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Reducing two-unit red cell transfusions on the oncology ward: a choosing wisely initiative

BACKGROUND/CONTEXT: Despite Choosing Wisely recommendations for single unit red blood cell transfusion orders, ~50% of orders on the oncology ward at London Health Sciences Centre (LHSC) were for two units. The oncology ward at LHSC is a 60 bed tertiary care unit. In mid 2016, LHSC was 18 months int...

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Autores principales: Gob, Alan, Bhalla, Anurag, Aseltine, Laura, Chin-Yee, Ian
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BMJ Publishing Group 2019
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6542431/
https://www.ncbi.nlm.nih.gov/pubmed/31206060
http://dx.doi.org/10.1136/bmjoq-2018-000521
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author Gob, Alan
Bhalla, Anurag
Aseltine, Laura
Chin-Yee, Ian
author_facet Gob, Alan
Bhalla, Anurag
Aseltine, Laura
Chin-Yee, Ian
author_sort Gob, Alan
collection PubMed
description BACKGROUND/CONTEXT: Despite Choosing Wisely recommendations for single unit red blood cell transfusion orders, ~50% of orders on the oncology ward at London Health Sciences Centre (LHSC) were for two units. The oncology ward at LHSC is a 60 bed tertiary care unit. In mid 2016, LHSC was 18 months into its implementation of computerised provider order entry (CPOE). AIM/OBJECTIVES: By December 2017, increase the proportion of one-unit red cell transfusion orders on the oncology ward from 50% to 80% MEASURES: Outcome: % one-unit red cell transfusion orders (aggregated monthly). IMPROVEMENT/INNOVATION/CHANGE IDEAS: Our initial theory was that unawareness of the guidelines (established in 2014) and subscription to the obsolete doctrine of two-unit transfusions were the primary behavioural drivers. Initial change ideas included an educational/awareness blitz including rounds presentations, memos and posters. Failure led us to revisit our hypothesis and carry out a real-time audit, where our team was notified on each two-unit transfusion. This revealed the true root cause: the overwhelming majority of two-unit transfusions could be traced back to standing orders that were entered on an admission order set. After provider engagement, we proceeded to remove all admission order sets containing two-unit transfusions. IMPACT/LESSONS LEARNED/RESULTS: After order set removal, our one-unit transfusion rate rose to 86% and was sustained for 17 months. We learnt two primary lessons. First that CPOE and poor order set design combined to perpetuate poor ordering practices. Second that revisiting our hypothesis and engaging in thoughtful root cause analysis that included direct observation ultimately led to an effective, sustainable solution. DISCUSSION/SPREAD: Our study underscores the importance of executing root cause analysis on a microsystem level. We would expect the factors driving poor performance to be completely different on a service such as general internal medicine. Our study also highlights the potential pitfalls of CPOE and the importance of regular order set review to ensure adherence to current evidence.
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spelling pubmed-65424312019-06-14 Reducing two-unit red cell transfusions on the oncology ward: a choosing wisely initiative Gob, Alan Bhalla, Anurag Aseltine, Laura Chin-Yee, Ian BMJ Open Qual BMJ Quality Improvement report BACKGROUND/CONTEXT: Despite Choosing Wisely recommendations for single unit red blood cell transfusion orders, ~50% of orders on the oncology ward at London Health Sciences Centre (LHSC) were for two units. The oncology ward at LHSC is a 60 bed tertiary care unit. In mid 2016, LHSC was 18 months into its implementation of computerised provider order entry (CPOE). AIM/OBJECTIVES: By December 2017, increase the proportion of one-unit red cell transfusion orders on the oncology ward from 50% to 80% MEASURES: Outcome: % one-unit red cell transfusion orders (aggregated monthly). IMPROVEMENT/INNOVATION/CHANGE IDEAS: Our initial theory was that unawareness of the guidelines (established in 2014) and subscription to the obsolete doctrine of two-unit transfusions were the primary behavioural drivers. Initial change ideas included an educational/awareness blitz including rounds presentations, memos and posters. Failure led us to revisit our hypothesis and carry out a real-time audit, where our team was notified on each two-unit transfusion. This revealed the true root cause: the overwhelming majority of two-unit transfusions could be traced back to standing orders that were entered on an admission order set. After provider engagement, we proceeded to remove all admission order sets containing two-unit transfusions. IMPACT/LESSONS LEARNED/RESULTS: After order set removal, our one-unit transfusion rate rose to 86% and was sustained for 17 months. We learnt two primary lessons. First that CPOE and poor order set design combined to perpetuate poor ordering practices. Second that revisiting our hypothesis and engaging in thoughtful root cause analysis that included direct observation ultimately led to an effective, sustainable solution. DISCUSSION/SPREAD: Our study underscores the importance of executing root cause analysis on a microsystem level. We would expect the factors driving poor performance to be completely different on a service such as general internal medicine. Our study also highlights the potential pitfalls of CPOE and the importance of regular order set review to ensure adherence to current evidence. BMJ Publishing Group 2019-05-29 /pmc/articles/PMC6542431/ /pubmed/31206060 http://dx.doi.org/10.1136/bmjoq-2018-000521 Text en © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
spellingShingle BMJ Quality Improvement report
Gob, Alan
Bhalla, Anurag
Aseltine, Laura
Chin-Yee, Ian
Reducing two-unit red cell transfusions on the oncology ward: a choosing wisely initiative
title Reducing two-unit red cell transfusions on the oncology ward: a choosing wisely initiative
title_full Reducing two-unit red cell transfusions on the oncology ward: a choosing wisely initiative
title_fullStr Reducing two-unit red cell transfusions on the oncology ward: a choosing wisely initiative
title_full_unstemmed Reducing two-unit red cell transfusions on the oncology ward: a choosing wisely initiative
title_short Reducing two-unit red cell transfusions on the oncology ward: a choosing wisely initiative
title_sort reducing two-unit red cell transfusions on the oncology ward: a choosing wisely initiative
topic BMJ Quality Improvement report
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6542431/
https://www.ncbi.nlm.nih.gov/pubmed/31206060
http://dx.doi.org/10.1136/bmjoq-2018-000521
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