Electronic, paperless transfusion process: improving patient safety and saving money

This Future Hospital Programme case study focuses on how Oxford University Hospitals NHS Foundation Trust (OUH) developed and implemented a fully electronic, paperless hospital transfusion process.

Key recommendations

An electronic, paperless transfusion process minimises the risk of ‘wrong’ and unnecessary transfusions.
Clinicians have full oversight of transfusion activity and blood availability for individual patients.
Develop/implement transferable solutions for other hospitals and clinical processes (eg medicine management, appropriate use of resources and promoting patient safety)
Use an electronic transfusion process to meet the requirements of The Blood Safety and Quality Regulations 2005.

Our story

Local context

OUH is an academic medical centre providing healthcare in Oxfordshire and the surrounding region for a catchment population of 2.5 million people. It has three acute hospitals, a specialist orthopaedic centre, and supports several community hospitals. It has about 1,300 beds and provides a full range of clinical services including emergency medicine, general and specialist surgery including cardiac surgery and organ transplantation, cancer and haematology services and obstetrics (with about 9,000 deliveries a year). There is a comprehensive transfusion service for the OUH where about 27,000 units of blood are transfused per year.

The challenge

We identified a need to minimise transfusion errors which could result in patient harm, to reduce the number of unnecessary transfusions and to increase the efficiency and timeliness of the transfusion service within OUH.

Detailed audits of practice were conducted before each stage of the implementation of the electronic process. Only 11.8% of staff followed the process for correct bedside patient identification. Wrong blood transfusions were documented as 1 in 27,000 units transfused, mislabelling of transfusion samples was 3% and poor documentation of transfusions (‘unfated’ units) was 16%. The median delivery time for urgently required red cell units was 18 minutes. Compliance with agreed transfusion triggers in haematology (i.e. a pre-transfusion haemoglobin concentration of <80g/L for red cell transfusion and a pre-transfusion platelet count of <10 x 10⁹/L for platelet transfusion) was 38% for red cell transfusions and 54% for platelet transfusions.

The need to improve transfusion practice and comply with UK/EU regulatory requirements for the traceability of blood and the documentation of transfusion and training meant we needed to develop improved and simplified processes for transfusion in our hospitals.

Our solution

Our solution was to employ information technology (IT) throughout the multiple steps of the transfusion process, initially by incorporating barcode patient identification and handheld computers at the bedside to prompt staff through every step and verify the correct blood is transfused.

An automated system for collecting blood from blood fridges was incorporated with the electronic bedside process to enable accurate blood tracking and a complete audit trail, and a remote issue function at the fridges was developed for the collection of previously unallocated blood, speeding its delivery to patients.

The system requires the transfusion laboratory to be linked with other IT systems, providing robust documentation and transfer of data relevant to transfusion practice at all stages of the transfusion process.

The final development was a rules-based blood ordering guidance clinical decision support system (CDSS). This centred on providing the most recent blood results within our electronic patient record (EPR) system to clinicians when blood orders are being made and alerting them to inappropriate orders. This system needed to be fully integrated with the existing electronic transfusion process.

The current costs for the OUH for the electronic transfusion management system are £350,000 per annum in a managed service contract with the supplier for the hardware including bedside handheld computers, software, and some support with troubleshooting, training and monitoring of the correct use of the system. In addition, the Trust employs a senior manager to ensure the correct day-to-day running of the system.

Outcomes

Our recent work has minimised transfusion errors which could have resulted in patient harm and increased the efficiency of the transfusion service within the OUH:

an improvement from 11.8% to 100% of staff following the process for correct bedside patient identification
no ABO (blood type) incompatible red cell transfusions or serious wrong blood events in over 10 years
a reduction in blood sample mislabelling (from 3% to 1%) and ‘wrong blood in tube’ errors
reductions in nursing time, only one nurse is now required and less time is needed to administer blood and do necessary laboratory work (around a 50% work time reduction)
more rapid delivery of urgently required red cell units (from a median of 18 minutes to 45 seconds)
the electronic system has provided a simple mechanism for compliance with UK/EU regulatory requirements for the traceability of blood e.g. ‘unfated’ units have reduced from 16% to 1%, and the documentation of transfusion and training.

The recent introduction of CDSS has resulted in a considerable reduction in unnecessary transfusions and cost savings:

compliance with agreed transfusion triggers in haematology (i.e. a pre-transfusion haemoglobin concentration of <80g/L for red cell transfusion and a pre-transfusion platelet count of <10 x 10⁹/L for platelet transfusion) has increased from 38% to over 90% for red cells and from 54% to over 99% for platelet orders.
a reduction of £0.5 million in the blood budget (equivalent to more than 10% of the blood budget) for the OUH in the first year of partial implementation of the CDSS throughout the OUH.

Barriers and levers

Some initial technical problems were encountered, such as interfacing with existing IT systems in pathology and transfusion. Remedying these problems was given high priority by the project team. Planning for the CDSS began in 2006 but it was not possible to implement it in practice until the OUH EPR itself was implemented in 2013, as it provided a platform for electronic ordering of tests and prescription of fluids and medications.

Team working was encouraged, with frequent team meetings and close collaboration with organisational colleagues and industry partners, in which all members were encouraged to participate. Meetings focussed on resolving immediate problems and actions were followed up straight away.

Engagement with clinicians and senior hospital managers was key to share the overall vision and objectives of the project, its challenges and how we would overcome them to obtain their initial support. We shared its results, successes and future plans to maintain their support

Methods

The first step in the development of an end-to-end electronic transfusion process was a focus on the safety aspects of transfusion outside the laboratory i.e. blood sampling, blood collection and administration of blood using barcode patient identification, handheld computers at the bedside and electronically controlled blood fridges linked to the OUH blood transfusion laboratory information system. The use of electronic systems for these processes was taken through pilot stages.

A further development was the issue of blood under electronic control at blood refrigerators remote from the blood bank (‘electronic remote blood issue’). It reduced the time to make blood available for surgical patients and improved the efficiency of hospital transfusion, enabling the development of a centralised transfusion service for Oxford.

The incorporation of the CDSS was the final stage to complete the electronic transfusion process. The team engaged with the EPR supplier, the OUH senior management team and senior clinical colleagues to develop and implement a rules-based blood ordering process.

Training the workforce

The design of the each step of the electronic process was done in close collaboration with the clinical colleagues most frequently involved e.g. nurses for bedside practices, and junior doctors for blood ordering and prescription of blood. The intial implementation of each step of the process involved a considerable effort in training, the design of educational and training tools and monitoring of practice before and after implementation and feedback of progress to clinicians.

Education and training in using the new system was delivered to doctors and nurses in the form of classroom tutorials, online training linked to individual staff training records, and the support of ‘floorwalkers’ on wards at the time when each ward goes live.

What next?

The challenge now is to help other NHS trusts improve their blood transfusion systems. OUH is a demonstrator site for electronic hospital transfusion; we are demonstrating this system to many other NHS trusts as well as many overseas centres in Europe, the United States and Australia. Some large NHS trusts are also asking for our support to resolve transfusion problems as they implement EPR. The use of electronic patient identification systems is included in the recommendations of a recently published NICE guideline on blood transfusion.

Patient and staff feedback

Feedback from both staff and patients was positive.

All patients were happy to have a barcode on their wristband, and they were interested in the new process.

Patient feedback included:

“… felt far more secure”
“… more accurate and safer process”.

Staff preferred using the new technology. Staff feedback included:

“a good, safe and logical system”,
“makes me think about what I’m doing”
“made me confident with the process”.

The OUH medical director commented that “it makes the right thing to do the easy thing to do”.

Who’s involved?

Professor Mike Murphy is a consultant haematologist at Oxford University Hospitals NHS Foundation Trust and NHS Blood and Transplant, as well as professor of blood transfusion medicine at the University of Oxford.

Professor Murphy’s expertise lies in hospital transfusion practice. He and his team have developed and implemented a paperless 'end-to-end' electronic transfusion process throughout the acute hospitals in Oxfordshire. This has enabled the establishment of a centralised transfusion service with one main transfusion laboratory at the John Radcliffe Hospital and a smaller transfusion laboratory at the Horton General Hospital, in Banbury. The service operates across the whole of Oxfordshire including at the three acute hospitals in Oxford (John Radcliffe Hospital, Churchill Hospital and Nuffield Orthopaedic Centre), the Horton Hospital and the local community hospitals where transfusions are administered. This work has won several national awards, and is the subject of a Quality and Productivity: Proven Case Study. It has received funding from NHS Blood & Transplant and the NIHR Oxford Biomedical Research Centre.

Email address: [email protected]

https://www.rcplondon.ac.uk/projects/outputs/your-story-electronic-paperless-transfusion-process-improving-patient-safety-and