Administrative Report
The Effect of an Educational Program on Transfusion Practices in a Regional Blood Program R. S. HILLMAN, S. HELBIG,S. HOWES,J. HAYES,D. M. MEYERA N D J. R. MCARTHUR From the Healfh Sciences Learning Resources Cenfer and the Pugef Sound Blood Center, Seattle, Washington
With the increased complexity of blood component therapy, it is important to be able to modify physician behavior with reliable educational programs. A standudlzed educatioorrl program on the use of red blood cells and whale blood was tested in 22 hospitals in a regional blood program using medical audit and computer monitoring to evaluate effectiveness. Most hospltals were eager to take advantage of the education program but were unwilling to use the audit-cducatiw cycle. At the same time, computer monitoring of individd hospital ordering and transfusion practices demonstrated an Increased utilization of red blood cells in 64 per cent of hospltds with an overall hnprovement of 8 per cent. The improved use of red blood cells was appreelated within the month of the program and then sustained for six to twelve months at the new level.
BECAUSE OF RECENT ADVANCES in technology and administration of blood center programs, there is a need to bring educational programs to physicians using blood components in their practice. Previous studies of the impact of educational programs on physician behavior and patient care have demonstrated variable results. Jones et ~ l .in, a~study of the effects of an educational program concerning the use of antibioticsin a university-afliliated Veterans Administration Hospital, found the program did influence antibiotic administration. However, Pozen and Bonnet5 studied educational and administrative interventions in medical outpatient clinics and reported no measurable improvement in patient care. Supported by U.S.P.H.S. grant HL 17265, National Heart, Lung and Blood Institute, National Institutes of Health. Received for publication April 21, 1978; accepted June 4, 1978.
The inability to show a change in physician behavior following an educational program has been attributed to a number of factors including, inadequate systems for monitoring physician performance and levels of patient care; lack of focus of educational programs; failure on the part of physicians to support continuing education efforts; failure to address educational need in the areas of skills of patient evaluation and management; an absence of quality standards for patient care; and finally, a failure to require recertification of physicians. In recent years, a popular prescription for improving inhospital patient care has been the audit-educationprogram cycle of Brown et al. to identify less-than-optimum patient care and define the cause of the problem, thereby setting the stage for a targeted education effort. This approach was applied to a study aimed at measuring the effectiveness of a transfusion auditleducation program on transfusion practices in the Puget Sound Area. The study, by the Research and Demonstration Center of the Puget Sound Blood Center, involved not only the use of existing audit programs, but also brought to bear the capabilities of a computer system to monitor physician transfusion practices following a singlefocused education program. Methods An audit was designed to look a t physician decision-making in the selection of either red blood cells or whole blood. A simple grading
0041-1132/79/0300/0153 $00.75 8 J. Tmnrfusion
Much-April 1979
153
B. Lippincott Co. Volume 19
Number 2
system was employed for determining the patient’s volume status and severity of anemia and blood loss so that a medical records librarian could determine whether the patient’s clinical condition required the use of red blood cells or whole blood. If the clinical picture was not clear-cut, it was also possible to record component selection according to whether there was a majority or preponderance of clinical indications for the use of one or the other product. The audit was pretested in five hospitals with different patterns of health care delivery. A two-page questionnaire was mailed to 86 physicians on the staff of three hospitals. Radiologists and psychiatrists were not included, since they rarely order blood components. Fifty-six per cent of the physicians returned the questionnaire which covered specific areas of knowledge concerning the ordering and transfusion of whole blood and blood components. It was mailed during the same period as the initial audit testing. Continuous monitoringof the number of whole blood and red blood cell units ordered and transfused by 22 area hospitals was camed out using the Puget Sound Blood Center’s computer records. Information collection was begun six months before implementation of an education program and then continued for twelve months after the program. For the purposes of data display, the number of red blood cell units transfused was expressed as a per cent of total red blood cell plus whole blood transfusions. Analysis was carried out using four-month averages so as to smooth individual monthly discrepancies resulting from irregular blood return practices at the end of each month at the Puget Sound Blood Center. The collected data were subjected to statistical analysis using the methods of linear regression analysis and t-test of significance. A full transfusion audit-education program was offered to 22 area hospitals. This was after the first medical audit had been pretested in five hospitals, the questionnaire returned and anaTable l . Per Cent of Red Blood Cells and Whole Blood Transfused Appropriately Whole Blood
Hospital 1 Hospital 2 Hospital 3
Tmafuaion
HILLMAN ET AL.
154
Red Cells
Required
Preferred Product
Required
Preferred Product
86 100 100
89 75 86
30 47 65
80 75 100
March-April lV9
lyzed, and six months of computer monitoring had been completed. The professional staff responsible for continuing education efforts and records administration personnel were contacted and offered both the transfusion audit and an educational program on blood component therapy. It was recommended that the transfusion audit be camed out first followed by the educational sessions. Hospital records administration staff were also asked to evaluate the usefulness of the transfusion audit in monitoring change in physician transfusion practices. At the same time, the use of the audit was not considered a prerequisite to the availability of the education program. If a hospital did not want to run the audit, it could still use the education program. In order to fit variations in hospital education systems, the program on blood component therapy was offered either as a presentation by a speaker from the Puget Sound Blood Center or the University of Washington, a packaged talk with appropriate slides for presentation by a member of the hospital staff, or a self-instructional slide-sevaudiotapeprogram for use in the hospital library.* Finally, a post-test was administered at the end of each presentation as a measure of the appropriateness of the program to educational needs.
Results The initial monitoring of physician behavior using the transfusion audit demonstrated deficiencies in the appropriate use of red blood cells and whole blood in each of the three hospitals (Table 1). The results of the questionnaire indicated that physician knowledge of transfusion practices was uniformly high. Overall scores exceeded 75 per cent correct in the selection of the appropriate component for straightforward clinical problems. However, in more difficult clinical situations many physicians did poorly in selecting the appropriate product. There were also misunderstandings as to routine blood ordering and administrative procedures and not all physicians were aware of the storage characteristics of red blood cells or their routine availability on an emergency basis. This appeared to reflect a lack of knowledge of recent advances in preparation and storage of blood components. Computer monitoring of the per cent of red blood cells transfused in the six-month period prior to the education program showed an average use for all 22 hospitals of 42.3 10.1 per cent with a range of 25.8 to 69.5 per cent. This
*
Volume 19
Number 2
EDUCATIONAL PROGRAM
wide range reflected, in large part, the diversity of the hospitals served by the Puget Sound Blood Center. Two of the hospitals using a high percentage of red blood cells specialize in pediatric care, elective surgery, or the care of patients with chronic anemias. Hospitals at the lower end of the range have major programs of cardiovascular and coronary bypass surgery and/or trauma care. Despite these differences in hospital programs, the aveage overall use for the community for the six-month period was quite constant (Fig. 1). Of the 22 hospitals offering the full transfusion audit-education program, only five hospitals chose to run the audit program prior to the delivery of the educational program. The apparent reason for most hospitals not using the audit was that they either had their own audit program or felt the recommended audit did not fit the requirements of the Joint Commission on Accreditation of Hospitals (JCAH). This reflected the fact that the audit looks at the decision-making process in the selection of blood products, while JCAH required outcome audits which look at overall improvement in health care.' At the same time, all hospitals took advantage of the education program on blood component therapy. The majority of the hospitals requested live presentations by a physician from the Puget Sound Blood Center or the University of Washington, and the program was scheduled as one of the regular housestaff or professional staff continuing-education programs. Two hospitals used the packaged instructional program delivered by one of their own staff and the teaching hospitals affiliated with the University of Washington incorporated the self-instructional program into their audio-visual libraries. When each hospital was monitored for the 12 months following the educational event (Fig. 1). there was a definite upward trend in the use of red blood cells. The most dramatic change occurred in the first month after the educational event and then was sustained at or about the same level for the next six months. Between six and twelve months there was a slight overall decline in the use of red blood cells from a mean of 50.3 to 48.6 per cent. When the 22 hospitals were analyzed individually (Fig. 2), 68 per cent showed increases in the utilization of red blood cells while 32 per cent showed no significant change. Change occurred regardless of the initial per cent utilization of red blood cells; hospitals at low, middle and high per cent utilization levels showed increases in the utilization of red cells. Unfortunately, the relatively small number of hospitals using the transfusion audit program made it impossible to correlate the predictive
"1
2
155 Educotionol Contoct
I
0 h 6 5 4 3 2 I
I
.
1
.
1
.
I
.
I
.
9
I
I 2 3 4 5 6 7 8 9 1011 I2
Months
FIG. 1. Mean of 22 hospitals f one standard deviation. Red blood cells utilized six months before and twelve months after educational contact.
nature of the transfusion audit in subsequent changes in the per cent utilization of red blood cells. Moreover, none of the hospitals used the audit to monitor the effectiveness of the educational program, making it impossible to correlate the overall change in per cent utilization of cells with improved physician selection as measured by audit. Post-tests were completed by 600 of the physicians attending the education programs. Only 4 per cent of physicians reported having previous knowledge of everything covered by the program. The majority of physicians had previous knowledge of approximately two thirds of the material presented with the balance representing new knowledge. Over the fivemonth period required to deliver the educational programs to all 22 hospitals, the results of the post-test questionnaire did not vary, demonstrat6 Months After Contact
22 Hospitals
12 Months After Contact
22 Hospitals
FIG.2. Hospitals monitored for utilization of red blood cells for six and twelve months after educational contact. Solid dots = mean utilization six months before educational contact; open circles = mean utilization six or twelve months after educational contact. Only one hospital showed an immediate reduction in red blood cell use following the program while a second showed a reduction during the sixtwelve month follow-up period.
HILLMAN ET AL.
ing the fact that there were no other educational influences changing their behavior or level of knowledge during that period.
Discussion Past studies of the reliability and effectiveness of educational programs in changing physician behavior have given variable result^.^.^ This has stimulated new efforts within hospitals to improve both procedures for monitoring the quality of health care and the effectiveness of continuing education programs for the professional staff. One such effort has involved the use of medical audits to identify problem areas, define the cause and characteristics of the problem, and stimulate specific educational or administrative corrective maneuvers. The increasing complexity of regional blood programs has established a need for blood services personnel to maintain a high level of communication with hospital administrators and professional staff. With the development of new programs of blood component therapy, blood centers need reliable methods of educating hospital staff to changes in transfusion practices. Otherwise, rational plans for changes in product availability is impossible. To look at this problem the Puget Sound Research and Demonstration Center carried out a study of the selection and use of two basic blood components, red blood cells and whole blood by physicians in 22 hospitals in the Puget Sound area. The study looked both at the value of medical audit programs in stimulating the use of an educational program and the Blood Center's ability to collect useful data through computer monitoring of hospital ordering and transfusion of components. Several conclusions can be drawn from this experience. Considerable difficulty may be experienced in using - medical audit systems for measuring and monitoring physician transfusion practices. Since blood center education programs are targeted at the decision-making processes of physician selection and utilization of components,
Transfusion M.rrh-Aprill979
transfusion audits need to be process audits. This does not necessarily match the interest of inhospital audit programs where JCAH requirementsfocus on patient care outcome.' This mismatch was reflected both in our failure to gain approval of blood center audits by records administrator personnel and by the dimculty experienced by records personnel in the collection and analysis of data from such audits. Most hospitals are eager to take advantage of any education program which fits their needs for continuing education. Organizing education efforts around the so-called bi-cycle approach of Brown et al.' takes both time and considerable inhospital coordination of administrators, physician staff and records personnel. Unless these individuals are cooperative, the program can rapidly become disorganized. It was our experience that the professional staff responsible for scheduling educational events did not want to wait for the audit results but wished to go ahead immediately with the educational program. The effectiveness of the education program was clearly demonstrable by simply monitoring individual hospital ordering and transfusion practices. The per cent of red blood cells used per month showed a significant change in 68 per cent of the 22 hospitals. The change was both immediate within the first month after the educational program and sustained for up to 12 months, ruling against an effect from an uncontrolled variable. Computer monitoring cannot be used, however, to predict which hospitals require an education program. Because of the differences in hospital activities in the Puget Sound region, utilization of red blood cells ranged from a low of 26 per cent to a high of 69 per cent of blood transfused. Regardless of the initial level of utilization, significant increases were observed. Moreover, the hospitals which did not increase utilization could not be identified from their initial level of red blood cell utilization. It was apparent that the effect of the educational
Volume 19 Number 2
157
EDUCATIONAL PROGRAM
package was not cancelled out by either inhouse educational events or administrative rulings within the hospitals. This is an important point since the apparent randomness of education programs and physician communication has frequently been used as an excuse for not mounting an organized educational program. It may be concluded from this study that medical audit results, physician questionnaires, and the expertise of blood center personnel can be used as a basis for developing a highly targeted educational program which will impact on physician behavior. As measured both by the change in overall percentage use of red blood cells and by a post-test questionnaire of participating physicians, a single program on blood component therapy answered the educational needs of physicians with widely diverse backgrounds and specialty interests in 22 hospitals. Organized educational efforts should not be feared as a potential cause of disorder or disruption of blood ordering practices. When the educational program on red blood cells versus whole blood was delivered in a limited period of four to five months, the utilization of red blood cells increased by better than 8 per cent overall and 64 per cent of the participating hospitals showed a significant increase in the percentage of red blood cells utilized. This was not accompanied by disruptive monthly swings in the number of red blood cell units used by individual hospitals. The average 8 per cent increase in utilization of red blood cells occurred
predictably one month after the education program and then was sustained for a six to twelve month period. This allows the blood center to make reliable predictions meshing its own internal planning process with the change in physician behavior which follows the educational program. References R. Jr., and H. S. M. Uhl: Mandatory continuing education. Sense or nonsense? JAMA 213:1660, 1970. Hillman, R. S.: Blood Component Therapy. University of Washington, Seattle, Health Sciences Learning Resources Center, 1977. Jones, S. R., J. Barks, T. Bratton, E. McRee, J. Pannell, V. A. Yanchick, R. Browne, and J. W. Smith: The effect of an educational program upon hospital antibiotic use, Am. J. Med. Sci. 27379, 1977. Meyer, D., S.Helbig, P.Engberg, and R. Hillman: Hospital transfusion audits in the management of blood center education efforts. Unpublished manuscript. Pozen, M. W., and P. D. Bonnet: Effectiveness of educational and administrative interventions in medical outpatient clinics. Am. J. Public Health 66:151. 1976.
1. Brown, C.
2.
3.
4.
5.
R. S.Hillman, Health Sciences Learning Resources Center, Seattle, Washington. S. Helbig, Department of Health Information Services, School of Science and Engineering, Seattle University, Seattle, Washington. S. Howes, Health Sciences Learning Resources Center. J. Hayes, Puget Sound Blood Center, Seattle, Washington. D. M. Meyer, Health Sciences Learning Resources Center. J. R. McArthur. Health Sciences Learning Resources Center.
The Effect of an Educational Program on Transfusion Practices in a Regional Blood Program R. S. HILLMAN, S. HELBIG,S. HOWES,J. HAYES,D. M. MEYERA N D J. R. MCARTHUR From the Healfh Sciences Learning Resources Cenfer and the Pugef Sound Blood Center, Seattle, Washington
With the increased complexity of blood component therapy, it is important to be able to modify physician behavior with reliable educational programs. A standudlzed educatioorrl program on the use of red blood cells and whale blood was tested in 22 hospitals in a regional blood program using medical audit and computer monitoring to evaluate effectiveness. Most hospltals were eager to take advantage of the education program but were unwilling to use the audit-cducatiw cycle. At the same time, computer monitoring of individd hospital ordering and transfusion practices demonstrated an Increased utilization of red blood cells in 64 per cent of hospltds with an overall hnprovement of 8 per cent. The improved use of red blood cells was appreelated within the month of the program and then sustained for six to twelve months at the new level.
BECAUSE OF RECENT ADVANCES in technology and administration of blood center programs, there is a need to bring educational programs to physicians using blood components in their practice. Previous studies of the impact of educational programs on physician behavior and patient care have demonstrated variable results. Jones et ~ l .in, a~study of the effects of an educational program concerning the use of antibioticsin a university-afliliated Veterans Administration Hospital, found the program did influence antibiotic administration. However, Pozen and Bonnet5 studied educational and administrative interventions in medical outpatient clinics and reported no measurable improvement in patient care. Supported by U.S.P.H.S. grant HL 17265, National Heart, Lung and Blood Institute, National Institutes of Health. Received for publication April 21, 1978; accepted June 4, 1978.
The inability to show a change in physician behavior following an educational program has been attributed to a number of factors including, inadequate systems for monitoring physician performance and levels of patient care; lack of focus of educational programs; failure on the part of physicians to support continuing education efforts; failure to address educational need in the areas of skills of patient evaluation and management; an absence of quality standards for patient care; and finally, a failure to require recertification of physicians. In recent years, a popular prescription for improving inhospital patient care has been the audit-educationprogram cycle of Brown et al. to identify less-than-optimum patient care and define the cause of the problem, thereby setting the stage for a targeted education effort. This approach was applied to a study aimed at measuring the effectiveness of a transfusion auditleducation program on transfusion practices in the Puget Sound Area. The study, by the Research and Demonstration Center of the Puget Sound Blood Center, involved not only the use of existing audit programs, but also brought to bear the capabilities of a computer system to monitor physician transfusion practices following a singlefocused education program. Methods An audit was designed to look a t physician decision-making in the selection of either red blood cells or whole blood. A simple grading
0041-1132/79/0300/0153 $00.75 8 J. Tmnrfusion
Much-April 1979
153
B. Lippincott Co. Volume 19
Number 2
system was employed for determining the patient’s volume status and severity of anemia and blood loss so that a medical records librarian could determine whether the patient’s clinical condition required the use of red blood cells or whole blood. If the clinical picture was not clear-cut, it was also possible to record component selection according to whether there was a majority or preponderance of clinical indications for the use of one or the other product. The audit was pretested in five hospitals with different patterns of health care delivery. A two-page questionnaire was mailed to 86 physicians on the staff of three hospitals. Radiologists and psychiatrists were not included, since they rarely order blood components. Fifty-six per cent of the physicians returned the questionnaire which covered specific areas of knowledge concerning the ordering and transfusion of whole blood and blood components. It was mailed during the same period as the initial audit testing. Continuous monitoringof the number of whole blood and red blood cell units ordered and transfused by 22 area hospitals was camed out using the Puget Sound Blood Center’s computer records. Information collection was begun six months before implementation of an education program and then continued for twelve months after the program. For the purposes of data display, the number of red blood cell units transfused was expressed as a per cent of total red blood cell plus whole blood transfusions. Analysis was carried out using four-month averages so as to smooth individual monthly discrepancies resulting from irregular blood return practices at the end of each month at the Puget Sound Blood Center. The collected data were subjected to statistical analysis using the methods of linear regression analysis and t-test of significance. A full transfusion audit-education program was offered to 22 area hospitals. This was after the first medical audit had been pretested in five hospitals, the questionnaire returned and anaTable l . Per Cent of Red Blood Cells and Whole Blood Transfused Appropriately Whole Blood
Hospital 1 Hospital 2 Hospital 3
Tmafuaion
HILLMAN ET AL.
154
Red Cells
Required
Preferred Product
Required
Preferred Product
86 100 100
89 75 86
30 47 65
80 75 100
March-April lV9
lyzed, and six months of computer monitoring had been completed. The professional staff responsible for continuing education efforts and records administration personnel were contacted and offered both the transfusion audit and an educational program on blood component therapy. It was recommended that the transfusion audit be camed out first followed by the educational sessions. Hospital records administration staff were also asked to evaluate the usefulness of the transfusion audit in monitoring change in physician transfusion practices. At the same time, the use of the audit was not considered a prerequisite to the availability of the education program. If a hospital did not want to run the audit, it could still use the education program. In order to fit variations in hospital education systems, the program on blood component therapy was offered either as a presentation by a speaker from the Puget Sound Blood Center or the University of Washington, a packaged talk with appropriate slides for presentation by a member of the hospital staff, or a self-instructional slide-sevaudiotapeprogram for use in the hospital library.* Finally, a post-test was administered at the end of each presentation as a measure of the appropriateness of the program to educational needs.
Results The initial monitoring of physician behavior using the transfusion audit demonstrated deficiencies in the appropriate use of red blood cells and whole blood in each of the three hospitals (Table 1). The results of the questionnaire indicated that physician knowledge of transfusion practices was uniformly high. Overall scores exceeded 75 per cent correct in the selection of the appropriate component for straightforward clinical problems. However, in more difficult clinical situations many physicians did poorly in selecting the appropriate product. There were also misunderstandings as to routine blood ordering and administrative procedures and not all physicians were aware of the storage characteristics of red blood cells or their routine availability on an emergency basis. This appeared to reflect a lack of knowledge of recent advances in preparation and storage of blood components. Computer monitoring of the per cent of red blood cells transfused in the six-month period prior to the education program showed an average use for all 22 hospitals of 42.3 10.1 per cent with a range of 25.8 to 69.5 per cent. This
*
Volume 19
Number 2
EDUCATIONAL PROGRAM
wide range reflected, in large part, the diversity of the hospitals served by the Puget Sound Blood Center. Two of the hospitals using a high percentage of red blood cells specialize in pediatric care, elective surgery, or the care of patients with chronic anemias. Hospitals at the lower end of the range have major programs of cardiovascular and coronary bypass surgery and/or trauma care. Despite these differences in hospital programs, the aveage overall use for the community for the six-month period was quite constant (Fig. 1). Of the 22 hospitals offering the full transfusion audit-education program, only five hospitals chose to run the audit program prior to the delivery of the educational program. The apparent reason for most hospitals not using the audit was that they either had their own audit program or felt the recommended audit did not fit the requirements of the Joint Commission on Accreditation of Hospitals (JCAH). This reflected the fact that the audit looks at the decision-making process in the selection of blood products, while JCAH required outcome audits which look at overall improvement in health care.' At the same time, all hospitals took advantage of the education program on blood component therapy. The majority of the hospitals requested live presentations by a physician from the Puget Sound Blood Center or the University of Washington, and the program was scheduled as one of the regular housestaff or professional staff continuing-education programs. Two hospitals used the packaged instructional program delivered by one of their own staff and the teaching hospitals affiliated with the University of Washington incorporated the self-instructional program into their audio-visual libraries. When each hospital was monitored for the 12 months following the educational event (Fig. 1). there was a definite upward trend in the use of red blood cells. The most dramatic change occurred in the first month after the educational event and then was sustained at or about the same level for the next six months. Between six and twelve months there was a slight overall decline in the use of red blood cells from a mean of 50.3 to 48.6 per cent. When the 22 hospitals were analyzed individually (Fig. 2), 68 per cent showed increases in the utilization of red blood cells while 32 per cent showed no significant change. Change occurred regardless of the initial per cent utilization of red blood cells; hospitals at low, middle and high per cent utilization levels showed increases in the utilization of red cells. Unfortunately, the relatively small number of hospitals using the transfusion audit program made it impossible to correlate the predictive
"1
2
155 Educotionol Contoct
I
0 h 6 5 4 3 2 I
I
.
1
.
1
.
I
.
I
.
9
I
I 2 3 4 5 6 7 8 9 1011 I2
Months
FIG. 1. Mean of 22 hospitals f one standard deviation. Red blood cells utilized six months before and twelve months after educational contact.
nature of the transfusion audit in subsequent changes in the per cent utilization of red blood cells. Moreover, none of the hospitals used the audit to monitor the effectiveness of the educational program, making it impossible to correlate the overall change in per cent utilization of cells with improved physician selection as measured by audit. Post-tests were completed by 600 of the physicians attending the education programs. Only 4 per cent of physicians reported having previous knowledge of everything covered by the program. The majority of physicians had previous knowledge of approximately two thirds of the material presented with the balance representing new knowledge. Over the fivemonth period required to deliver the educational programs to all 22 hospitals, the results of the post-test questionnaire did not vary, demonstrat6 Months After Contact
22 Hospitals
12 Months After Contact
22 Hospitals
FIG.2. Hospitals monitored for utilization of red blood cells for six and twelve months after educational contact. Solid dots = mean utilization six months before educational contact; open circles = mean utilization six or twelve months after educational contact. Only one hospital showed an immediate reduction in red blood cell use following the program while a second showed a reduction during the sixtwelve month follow-up period.
HILLMAN ET AL.
ing the fact that there were no other educational influences changing their behavior or level of knowledge during that period.
Discussion Past studies of the reliability and effectiveness of educational programs in changing physician behavior have given variable result^.^.^ This has stimulated new efforts within hospitals to improve both procedures for monitoring the quality of health care and the effectiveness of continuing education programs for the professional staff. One such effort has involved the use of medical audits to identify problem areas, define the cause and characteristics of the problem, and stimulate specific educational or administrative corrective maneuvers. The increasing complexity of regional blood programs has established a need for blood services personnel to maintain a high level of communication with hospital administrators and professional staff. With the development of new programs of blood component therapy, blood centers need reliable methods of educating hospital staff to changes in transfusion practices. Otherwise, rational plans for changes in product availability is impossible. To look at this problem the Puget Sound Research and Demonstration Center carried out a study of the selection and use of two basic blood components, red blood cells and whole blood by physicians in 22 hospitals in the Puget Sound area. The study looked both at the value of medical audit programs in stimulating the use of an educational program and the Blood Center's ability to collect useful data through computer monitoring of hospital ordering and transfusion of components. Several conclusions can be drawn from this experience. Considerable difficulty may be experienced in using - medical audit systems for measuring and monitoring physician transfusion practices. Since blood center education programs are targeted at the decision-making processes of physician selection and utilization of components,
Transfusion M.rrh-Aprill979
transfusion audits need to be process audits. This does not necessarily match the interest of inhospital audit programs where JCAH requirementsfocus on patient care outcome.' This mismatch was reflected both in our failure to gain approval of blood center audits by records administrator personnel and by the dimculty experienced by records personnel in the collection and analysis of data from such audits. Most hospitals are eager to take advantage of any education program which fits their needs for continuing education. Organizing education efforts around the so-called bi-cycle approach of Brown et al.' takes both time and considerable inhospital coordination of administrators, physician staff and records personnel. Unless these individuals are cooperative, the program can rapidly become disorganized. It was our experience that the professional staff responsible for scheduling educational events did not want to wait for the audit results but wished to go ahead immediately with the educational program. The effectiveness of the education program was clearly demonstrable by simply monitoring individual hospital ordering and transfusion practices. The per cent of red blood cells used per month showed a significant change in 68 per cent of the 22 hospitals. The change was both immediate within the first month after the educational program and sustained for up to 12 months, ruling against an effect from an uncontrolled variable. Computer monitoring cannot be used, however, to predict which hospitals require an education program. Because of the differences in hospital activities in the Puget Sound region, utilization of red blood cells ranged from a low of 26 per cent to a high of 69 per cent of blood transfused. Regardless of the initial level of utilization, significant increases were observed. Moreover, the hospitals which did not increase utilization could not be identified from their initial level of red blood cell utilization. It was apparent that the effect of the educational
Volume 19 Number 2
157
EDUCATIONAL PROGRAM
package was not cancelled out by either inhouse educational events or administrative rulings within the hospitals. This is an important point since the apparent randomness of education programs and physician communication has frequently been used as an excuse for not mounting an organized educational program. It may be concluded from this study that medical audit results, physician questionnaires, and the expertise of blood center personnel can be used as a basis for developing a highly targeted educational program which will impact on physician behavior. As measured both by the change in overall percentage use of red blood cells and by a post-test questionnaire of participating physicians, a single program on blood component therapy answered the educational needs of physicians with widely diverse backgrounds and specialty interests in 22 hospitals. Organized educational efforts should not be feared as a potential cause of disorder or disruption of blood ordering practices. When the educational program on red blood cells versus whole blood was delivered in a limited period of four to five months, the utilization of red blood cells increased by better than 8 per cent overall and 64 per cent of the participating hospitals showed a significant increase in the percentage of red blood cells utilized. This was not accompanied by disruptive monthly swings in the number of red blood cell units used by individual hospitals. The average 8 per cent increase in utilization of red blood cells occurred
predictably one month after the education program and then was sustained for a six to twelve month period. This allows the blood center to make reliable predictions meshing its own internal planning process with the change in physician behavior which follows the educational program. References R. Jr., and H. S. M. Uhl: Mandatory continuing education. Sense or nonsense? JAMA 213:1660, 1970. Hillman, R. S.: Blood Component Therapy. University of Washington, Seattle, Health Sciences Learning Resources Center, 1977. Jones, S. R., J. Barks, T. Bratton, E. McRee, J. Pannell, V. A. Yanchick, R. Browne, and J. W. Smith: The effect of an educational program upon hospital antibiotic use, Am. J. Med. Sci. 27379, 1977. Meyer, D., S.Helbig, P.Engberg, and R. Hillman: Hospital transfusion audits in the management of blood center education efforts. Unpublished manuscript. Pozen, M. W., and P. D. Bonnet: Effectiveness of educational and administrative interventions in medical outpatient clinics. Am. J. Public Health 66:151. 1976.
1. Brown, C.
2.
3.
4.
5.
R. S.Hillman, Health Sciences Learning Resources Center, Seattle, Washington. S. Helbig, Department of Health Information Services, School of Science and Engineering, Seattle University, Seattle, Washington. S. Howes, Health Sciences Learning Resources Center. J. Hayes, Puget Sound Blood Center, Seattle, Washington. D. M. Meyer, Health Sciences Learning Resources Center. J. R. McArthur. Health Sciences Learning Resources Center.
