James M. Crawford,
MD, PhD, FCAP
James M. Crawford, MD, PhD, FCAP, came to North Shore-LIJ (NSLIJ) Health System in New York in 2009, when coordinated care was just picking up steam. He joined a forward-looking health system intent upon building a model-integrated health care network in a service area of 7 million patients.
Shortly after arriving from the University of Florida Medical Center at Gainesville, where he had chaired the Department of Pathology, Immunology, and Laboratory Medicine, Dr. Crawford took responsibility for investigating the reasons for highly variable blood utilization across NSLIJ sites of care. In such a huge system (16 hospitals/2,400 physicians), small ripples could have a large impact. Did the numbers reflect higher clinical acuity at some sites versus others? Or was NSLIJ as a whole overutilizing blood products?
Dr. Crawford is senior vice president for laboratory services for the entire NSLIJ Health System as well as professor and chair, Department of Pathology, Hofstra NSLIJ School of Medicine, and medical director of the clinical laboratory for the system's largest hospital, North Shore University Hospital (NSUH). He was well prepared to effect change in an already dynamic environment.
A new division of blood banking and transfusion medicine was created in 2009 for the health system, and seniorlevel blood bank physicians were
recruited. As a first step, NSLIJ improved its procurement posture by making blood product purchases as an integrated health system. The critical piece, however, was tied to behavior. How did sitespecific blood utilization practices come into play?
Multidisciplinary meetings with orthopedic surgeons, thoracic surgeons, obstetricians, oncologists, hospitalists, and general physicians (adult and pediatric) gave the blood bank team the insights required to evaluate utilization practices. The pathologists worked to standardize criteria for blood product
utilization and established servicespecific blood management programs. NSLIJ Health System blood expenditures dropped from $29.5 million in 2008 to $21.6 million in 2012. In those same four years, blood-product costs per adjusted discharge dropped from $129 to $76 systemwide. At the largest hospital alone (NSUH), blood product costs per adjusted discharge dropped from $201 in 2008 to $92 in 2012.
The change in procurement pricing accounted for about 30% of the savings, Dr. Crawford says, but standardization and management of utilization brought in the rest. Dollars are quick measures, he adds, but improvements in patient safety are the more meaningful outcomes: decreased risk of transfusion reactions, decreased likelihood to form antibodies (which affects recipients' risk in receiving future transfusions), and decreased opportunity for human error in the dispensing of blood products.
Another innovation in the hospital-based environment was identified by complaints about understaffing and wait times for preadmission and "walk-in" blood draws at the ambulatory draw-station of NSUH. The four full-time phlebotomists were unable to handle peak loads. With the support of hospital administration, these phlebotomists were absorbed into the 132-person, system-based phlebotomy service run by the laboratory service line, which enabled successful cross-support for handling peak-load phlebotomy times at NSUH and expansion of hours for the ambulatory draw-station. As a result, blood samples throughout NSUH were drawn and received by the laboratory on a timelier basis; and at the ambulatory draw-station, wait-times were eliminated and windows during which "walk-ins" could get their blood drawn were extended.
Properly constructed guidelines can enable pathologists to identify and document those laboratory findings most useful to their clinical partners. Intentional communication within medical teams will further free up physicians' collective bandwidth by creating a continuous feedback loop that informs and educates all parties about how best to share what they know and what they need to know. Patients benefit, efficiencies multiply, economies emerge. People start thinking about doing things differently. And from there, as the saying goes, the sky's the limit.
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