Transcript: Transfusion Medicine

Episode information

Date of session: 11/18/20

Facilitator
Triona Henderson, MD, MPH
Centers for Disease Control and Prevention

Didactic speaker
Susan Weiss, MD
UNC-Chapel Hill
Susan.Weiss@unchealth.unc.edu

Transcript

TRIONA HENDERSON: OK, once Dr. Weiss gets her slides up I will go ahead with the introductions. Perfect.

OK, good afternoon. My name is Triona Henderson, and I'm a clinical pathologist and the facilitator of this ECHO pilot project. I extend a chilly welcome to you from the Division of Laboratory Systems at the Centers for Disease Control and Prevention in Atlanta, Georgia. Thank you for joining us. Today's topic in interactive web discussion is transfusion medicine and blood banking. Our subject matter expert today is Dr. Susan Weiss, she'll present the topic.

She's an associate professor of pathology and laboratory medicine at the University of North Carolina, where she serves as the Associate Medical Director of the Transfusion Medicine Services. And the Medical Director of blood bank and the blood donation center at University of North Carolina hospitals. Thank you for joining us today, Dr. Weiss. So, here's some technical information. If possible, please use your videos wherever possible, if your device actually has a camera. It'd be very helpful to put a name to the face as we go through this interactive session.

All of your microphones are now muted. During the discussion section, you will be allowed to mute your yourself. If you're connecting by phone only, and would like to participate in the discussion section, please announce your name and organization before you begin to speak. If you're experiencing any technical difficulties during the session, please send a private message to Johanzynn Gatewood labeled as DLS ECHO Tech. And she's waving at you right now. She will do her best to respond to your issue. Finally, we've designed relevant sessions based on your evaluations.

As we wind down onto the end of this pilot project, we encourage you to complete the post session evaluation. Some of you have been consistently participating to receive a pay certification for your CEUs. Others just want a certificate of participation. You have the option to choose which one you will get at the end of the post-session evaluation. If you have additional comments, please send a private chat message directly to Johanzynn. Or you can email us directly at D, L, S, E,C, H, O. That's DLSECHO@cdc.gov.

So, just a brief introduction as to how these ECHO sessions are different from any first time visitors that we have today. So, these are really based on discussion of cases, or clinical laboratory challenges, as the main feature. Our subject matter experts are going to share their experiences from the institutions that they are in. Or multiple institutions that they've been a part of that may be translatable to all of you in your individual laboratories. These ECHO sessions will focus exclusively on clinical laboratories in the United States and U.S. territories.

Once again, we value the discussion amongst all of you. Susan wants to encourage you to share your own experiences and challenges on this topic. This will be an overview of the process. So, the subject matter expert will share their presentation, I will ask some clarifying questions, and then we're going to open up the floor for shared experiences and/or questions and comments to our SME. Then we will have closing comments and reminders, and then adjourn. Today's session is being recorded. If you do not wish to be recorded, please disconnect now. Closed captioning is now also available, and you can find the link in the Zoom chat box.

The audio and transcript will be shared on the ECHO website after this session. And for any sessions that you have missed, you can also find all the recordings from February until this month. We will also send slides from the presentation via email to registered participants after the session. If this link has been shared with you but you did not register, but would like to receive the slides, please send an email to DLSECHO@cdc.gov.So here is a bio sketch of Dr. Weiss. She received her undergraduate degree in chemical engineering from the University of Nevada. She attended medical school at the University of Toledo, following residency in anatomic and clinical pathology at East Carolina University. She completed her blood banking and transfusion medicine fellowship at Stanford University. Now we'll invite Dr. Weiss to begin her presentation. As she's doing so, please begin thinking of similar situations which you may have encountered that you might apply to Dr. Weiss's experiences at your institution. We expect a robust discussion, please offer your questions and feedback during the discussion period. Dr. Weiss.

SUSAN WEISS: Thank you Dr. Henderson for inviting me to speak today. So, I will get started. Somebody tell me if I'm not clicking on the right computer. So, here are some of the topics that I thought of when I was asked to put this topic together. By the title you clearly know which one I chose was the first one. But another important one is that second specimen. Where you verify the IDO type, and I have a similar pattern of stories I could tell on that one but that's for a different time. An other thing that everyone should be aware of, it was another topic that I thought of, was the changes to the platelet guidelines that are going to be implemented this spring. And another thing people always ask me to talk about, like 10 years ago people always ask me talk about massive transfusions. And now they want me to talk about convalescent plasma.

But, to save myself, I'm not going to talk about that today. I'm just going to talk about patient blood management. OK, so there's different definitions of patient blood management. And one of my favorite resources for patient blood management is the Society for the Advancement of Blood Management. They have a lot of resources on their website. So, this is a good one to think of. If you need some just free, easy access resources.

And one of my attendings, when I was a fellow, used to refer to them as the Society for Bloodless Medicine. It's what he called it, but as a joke. They are trying to minimize the use of blood, which is kind of funny. Because, I mean, that's what I do. So, it's interesting. And I'm trying to minimize what I do for a living is transfusing blood, and I'm trying to stop people from doing it. So, it's kind of a strange position to be in. But it's really important because there are known risks for transfusing blood.

People of a certain age always think about HIV, but there's also unknown risks. So if you were involved in a blood center when Zika came out, you know it became a big thing where you had to test for Zika. So there's emerging infections that we don't know about. So those are some things that we want to also prevent giving people. And also, as you know, this is a very limited resource. People have to, of their own free will, give blood. We are always — if you have a lab that transfuses blood, you know your blood supplier. And you are always concerned with conserving that limited resource.

And, of course, it's an expensive thing, right? You're the most expensive part of the lab, if you're involved in blood product acquisition. So, you know that somebody is always asking you to cut costs in a hospital today, no matter which department you're in. So, there's multiple agencies that are involved in having a patient blood management. I think it's very well encouraged. I know places where they've changed the name of their transfusion committee to the patient blood management committee, just so they can say we do patient blood management here. So, it is important. And there's a lot of different organizations that are involved.

This next piece is, kind of, the way I like to look at it. So, this is also from SABM. And they say, you know, they've got four different pieces that improve the patient altogether. So first off, managing anemia. Why is your patient anemic? And taking care of that maybe before you go to surgery. Also, using different resources. And getting all the different parts of the hospital to try to conserve blood and not transfuse as much of it.

Optimizing coagulation, I'm not really talk about that. Because I haven't had much success in that area. But that is something that people bring in, like TEG and ROTEM. And that's something that I've just not been — I shouldn't say I don't have success in that area. I've just not been involved in that. So, I'm certainly not a subject expert there. And there are a lot of places where the patient makes the decision. There are a lot of hospitals out there who actually have a website devoted to the patient. Saying, you know, you don't necessarily need this blood product. Make sure you know that you want it before you're given it.

So, I'm going to use this little graphic again, and again, when I talk about the different places I've been and what they've done. There are actually certification programs in patient planned management. And you can get that from, say, the ABB, and different places. You can sign up and pay to do these things. Or there's different software companies that will help you work on that, too. But, I'm going to tell you upfront, most of the things that I've been involved in are us on the ground, doing things, and working with different teams to make it happen.

I haven't been in a place that's bought a fancy software package, or even been certified by one of these agencies. Because we're always trying to cut costs and those kind of go against that. The different standards, and these ones I think are from the ABB, so you have to have requirements. And you have to have educational requirements for people who transfuse blood, your clinicians, your nurses. You need to have guidelines for transfusion orders in order to meet these standards.

So, your hospital, if it doesn't already have them, needs to come up with guidelines. And I'll talk more about how you can make that happen. Obviously, you need procedures for a massive transfusion. You need intraoperative methods for patient blood management. These are just some of the things that would be required to get certified for a patient blood management program. Also, you'd have to annually report on your program performance. You have to be able to show that you can care for patients who don't want blood, or won't use blood products.

You need procedures, like not having standing orders everyday, where you check the CBC because you want to minimize blood loss through phlebotomy. And there's different preventative actions required. So, if you are trying to meet certification, and you don't have a conformance, then you need to have a root cause and those kinds of things. So like I said, I have not been involved in getting certified for one of these programs.

The next slide just shows you some of the different Choosing Wisely campaigns. So, if you're trying to get patient blood management moved forward in your hospital, and you're alone in the lab, and you're trying to do this on your own. Then these are some tools that you could use. The Choosing Wisely campaign is from the American Board of Internal Medicine. And what they wanted to do is promote conversations between clinicians and patients by helping patients choose care that's supported by evidence. They also want to do things like not have duplicated tests.

So, they don't want patients to get tests or procedures that they've already had. And they want to make sure people are free from harm. So, these are, like I said, initiatives that ABIM put forward. But different organizations have gone with them. And I'm just listing in the presentation, actually, the ones that had to do a transfusion of blood. The Society for the Advancement of Blood Management actually has five of them. So. All of theirs are involved with blood. Like, don't go to elective surgery if you're anemic if you can avoid it. Don't perform unnecessary testing and cause people to become anemic based on drawing too much blood. Another one that they talk about is, don't transfuse in the absence of active bleeding or actual significant laboratory evidence.

If you're in a transfusion service, you know that there's probably a lot of knee jerk reaction out there to order blood based on a number when that isn't always necessarily the best thing for the patient. They also want you to start to not transfuse when you can use antifibrinolytic drugs to minimize surgical bleeding. And then, just avoid transfer using if there's alternate things available. So that's SABMs. But there's also, ABB has some.

They're also, of course, involved with blood. So those are the ones that they have. And it's the same kind of thing. You're going to hear this, don't transfuse more than you need to. Don't transfuse for iron deficiency or other things where you can treat the anemia another way. So, I think if you're in the blood bank you're probably thinking these are very logical things that you understand. But maybe not out on your floor.

And just in case you need extra resources, you can look for the Choosing Wisely campaigns from the American Society of Anesthesiologists, the American Society of Hematology. Both of them are saying, don't transfuse unless your hemoglobin gets below a certain number. Which, I was surprised when I actually was working on this talk and saw the one for anesthesia. Because I don't believe that anywhere I've been, they really look at a threshold of six.

But I think it's higher. I thought it was interesting. And you can keep going, because there's more societies. There's a Critical Care Society Collaborative, which includes multiple different agencies. And also the Society of Hospital Medicine. All of them have something in their Choosing Wisely campaign about reducing the transfusions. Now I'm just going to kind of give you a overview of what I've been able to implement at a few different hospitals. So you can, kind of, get an idea of what you can maybe do. What worked for me, what didn't work for me.

The first hospital I was at, it was in September, I just called it year one. I tried to take out the names of the hospitals in case anybody was offended from hospitals that I left. So, this was a level one trauma center. And there was a very active stem cell transplant. And they basically had no review of transfusion. So what they had, as far as my little graphic, was nothing. We didn't have, really, any of these things going on when I got there.

We had a transfusion committee but it was very disengaged. There was low attendance, all they did was basically put up quarterly data and review it. They had developed guidelines, but they were pretty outdated. I think the hemoglobin level was 10, and then that was kind of the end of it. So those needed to be updated. They didn't really have transfusion audits, as far as ordering outside of the guidelines, because they didn't have guidelines.

What they had was sometimes a text would say, hey, this person ordered six platelets would you look into it? So it was just very tech dependent. And so if the tech felt it was out of the normal range they would flag it. There was no physician peer review process, or feedback to the clinicians. Fortunately there I was very lucky. They'd had a big gap in transfusion medicine director leadership where I was there. So, I came in and it had been empty for a while.

The techs just, basically, handed out anything that was ordered. But my CMO was very interested in reducing blood. So he held the transfusion committee to task. He said, you're going to meet every month. And you're going to figure out a process. So that was really helpful. So, you have somebody on the outside who's ready to help you and hold people accountable, that's great. I was also very fortunate that I had a physician champion there who was the hematology oncologist. And he knew the risks of transfusions. So he was very helpful with us.

The only restriction that the CMO put on us was we could only do retrospective review. We couldn't tell a physician ahead of time, hey, you ordered three units of red cells and you really only need one. You can't have them. We had to do everything from the back end. The hospital that I had come from when I got there, we had a very strong prospective review. Residents, or Fellows, looked at what was ordered. And told people that they could or could not have it. And they also had a retrospective review. So this new land I was in where only go backwards was interesting.

The first thing I always think about when I go somewhere new, is I need to understand the landscape. I was at a corporate hospital, but the physicians were mostly University physicians. We worked for the University, the people worked for the hospital, the techs and other people. And we had residents, they had some very limited contracted physicians just at the E.D. It was pretty straightforward.

There's a group of physicians in a hospital, right? And they worked together relatively seamlessly. When you're trying to develop guidelines, it's important to get a lot of different disciplines involved. And this is where I was fortunate to have some physician champions. And, you know, the one I took from HEMOC was very well respected in the hospital. And he was able to get us some other people. And, so, it was very — I highly recommend you find yourself a physician champion. I am a pathologist, but I discourage that it be from pathology.

Because I feel like if pathologists are telling clinicians what to do, that doesn't usually go over well. So, we spent a long time, and we finally agreed on some guidelines. We put them together in these neat little pocket cards that everyone could have. And putting together guidelines, there's a lot of resources out there. As far as the ABB, BCA, and ADC can help you with all those things. What we did was we came up with an auditing process.

Like I said before, it was just flagged by the techs. But what we did was developed a report based on our guidelines. And it would print out anything that was ordered, or actually anything that was given, outside of those guidelines. The Resident, I was fortunate enough to have a Resident, would review that daily report. And then we had multiple processes of our audit. So we had to go through many iterations before we got to what we wanted. I apologize, you guys. I'm on service and I just need to make sure someone else is handling that message.

There's a big sign on my door that says don't come in. But, it doesn't keep the electronic medical record from paging me. OK, so we started paper forms and that didn't work well. We move to an Excel spreadsheet. And I was fortunate to have somebody build an Access database. So, basically, the resident would go in, they would enter daily totals, they would say who was the physician? Who was the patient? What did they do? Why were they outside? And then they would review how many cases were reviewed every day. So we were able to report back to the CMO exactly what we looked at. So that made him very happy, that we were looking at everything.

It's also important when we do these things that the guidelines aren't the same for everyone. Now I don't advertise that to the people at the front end. I say, you know, we're going to develop these criteria and these guidelines. But then on the back end, there are some things that I make exceptions for. Like infusion clinic, those patients are trying to get bridged from one appointment to another. So I may give them blood over a guideline. And, also, things like trauma. If they're coming in and bleeding I'm not going to say, well, you know, your hemoglobin was 12. You can't have those units.

So there's always things on the back end that you can just weed out. But I don't recommend doing it on the front end. Because then every different area of the hospital is going to want an exception. We came up with a physician peer review process by those guidelines. And then the resident would audit daily. And then I would get to audit it. So what would happen was I would send an email to the clinician. And it came from not my email address, but from the transfusion committee got an email address. And if their response was appropriate, then we were done.

We just closed the case and said, that was that. But if the physician did not respond, or the response was inappropriate, then it would go back to the transfusion committee to review. And if it was really egregious, then we would notify the Chief of Service. And then it got escalated to there. It was in the process that it could get escalated to their credentialing file. So, I could go through and look at who needed an email. I emailed one to myself. And it said, you know, you didn't follow our guidelines, here's a copy of our guidelines. Can you please explain yourself, basically.

And so that's what that would send out. And then we would just look for a response. So, it took 18 months from the beginning of the process to actually get the guidelines approved. And once we'd optimized that auditing tool, and we had a formal process for physician review. But I point that out, that took 18 months. And that was a transfusion committee that was tasked with meeting monthly until it got done. So, these things take time. Getting everyone to agree on the guidelines is not easy. So, we'd learned some things.

We did learn very quickly that there was a tendency to order two red cells instead of just one. Which is a very common thing that a lot of places need to look at. We did find some significant departmental physician outliers, which was interesting. So, the things that we learned was the collaboration and the relationships that we built with those clinicians was the key to making any of this work. Also, understanding the landscape was super important. On that pocket guideline that I showed you, we put transfuse red cells at this number or for symptomatic anemia. So then we learned very quickly that everyone had symptomatic anemia in our hospitals.

So, we basically created an epidemic because we gave them that as an option. So, I would be careful what you put in your guidelines as a reason to do something outside of it. Because people run with it. So we've kept going with physician education, and we met with chairs of departments who had significant outliers. And we did have a campaign called Why Issue Two When One Will Do. And then, on my third year there, we actually were moved into a different division of the hospital. And that division asked us to do all these things that we had already done.

So that was excellent, because we said, oh sure. We'll get right on that. And we'd actually finished all of those things. But the exciting thing that we got out of that, was they put together these dashboards. So we could compare based on DRG, or based on clinician name, what was being transfused at our hospital versus the division. And it would do different things. So, it's looking at the hemoglobin threshold and telling you which of your transfusions are under hemoglobin of seven, versus which ones are over hemoglobin of 10.

And it can point it out by patient diagnosis, or– and this was ours. So, you can see this was the whole division, and then this was ours. And it just looks at different things. So, we had already done quite a bit of work. And then the fun thing was you could actually do it by– I too the physician's names out– but you can actually do it by physician. So you can see right away that I have one physician that's an incredible outlier as far as transfusing blood. So, it was a lot of fun, actually, to show these to our physicians.

Because I would show them what the names all right there. And they get very competitive, especially the surgeons. And sometimes that was enough just to get them to change their behaviors. This is just more of the data. So, I think is really great if you can get a dashboard put together. I'm going to tell you it was very difficult to make this happen. Then at the next hospital that I went to, it didn't happen at all. So after our four years we got as far as getting one X out of the way here. There are things that we plan to do in the future, like order entry alerts, and things like that.

But then I left, and I actually went to a blood center. If you feel like you're on your own, and you don't have a transfusion medicine doctor, you really need to reach out to your blood center. Because they have a transfusion medicine person. And when I was at the blood center, I would do multiple physician education things. And work with different patient blood management groups at the different hospitals that we served. So just remember that these are available to you from your blood center, hopefully. We did have some interesting things that we looked at.

Because I had come from a hospital to a blood center that had served that hospital, the blood center felt that they used too many O neg units at the hospital that I came from. Which was interesting, because when we actually looked at it, we realized that they would give them short date units. And then the techs felt it was very important to use the unit and not waste it. So they would use O neg unnecessarily just to make sure that it didn't expire. So, it was kind of interesting to be on both sides of that coin. And realize what they thought was a huge problem, was actually created by the blood center.

Then I go to the next hospital and there, again I don't know how I keep running into this plan, but there had been a gap in blood bank management directorship from the physician level, from the pathologist. They did have the Patient Blood Management Committee. And they had actually made some pretty impressive changes on their own. The Patient Blood Management Committee was not terribly engaged, though.

When I got there, there was only two physicians, I think, two different departments represented. We did a lot just building up the Patient Blood Management Committee and trying to get more engagement. They had made, like I said, impressive changes. And their manager of that lab always joked that they had made changes in spite of themselves. So I'll show you some of their data. But they had developed guidelines when I got there. They already had guidelines, they had preop anemia referral. So now I'm working at a place that's already knocked out two of these things.

So, you can see before I came they had pretty much significantly reduced the red cell usage. To a point where it wasn't going to go much farther. And the same with the platelets. But we did have some issues with plasma and cryo. So like I said, PBM was not a high priority. And the PBM meeting had some loss of engagement. And they had had a physician champion in the CBOR.

And you can see, the red line is that department's blood use. And you can see where the arrow is where he left. So when he left, you can see that the usage went up incredibly. And the cases and things like that did not really change that much, or the number of cases. So, now I'm at this second hospital figuring out how we can move forward, engage the things more do review. And now this hospital landscape is completely different.So you have university physicians, you have resident physicians, you have private physician groups. Where I was before I could go to the anesthesia chair and say, hey, your people are not doing what they should be doing. Here the anesthesia was a private group. So there was really no hold on them. And there were also a lot of hospitalist, and a lot of physician extenders. So that's why I have a picture of the maze. Because it was a much more difficult landscape to navigate.

So, again, I worked on building the relationships, attending meetings, I'm really a big fan of attending meetings. I've attended so many meetings I didn't need to be in just because I would hear, oh, the blood bank did this. And then I would speak up and say, well, wait a minute. What was that issue? So I'm a big fan of being present in meetings just to know what's going on, and to be able to defend yourself. One of my colleagues had said, if you're not at the table, you're on the table.

So, I kind of believed that. I did unnecessarily go to lots, and lots, of meetings. In both of these previous worlds. What we were able to do here, actually, was present data to the physicians. It took me a long time to get into this fancy meeting that I was in, where the second red arrow is. But once we showed them their data of what had happened after their physician champion left, you can see that they actually started making changes.Just based on the data alone. We really didn't do much more with them. I'm a big fan of data, and providing your physicians with data. Also, you have to think there's a lot of people who need to do quality projects. Residents, a lot of them have to do quality projects. So you can use this as a way to get things done. I had a medical student who is involved in this fancy program, and she needed to do a quality project.

When she came in we went and looked back at that plasma waste and that cryo waste. And we were actually pulling the plasma for apheresis cases. Which I don't know if anybody does this. If you do, I recommend you don't. The nurses love it, because they only have to spike one bag of plasma. But you run into all kinds of trouble. Because if that case gets set up, and you pull 12 units a plasma, and then the case gets canceled, now you have 12 units of plasma and you're discarding. So, we stopped doing that.

Because then that plasma could be used. If it was a single unit that got thawed it could be used somewhere else. But if it was a pool, we couldn't do it. So we stopped doing that. Some of your waste things, and things, you've really got to listen to your people, right? We were wasting a lot of cryo. And one of the lab techs in the blood bank came to me and said, we thaw this during the– we start thawing it during the first round to use in the second round. She goes, but we hardly ever go to the second round. So, why are we doing that?

We spent some time, we met with trauma and the different groups. And we said, can we just push this into the third round? And you can see the, plasma is the yellow line, and you can see when we– I think that's the second, or the third arrow. So, when we discontinued pulling plasma, we dropped our plasma wastage a lot. And we also dropped our cryo wastage just by moving that to the third round. So I know cryo, kind of, goes up and down depending on how many MTPs we have. But, the trend was there.

Most of our work was done with data we already had and using a med student who needed a quality project. So, make sure you leverage people that need quality projects. There's a lot of them out there. And she actually presented that at AABPN 2019 and won an award for it at a local meeting. The future endeavors there were, one, we started collaborating with the consultants. Which wasn't my favorite thing to do. But the hospital was really engaged with consultants. And they were able to get us some things that we weren't able to do.

Like, they started developing a dashboard and things like that, that we had tried to do on our own but weren't able to get there. So, there was a lot of education that went on, too. And remember that's something, if you don't have somebody internally your blood supplier should be able to supply you with a physician to give physician education about transfusion. So like I said, these are the things that I learned so far. Getting people engaged, being present, showing up in meetings. Getting physician champions from clinical areas who can help you. And then knowing what your resource availability is. I didn't like working with the consultants, but I knew they could get me resources that I wanted.

Medical students, residents, people who need quality projects, also a resource. Because they need to work and do something. Our pathology residents have to do a quality project every year. So, if you think about things like that, and you have those available it's helpful. Then I came to a new hospital. It's a very strong interdisciplinary relationships, they had guidelines, extensive prospective review. Every lab, every tech checks the lab value when a product gets ordered. If it doesn't meet the guidelines, then they escalate it to the resident or the fellow.

And that person makes a phone call. So, that happens 24 hours a day. We've got a lot going on. It seems like from where I've been, to where I am now, all these things are in play. They have a preop anemia clinic. I probably shouldn't put X's in the bottom, because quite honestly I don't know what the coag department is doing. But, I don't think we have a plan as far as patient centered decision making. So, I got here and I'm all about being present. Showing up in meetings, getting to know people, and then the COVID virus decided to appear.

I mean, I wasn't even here three months. So, it's like, complete shut down. You can't talk to anybody. And if you do, you have a mask on. And if I see you again, I don't know who you are, because everyone's wearing a mask. Just as a quick FYI, when COVID happened, I don't know about your blood supplier, but our blood supplier said, watch out we're going to have huge shortages. And they did, right? They had to stop some of their collections because of physical distancing, and things like that.

We were fortunate enough that we were very engaged with the teams already. We immediately notified the teams and said, hey, our supplier is doing this. What can you do to help us? They moved very quickly. We actually stopped a lot of the red cell exchanges that could actually be switched to simple transfusion for a few months. Some of them have come back on board. Our outpatient hematology clinic actually changed their threshold for transfusing. From hematocrit of 25, down to 21.

And, of course, everyone probably experienced that outpatient surgery decrease, which also helped our supplies. So we were pretty lucky as far as the short supply and what we could do. Because I don't know, it depends really, I think, on your blood supply. And where you are, and how much you're affected by these things. Then after I'd been here a while I got emails, or pulled into some Zoom meeting– now everything's Zoom, there's no in-person– by this care redesign team. This is a bigger hospital system, there's multiple hospitals.

And we're the biggest one of the hospitals. And they have a system wide program where they look at different things, and they look at some of the Choosing Wisely guidelines that aren't just about blood, but about other things. And they want to just reduce them more into the care variation and implement care pathways. They're trying to make things easier for the whole system. And setup things that help out.

By coordinating the resources and project management. So this, to me, is amazing. This is like the best thing ever. I have this lovely woman, Pamela Ansel, who runs a team. And she gets everything organized. She gets us all into meetings. We had a meeting with the marketing people. So, that campaign that I wanted to do at a different hospital, of the why use two when one will do. The marketing people here are already talking about how they can put that together. I've never had this many resources. I'm very excited about how this is going to work out.

But, unfortunately for you, we're at the very beginning of this process. So I don't have a lot of information on where it's going to go. But they're putting together a dashboard. This is the secret version of their dashboard, which I took the hospital out. But, right now we just looked at how many, across the board of the hospitals, how many times people are ordering two units to one. And I won't tell you which hospital I am, but I was actually shocked.

Because we have all that prospective review. So I thought our numbers would be much lower than that. So that's why we're moving forward with the why use two when we do campaign. But that, just to point out, that resources are so excited when you have somebody available to put those things together for you. Kind of as a summary, you just have to think about the tools that you have available. And it may be very hospital dependent, but look into these websites. SABM has a lot of stuff that's free.

You can go on there, there's presentations, there's tool kits, there's all kinds of stuff that you can just get on there and help to use. The Choosing Wisely campaigns, also, you can look at from the different sources. Physician champions are big. You know, usually hospital administrators are all about decreasing blood supply. Depending on your hospital you may get a lot of buy in from them. And they can help add resources to your tool box. People who are looking for quality improvement projects are very important.

And also don't forget the data. If you show physicians data, especially if you show them that they're an outlier to their peers, that gets their attention. So I always ask for data. Show us the data. And that's why those dashboards are so helpful if you can get somebody to put them together. So once again, the things that I really value, as far as trying to get these things done, are relationships, presence, and just going to endless meetings.And I put a question mark after the Zoom, because I don't know about you, but not today obviously– but when I'm on a Zoom meeting I tend to be multi-tasking. I'm not really sure that Zoom is the way to go. I'm much better in an in-person meeting where I can pay attention. But I think it's going to be interesting, our future.

And I don't have any solutions or how that's going to work. I don't know the answer to that. I don't know, that is all that I have put together to talk about. And I don't know, I have some references here. And I highly recommend you, if you want to continue looking at PBM, you look at some of these resources. And I don't have any questions.

HENDERSON: Thank you so much, Dr. Weiss. I thoroughly enjoyed this presentation, probably because I'm a blood banker myself. And have subspecialty training in blood banking. But, you know, either you really, really love blood banking, or you really don't like it at all. And it's so funny with your summary slide, that you said show the data. Because I was writing notes and that's exactly what I wrote on my paper, show the data.And you've been to so many, through your career, a variation of landscapes and hospitals. And I think that will be so helpful to our community participants on here. Because I'm sure there's some flavor in what you've presented that they are currently facing in their institutions. And one of the main things that stood out to me was culture, culture change. It's always been, you know, this is how we've done it. And especially if you're coming from a place like I did that had prospective review of blood products before handing them out to physicians.

And then you end up in a place where it's just, usually, the clinicians rule that part of it. And they get what they want. And you have to do retrospective. I think, for me, practicing that was one of the hardest things for me to transition to. And I don't know how many pathologists we have on the line, or young pathology trainees, but I think understanding that there's such a variation in the landscape.

You may be trained one way, but then having to flip your mind and say, OK, how do I overcome not being able to have the perspective? But do it retrospective. And then be able to show the data to the clinicians. And say, hey, even though we didn't do perspective, but retrospectively, this is what we've discovered. I think is really important, them showing the data. And you did in all your institutions that you've been in. It was really, really, really helpful. And I just really enjoyed this presentation. So, a couple of questions.

What advice would you give to smaller community hospitals? Where they may not have many pathologists, or blood bankers, or blood bank specialists, who can bring them resources. I know in the beginning you shared so many resources. And I hope everybody will have these slides so they can go back and look at them. But, do you have any advice for them, just in general? If they want to set up a patient blood management, or any advice that you'd have for them.

WEISS: If you're come coming from a lab, you really need somebody. And I am not discounting administration, but my best advice is to find some physician. Usually it's an anesthesiologist, or a hemoc doc, or somebody who's is a little bit passionate about the idea of using blood properly. Because that person, in order to get physicians to kind of change what they're doing, you really need someone in their camp. Because coming from a pathologist, for me to say, well, you shouldn't use that blood.

You know, they're going to say, well you're a pathologist. You don't see my patients. You don't understand. I've always tried to get somebody on my side who will understand that. And then maybe you have to give them all the data. Or you have to help them out. One of the things that I learned in a few places, the transfusion committee would just read off some report. And then people were just not engaged at all.

I put some slides together that just showed some graphs, and things like that. Even though it wasn't any different, it was the same data, it was just pictures. And I hate to say, well, show physicians pictures. But that's what I did. Because I showed them the data, and the pictures, instead of someone just referencing along a report. I think that helped just get people engaged. It's hard, I mean it really is difficult to get people engaged. But if you can just get a few people engaged. And keep figuring out what works and your institution.

And I have been a medical director at small community hospitals. And honestly, it's sometimes a lot easier to get things done. Because you have a smaller group of, usually, very clear collegial physicians. So if you just figure out who the person is that can help you move through that, then they will listen. And if you get somebody– and you can always, like I said, use your blood center as a resource. Your blood supplier. Because they should want you to use blood properly, as well. If you feel like you have people that are overusing, or things like that. They should be able to help you get some resources.

HENDERSON: That's awesome, thank you. So, another question. You and I have both been at smaller rural hospitals at some point in our career. And we've probably both been up against, this is how we've done it for the last 20 years, or 30, or 40, or 50 years. And, you know, we were born there, raised here, worked here, we'll die here type of culture. How do you educate physicians who are not necessarily on the cutting edge? So they don't do a lot of national meetings. Or they're not participating in national, and things are changing. You know, the tides are changing with respect to blood banking, apheresis, all that stuff. How do you educate them to bring them up to the time that you're in?

WEISS: So, that's an interesting point. And when you say physician education, I want to point out to anyone on the call who doesn't understand this. I have taught at three different medical schools now. Do you know how much education physicians and medical training, get on transfusion medicine? The most I ever had was four hours of lecture in their first year. So they're just in lecture, they're not on the floor. It doesn't compute to when I go to order blood, I need this.

Transfusion medicine is a very, very small part of education. In most places I've been, it's actually one hour. So I get one hour in their first or second year of med school and then they never hear from me again. When you talk about physician education, I think there are things, especially if you're a blood banker. And you're thinking forward and reverse typing, antibody screening, antibody panel, and you think those are the most easy parts. Like, how do you not know what that means? But you have to think that the people you're talking to do not always understand what you understand.

You have to make sure that you find somebody who will work with you, right? And help you educate the people. And that's why I say blood suppliers. When I was working for a blood supplier, which I did so many talks with so many different groups of physicians at the hospitals that we serve. So if you reach out to your blood supplier and say, hey, do you have a physician you can come do this talk at lunch or– I guess everything's Zoom now, though. So, you know, you may find somebody that way. But you've got to find somebody internally that's engaged in this idea. And usually somebody in anesthesiology, or some hematologist, or somebody who transfuses a lot, will be interested in what you're doing.

HENDERSON: Perfect. The floor is open. I know we have, let's see, Martha Casassa. Or anybody else who has any questions. Trying to see if I recognize any of these names. You can either raise your hand or type your question in the chat box. Before Susan and I go back and forth. And J.Z., monitor from me. Because I can't see the chat and the participants. OK, we have a question from Victor. J.Z., have you unmuted him? Go ahead, Victor.

VICTOR DE JESUS: Hello, good afternoon. Can you hear me?

HENDERSON: Yes, now we can.

DE JESUS: good afternoon, everybody. Dr. Weiss, thank you for the presentation. This was very, very interesting. I want to follow up on something that you mentioned, to make sure that I understand it correctly. You were talking about one specific scenario where the blood bank had a high utilization of O negative blood that was short dated. Did I capture that right?

And if I remember correctly, the discussion, it sounded to me like that presented an issue. Would you mind going back to that particular discussion point and describing the situation again? Because, as I understood it, using short dated blood was considered an issue. But, in my mind, and I'm not an M.D., first full disclosure. Wouldn't that be appropriate? To ensure that existing blood supply that's still good and about to expire, actually gets used?

WEISS: Yeah, there wasn't an issue with that piece of it. The issue was that the blood center felt like that hospital's use of O neg was really high. And shouldn't be that high. But they weren't thinking about the fact that they were giving them short date units. And they were using them just to not let them expire. So, it's like they thought that they were overusing O neg. And I don't know if you've had your blood supplier come and say, you're using too much O neg.

But that's what they were doing for this hospital. But since I had just left the hospital, I was like, no we don't overuse O neg. So, when we looked into it, that was the reason. It was because they were trying to help the blood supplier by using units that they didn't want to expire. But at the same time, when the blood supplier was looking at their data they were saying, well this hospital has too much O neg usage. But when you put the two pieces together it makes sense. Yeah, I wasn't saying don't use dated blood.

DE JESUS: Thank you for clarifying that. Because, you know, my initial reaction was like, well, no not necessarily. But thank you for that clarification. I appreciate it.

HENDERSON: And Martha commented that she really enjoyed the presentation. She'll review the slides later. Her blood bank supervisor was on. But they have no questions right now. Perfect, another question. You're at an institution, or system actually. Because you have lots of hospitals in your system. Is there a way that you feel that, if you have community hospitals, you're a large academic institution with smaller community hospitals attached, if there's a strain in the relationship?

And the reason I ask that, because I've been at a few places where sometimes it seems that the large — or the interpretation from the community hospitals, is that the large academic institution is doing their own thing. And they want to just mother them. Versus it being a fully collegial relationship. Have you experienced that? And how would you overcome that? It'd be more of a big sister, little sister thing, versus a competitive thing.

WEISS: Matt has to go back to those relationships, right? And that's really hard in the time of COVID and the time of limited resources at every hospital. If you have — it's really hard, but if it's possible, and you're the community hospital, and you can switch techs. Maybe your tech from the community hospital goes to the main hospital for a day, just to see what they do. And then your tech from the main hospital can come to the community hospital and see what they do. Because I think that once you build those relationships, it's a lot better.

And I actually ended up at one large hospital. I was a director there, and then I also was a director at one of the smaller hospitals. And because I was at both places I could then — don't want to criticize anybody. But the main hospital say, well, they don't know what they're doing at the little hospital. And the little hospitals say, they told me I shouldn't do this. It was just a lot of miscommunication.

And once you had somebody that understood both sides of the story, or the needs of both places at work. So, unfortunately, I think the biggest thing there is just somebody developing the relationship. And being present in both places. To understand what the issues are. And I've seen it in different scenarios. Where, exactly what you said, the little hospital is like, don't tell me what to do. It's not the same here. And they feel like the big hospital is not understanding them. And then I've seen it, too, where the big hospital is just not nice. And like, why should I do their work for them?

So, I mean, I don't know. There's no perfect answer. But, honestly, I think just developing those relationships between the two organizations is probably what's helping. That care redesign right now that our piece is on here, is actually working to get the guidelines from all of the different hospitals. To see if we can put them together before we move forward changing anything in our EMR.

That's going to be interesting. Because they said, oh, we'll just get that. And we'll coordinate them and make them all the same, and we'll just move on. And I was like, oh, I think that's going to take a lot longer than anyone thinks. To make all those transfusion level thresholds the same.

HENDERSON: That's awesome, thank you so much, Dr. Weiss. And for anyone who joined late, definitely take a look at these slides. I think they're filled with so much information. If you're starting up, even if you're just new to your position in blood banking. There's a wealth of information in there. And we really want to thank you, we want to thank the participants. Can we go to the last slide please, Dr. Weiss?

So, for our final month for this pilot project, it will be on Wednesday, December 16 at 1:00 PM. And we will end it off with anatomic pathology with Dr. Vinita Parkash from the Yale New Haven Hospital in New Haven, Connecticut. Please visit DLS ECHO's website to register for this session. I want to thank everyone. Thank you for participating today in our discussion. We hope that you found it really valuable in the work that you're doing. And engaging with your specific laboratories.

We look forward to your participation in our final session for this pilot project. And we'll keep you posted on any changes. The link is now in the chat box. We will adjourn for today. Thank you and have a great day. And thank you again, Dr. Weiss, for your time.

WEISS: Thank you.