in 2015 with the goal to create an order set requiring completion of a risk stratification tool (Well’s score) prior to ordering a CT for pulmonary embolism, which the American College of Chest Physicians and the American Thoracic Society address in their joint Choosing Wisely recommendation. The team decided on a first-of-its-kind approach of building the Well’s calculator directly into the physician order-entry system.
“A key part to the interventions is data collection and providing reports back to physicians with really meaningful data,” said Dr. Fletcher, who carries Choosing Wisely materials with him in case he has a chance to discuss them. “Being transparent is important, as is letting clinicians see the results and compare themselves against their peers. They want to do better and practice good medicine.”
Data for their first project on blood utilization was difficult to extract and took about a year to get underway. But the team learned a lot from the process and was able get the second project focusing on CT scans up and running in about three months. Results from that project included a 31.4 percent decrease in CT scans and shorter patient stays in the emergency department.
“This work might be hard but it’s important to our patients,” Dr. Seligman said. “That is what we want to communicate across the organization. It can take years to adapt practice, but we are coming up with ideas to speed up the adoption rates for changes based on proven evidence.”