Saving Blood, Saving Lives
Edendale Hospital, Kwazulu Natal Department of Health

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Blood products are lifesaving, but they are both an expensive and scarce resource (there is a national blood shortage crisis in South Africa). South Africa has a declining pool of blood donors and a high percentage of people excluded from donating due to HIV infection. The need for blood products in South Africa is increasing despite this blood product shortage and a worldwide trend to use less blood (based on scientific publications regarding transfusion triggers and targets). Edendale Hospital was deemed one of the worst provincial performers in Kwazulu Natal in terms of the amount and cost of blood products used, misuse and ordering of products, unnecessary afterhours levies, this despite having a blood bank on site at the hospital. The hospital would frequently run out of blood and patients would unfortunately suffer. The South African National Blood Transfusion Service supplies blood to 8 of the 9 provinces in South Africa. So blood wasted at Edendale Hospital, had far reaching effects, as there would be less blood for other provinces. Additionally, a major problem related to blood product utilization is their tremendous cost. The Saving Blood, Saving Lives Project aimed to turn this situation around. The challenge was developing an innovative strategy to ensure the correct use of blood products, decrease the amount of blood products used, and reduce expenditure – all of this without incurring any costs, as we had no budget. We had no additional technology available to us, not additional staff or time, but had to create a healthcare strategy to improve responsible blood usage by healthcare professionals. The project had 3 primary objectives: • SAVE BLOOD: To improve responsible blood product usage, thus saving blood and avoiding the complications associated with transfusions, and making more blood available (to the hospital and province) for other patients to benefit. • IMPROVE SERVICES: Avoid wastage and decrease the amount of blood products used, decrease unnecessary laboratory work, thus making more blood available in an efficient system for the province – making it possible to save more lives. Fewer transfusions also means fewer complications for patients. • SAVE MONEY: Reduce blood product expenditure, one of the biggest cost drivers in the province and nationally. This money could ten be used to improve the care of our patients.

B. Strategic Approach

 2. What was the solution?
The solution was a healthcare management strategy that included a combination of education, video presentations, cooperation amongst all departments and transparency. At the heart of this was an innovation called an “Accountability Form” that had to be completed with each order for blood. The “Accountability Form” and other strategies guided the clinician through each transaction, and aimed to change healthcare professional behavior, create a culture of responsible blood utilization, and enable ongoing audit and intervention to ensure sustainability.

 3. How did the initiative solve the problem and improve people’s lives?
Methods • A literature search was performed and a new hospital blood product utilization protocol was devised. • A video presentation of the revised protocol was created and distributed and presented at each departmental meeting on a regular basis, ensuring good communication. • A new innovative system of using a “blood accountability form” was introduced facilitating clinical governance of the changes and holding healthcare practitioners accountability for their actions (healthcare workers were held accountable for ordering any blood products). • The Hospital Transfusion Committee was revitalized with support from the hospital’s Senior Medical Manager to ensure sustainability. • Monthly meetings and auditing of accountability forms and SANBS statistics helped refine our policies, identify new problems, and improve communication. Key to all of these strategies was accountability. Feedback to the hospital was also provided through posters, meetings, and departmental representatives on the Hospital Transfusion Committee. The project achieved its goals with greater success than predicted. The accountability form enabled ongoing clinical governance and re-education until responsible blood utilization practices were embedded in a new culture within the hospital. The hospital initially saved 1820 units of blood and R6.5 million (taking inflation into account) in the first year. The project has built on those achievements in subsequent years saving 2580 and 2952 units of blood, and R7.99 and R8.12 million in 2015 and 2016 respectively. In total, the project has saved 7352 units of blood and R22.6 million in three years at just one hospital. This is amounts to: - 41% reduction in the use of blood products - 42.5% reduction in expenditure Edendale hospital 900 bed regional hospital is situated in a former township area and serves a community with high unemployment and serious economic and social challenges. This is the population that has benefitted. The quality of improved services include: - More blood available for patients, potentially saving more lives and helping those critically injured or sick - The cost-saving benefits enable finances to be spent in other areas of healthcare and improved patient care. o at Edendale Hospital, the money has been used to employ more doctors to improve patient care and service delivery - Appropriately used blood bank services and fewer tests, means that our blood products and testing is performed quicker, with life-saving blood available in less time than before the project was initiated. - Although difficult to quantify, fewer blood transfusions and reduced inappropriate transfusions means fewer patients are at risk from the complications of receiving blood products. These risks include contracting infectious diseases and various immunological reactions, and even complications from human error

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The innovation is the use of a form and video presentations to change clinicians’ behaviour. Dr Peter Pronovost, from John Hopkins Hospital in the United States, appeared on the cover of Time Magazine after the successful implementation of a simple checklist that saved both money and lives in his state. Similarly, our blood accountability form, monthly audits, and improved communication through electronic media helped to surpass our goals, saving both lives and money. Simple, cheap and hugely successful – the concept of an accountability form was introduced together with the system of accountability and ongoing clinical audit. Doctors had to complete the form for all blood product requests. The form is designed in such a way that it changes behaviour. Together with the use of audiovisual material and monthly follow-ups we have reached our goal The introduction of an accountability form, together with the auditing process employed is believed to be the first of its kind for this purpose. The accountability design and video presentations are all original.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
Edendale Hospital is a busy 900 bed regional Hospital located in a heavily populated semi-urban community that was formally an informal settlement during the “Apartheid” era. It lies on the outskirts of Pietermaritzburg, the capital of Kwazulu Natal Province. The hospital serves a population of 1.4 million people and sees a large clinical burden of trauma, HIV related illness, and obstetric emergencies. It is a government hospital and serves a community with a high unemployment rate that relies on free healthcare services from the government. The hospital relies on junior medical staff that rotates between 2 other hospital in the city and thus the high turnover of junior staff makes communication challenging. Dr Robert Wise, an anaesthesiologist and intensive care specialist, employed as the Head of Critical Care at Edendale Hospital, runs the project. He coordinates the Hospital Transfusion Committee and is responsible to replicating the project in other hospitals around the country. The project has benefitted all those served by Edendale Hospital (population of 1.4 million). Additionally, the project has been successfully replicated in other hospitals in Kwazulu Natal and also in Johannesburg (Gauteng Province). Dr Wise is hopeful that with continued awareness and support from national and international structures, this project can eventual be run throughout the country and will solve the blood shortage crisis facing South Africa, and possibly even Africa. The amount of blood saved is tremendous – to put this into context, the blood saved from the first 2 years of the project is sufficient to provide all the bleeding obstetric patients in Mpumalanga Province in South Africa for a year.
 6. How was the strategy implemented and what resources were mobilized?
A literature search was performed and a new hospital blood product utilization protocol was devised. • A video presentation of the revised protocol was created and distributed and presented at each departmental meeting on a regular basis, ensuring good communication. • A new innovative system of using a “blood accountability form” was introduced facilitating clinical governance of the changes and holding healthcare practitioners accountability for their actions (healthcare workers were held accountable for ordering any blood products). • The Hospital Transfusion Committee was revitalized with support from the hospital’s Senior Medical Manager to ensure sustainability. • Monthly meetings and auditing of accountability forms and SANBS statistics helped refine our policies, identify new problems, and improve communication. Key to all of these strategies was accountability. Feedback to the hospital was also provided through posters, meetings, and departmental representatives on the Hospital Transfusion Committee. Importantly, involvement and cooperation of all Heads of Disciplines in the Hospital were included from the outset. This improved trust and early speed at which change could be achieved. The monitoring of the project takes place monthly. All the accountability forms are reviewed monthly (takes about 2-3 hours). Problems are brought to the Hospital Transfusion Committee Meeting where representatives are briefed and then take the problems forms back to those healthcare professionals involved. Re-education, discussion, and fears are addressed in a non-threatening and cooperative manner. The only financial costs were the paper the accountability form was printed on, and the CDs used to distribute the pre-recorded video/ PowerPoint presentations. The project took 3 months to set up and now takes Dr Wise approximately 3-4 hours per month to run. He does not have any administrative or secretarial support. Members of the Hospital Transfusion committee devote about 2 hours per month to the meeting and follow-up system. The project has received no funding. Prize money that the project been awarded has been used to purchase a computer, a projector and a laser pointer so that Dr Wise can continue to spread the project to neighbouring provinces. The project is also developing a website with recent prize money from the CPSI award.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The project has been led by Dr Robert Wise, and duly supported by those on the Hospital Transfusion Committee. The accountability form has been through 61 versions, refining it to its best possible form, through suggestions from the committee members and hospital staff. The project has focused on remaining flexible and keeping an open mind to suggestions and change. Thus, anyone in the hospital can suggest changes, from senior management to the youngest nurse or training doctor. The South African Blood Transfusion Service has been very helpful in supporting the project with all the statistics required for ongoing audit, as well as supporting the changes to our hospital protocol. All the material which we have generated, including video presentations, accountability forms, blood utilization protocols, scientific literature, and audit templates have been circulated and made available to these hospitals. Presentations on our system and feedback on our success has also been posted in the intranet, accessible to all KwaZulu-Natal DOH Hospitals. The project has been supported by the Department of Health, particularly the Senior Manager of Hospital Services (Specialized Services and Clinical Support) and the Budget Manager for the province. We are hopeful to see similar results from the hospitals adopting our new system. We are proud to be part of the Saving Mothers Campaign (aimed at reducing maternal morbidity and mortality across the country) and in a joint venture with SANBS, presented our project in Kwazulu Natal, Mpumalanga, Limpopo, North West, Gauteng and the Eastern Cape. The project was well received and now several hospitals in other provinces are interested in replicating the system. The project has also been supported by the Centre for Public Service Innovation who have funded several outreach and training efforts to Gauteng Province.

 8. What were the most successful outputs and why was the initiative effective?
Ensure healthy lives and promote well-being for all at all ages 1. In total, the project has saved 7352 units of blood and R22.6 million in three years at just one hospital. - 41% reduction in the use of blood products The blood saved has been used in other parts of Kwazulu Natal. It is our hope that these blood products will even reach the deep rural areas of our province, areas where some of our most vulnerable patients have limited access to emergency blood. With additional blood supplies, blood can be exported to these rural hospitals and stored in fridges to be used in emergency situations. 2. In total, the project has saved R22.6 million in three years at just one hospital. - 42.5% reduction in expenditure This money has been used to improve the care of our patients through the employment of more doctors. More and more hospitals are implementing the Saving Blood, Saving Lives system and it is predicted that potentially hundreds of millions of Rands will be saved in the next few years. Ensure sustainable consumption and production patterns 3. Saving Blood, Saving Lives success means that even with a declining number of blood donors, a high HIV infection rate, and a growing population, we can realize the goal of responsible blood product utilization and enough blood for the people that need it most. Promote peaceful and inclusive societies for sustainable development, provide access to justice for all and build effective, accountable and inclusive institutions at all levels 4. The project has been replicated succesfully and is promoting a system of accountable and inclusive hospitals in South Africa. Blood products in South Africa are shared amongst 8 provinces so success achieved by this project means improved access to blood, better accountable amongst healthcare professionals and institutions, and solutions for the blood shortage facing South Africa and Africa.

 9. What were the main obstacles encountered and how were they overcome?
Several challenges have been overcome, particularly in the development of the protocol, communication, learning how to change peoples’ behaviour, and in the designing of the innovative accountability form. The protocol has been revised on multiple occasions to ensure practicality, pragmatism, and safety. Communication in a large 900 bed regional hospital is challenging, and it was important to get the same message out to every staff member to avoid confusion, ambiguity, and misunderstanding. We learnt that a video presentation with a pre-recorded audio was the best method and worked well. This presentation was played to all new staff and repeated in each department on a quarterly basis. Changing peoples’ behavior is a difficult and often frustrating task. However, we learnt that it is possible to change clinician behavior through simple measures such as “making them re-think” decisions through an uncomplicated form, making people accountable for their decisions, and holding them accountable through appropriate follow-up. The accountability form went through various design changes as we found it crucial to have the best layout to make it both easy, and ensure compliance with filling in each required field. “Design – test – and then re-design” is required to ensure the best possible outcome. These processes took about 3 months before we had the various components of our strategy refined.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Compared to the hospital’s performance prior to the initiation of the project, April 2014 – February 2017 (results projected for March 2017) achievements: • SAVED BLOOD: 7352 units of blood o 1820 units 2014/15 o 2580 units 2015/16 o 2952 units 2016/17 (projected) • IMPROVED SERVICES: 1. If it takes 4 units of blood to save a life, then this project is potentially saving 62 lives a month (738 lives a the last year). 2. Massively reduced workload at the hospital blood bank resulting in faster processing times for emergency blood, meaning it is available to patients quicker. 3. More blood available to patients – improved survival. • SAVED MONEY: R 22.6 million saved in blood product expenditure. • IMPROVED ACCESS TO BLOOD • REDUCING RISK FROM UNNECSSARY BLOOD TRANSFUSIONS The amount of blood products utilized has decreased enabling the availability of more products to the province and potentially saving lives. The average number of units of packed red blood cells over 3 years has decreased by nearly 41%, from an average of 601 per month to 355 per month, thus making an additional 246 units available per month.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Accountability isn’t an answer on its own; however, it is vital when working within a team, with limited resources, and a highly stressful and over-burdened working environment. The concept of accountability was key in this project; in fact, it was nearly called “Change though Accountability”. We believe that doctors and nurses want to do the right thing, but often they don’t know what that action is – possibly due to lack of training, experience, or junior status. We adopted a philosophy of showing people the way forward, and not just instructing people what to do. We set about to mentor and lead with an example that is backed by scientific evidence. We then followed through with our intention to hold each other accountable (through the Accountability Form) for our decisions related to transfusions, as these decisions affected all of us – we were al using a common pool of blood products, so our decisions impacted everyone. The result was being able to hold each other accountable for our clinical decisions, we could hold management accountable for the money that was saved and ensure that it was used to better the lives of our patients, and we could work together with the South African Blood Transfusion Services to ensure an efficient and sustainable system.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
This project benefitted all patients or every gender and race. It has been only been replicated in government hospitals, where those that cannot afford private healthcare go for medical attention. The project has thus benefitted those patients and institutions that serve the most vulnerable and poor in our healthcare system, as they rely on these government hospitals.

Contact Information

Institution Name:   Edendale Hospital, Kwazulu Natal Department of Health
Institution Type:   Government Department  
Contact Person:   Robert Wise
Title:   Dr  
Telephone/ Fax:   +27735133859
Institution's / Project's Website:  
E-mail:   robert.wise@kznhealth.gov.za  
Address:   40 Ashby Road, Boughton
Postal Code:   3208
City:   Pietermaritzburg
State/Province:   Kwazulu Natal
Country:  

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