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7/19/12

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Introduction

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Katy Loos, RN, MSN

PATIENT BLOOD MANAGEMENTPATIENT BLOOD MANAGEMENTKaty Loos RN, MSNKaty Loos RN, MSN GOOD SAMARITAN HOSPITALGOOD SAMARITAN HOSPITAL

CINCINNATI, OHCINCINNATI, OH

OBJECTIVESOBJECTIVES

Identify areas of practice ready for change

Implement strategies to decrease or

eliminate allogenic transfusions

Identify strategies to manage anemia

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BLOOD MANAGEMENT AT GSHBLOOD MANAGEMENT AT GSH

Started Early 2010

Identified 3 largest users of Blood Products

Focused on Orthopedics, ICU, and Oncology

Other areas were rising to the top in usage

by remaining static giving us our next area

to tackle7

BASIC TENETSBASIC TENETSBASIC TENETSBASIC TENETS

Anemia is a treatable medical condition

Red cells should not be used to treat

anemias that can be corrected with

medications (AABB, American Blood Centers, American Red Cross)

Always document reason for transfusion

Use one unit whenever possible

Recheck labs before ordering more blood

products

IDENTIFY AREAS NEEDING CHANGEIDENTIFY AREAS NEEDING CHANGE

Know your data!

Target key problem areas first

Celebrate and congratulate all gains

Know your practices !

Data DivesData Dives……

Blood utilization by MSDRG

Physician practice

Premier benchmarking

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……drive the focusdrive the focus

Top 10 MSDRGs by Blood Case Count for Discharges January 2009 Top 10 MSDRGs by Blood Case Count for Discharges January 2009 to December 2009 - Inpatientto December 2009 - Inpatient

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Blood Products No Blood Products Var Yes vs. No

MS DRG DRG Description Cases ALOS

Avg Chrgs Cases ALOS

Avg Chrgs ALOS

Avg Chrgs

470

Major joint replacement or reattachment of lower extremity w/o MCC 206 3 59,188 735 2 55,120 1 4,067

765 Cesarean section w CC/MCC 79 8 39,301 960 6 23,264 2 16,037

377 G.I. hemorrhage w MCC 77 5 34,336 23 4 21,902 1 12,434

378 G.I. hemorrhage w CC 62 3 23,686 27 3 19,555 0 4,131

790 Extreme immaturity or respiratory distress syndrome, neonate 60 67 399,723 100 28 152,825 39 246,898

460 Spinal fusion except cervical w/o MCC 59 3 95,448 232 2 70,354 1 25,094

871 Septicemia or severe sepsis w/o MV 96+ hours w MCC 53 8 50,043 306 6 33,643 2 16,400

812 Red blood cell disorders w/o MCC 47 3 16,936 11 1 12,491 2 4,446

811 Red blood cell disorders w MCC 34 4 31,336 7 2 16,391 2 14,946

469

Major joint replacement or reattachment of lower extremity w MCC 34 7 91,471 29 5 64,869 2 26,602

Hospital Average 23% 77% 37,106

Transfusion Practice at GSH by DRGTransfusion Practice at GSH by DRGPEER DataPEER Data

HOSPITAL (OH)) And (({Community Status} = Urban) And ({Council of Teaching Hospitals} = COTH) And ({Bed-Size} = Facilities w/ 501 Beds or More)) And ({Perspective Clinical Summary} = BLOOD PRODUCTS)

MGSH-Top 15 MSDRGS by Blood Product Cases MS-DRG Blood Cases for

FacilityBlood Cases

for Peer

Patient Populatio

n for Facility

Patient Population for Peer

Patient Pop

Utilization Rate for Facility

Patient Population Utilization Rate for

Peer

Pat Pop Util Rate

Variance (Facility-

Peer)Total 826 16,916 4,720 103,823 17.50% 16.29% 1.21%

470MJR JNT RPLCMNT/RTTHMNT OF LWR ET W/OMCC

197 3,052 908 22,973 21.70% 13.29% 8.41%

377 GI HEMORRHAGE WITH MCC 75 1,279 100 3,130 75.00% 40.86% 34.14%765 CESAREAN SECTION WITH CC/MCC 68 596 1,005 13,618 6.77% 4.38% 2.39%

812RED BLOOD CELL DISORDERS WITHOUT MCC

66 2,640 83 6,681 79.52% 39.52% 40.00%

460SPINAL FUSION EXCEPT CERVICAL W/O MCC

62 518 286 6,041 21.68% 8.57% 13.10%

790EXT IMMATUR OR RESP DISTRESS SYN NEONATE

60 947 163 3,047 36.81% 31.08% 5.73%

378 G.I. HEMORRHAGE W CC 54 1,977 80 5,538 67.50% 35.70% 31.80%

871SEPTICEMIA/SEVR SEPSIS W/OMV 96+HRS WMCC

46 1,719 321 11,477 14.33% 14.98% -0.65%

469MAJ JOINT REPLACE/REATTACH LOW EXT W MCC

31 429 53 1,329 58.49% 32.28% 26.21%

811RED BLOOD CELL DISORDERS WITH MCC

31 964 41 2,095 75.61% 46.01% 29.60%

945 REHABILITATION W CC/MCC 30 350 536 9,891 5.60% 3.54% 2.06%

774VAGINAL DELIVERY W COMPLICATING DX

29 158 867 8,908 3.34% 1.77% 1.57%

481HIP & FEMUR PROC EXC MAJOR JOINT W CC

28 1,022 48 3,241 58.33% 31.53% 26.80%

329MAJOR SMALL & LARGE BOWEL PX W MCC

25 900 57 2,976 43.86% 30.24% 13.62%

742UTERINE&ADNEXA PX NONMALIGNANCY WCC/MCC

24 365 172 2,878 13.95% 12.68% 1.27%

 

Transfusion Practice by Top 10 MDs Transfusion Practice by Top 10 MDs

Blood Products No Blood Products Var Yes vs. No

Attend MD Cases ALOS Avg Chrgs Cases ALOS Avg Chrgs ALOS Avg Chrgs

1 159 4 37,131 983 0 8,031 4 29,100

2 93 53 336,243 606 17 88,146 36 248,096

3 70 6 45,824 768 3 22,702 3 23,122

4 61 6 40,356 778 2 20,504 4 19,852

5 55 6 31,756 4769 1 5,970 5 25,787

6 53 7 121,419 435 1 24,366 6 97,052

7 43 3 25,601 680 0 8,116 3 17,485

8 43 8 64,414 278 3 26,218 5 38,196

9 40 4 91,258 211 0 17,306 4 73,953

10 40 3 60,370 481 2 45,024 1 15,346

ORTHOPEDICSORTHOPEDICS

Example of physician blinding for elective total hip arthroplasties

OrthopedicsOrthopedics

Blinded physician-specific transfusion data Presented at Section meeting

Extensive literature review for evidence based best practice New practice initiatives for pre, intra, and post-

operative conservation Amended order sets to reflect changes Established Anemia Clinic

Orthopedic Center of Excellence (OCE) Quality measure: Preoperative anemiaEstablished metrics Posted on OCE dashboard

Orthopedic RecommendationsOrthopedic Recommendations Document Reason for Transfusion:

HGB ≤7, HCT ≤ 21, Hypoxia, Weakness, or other signs of decreased oxygen carrying capacity.

Reasons and Triggers for Autologous transfusion same as allogenic. While autologous transfusion is safer, it is not without risk

Limit autologous donations for indications such as known antibodies on T&S, complex surgery, or patient refusal of blood products.

Check HGB or HCT before automatically transfusing, thereby documenting lab value, and reason for transfusion Do not give PRBCs in PACU without lab results.

Transfuse ONE unit at a time. Then recheck labs, re-evaluate patient. Give second unit only if needed.

INTENSIVE CAREINTENSIVE CARE Physician and Resident education

Newsletter E- LEARN

Mandatory transfusion order set usage Audited for compliance

Established ICU transfusion dashboards Intensivist scorecards delivered quarterly Transfusion order sets revised

Decreased H/H trigger to 7/21 Decreased number of PRBCs to 1 Increased INR trigger on FFP to 1.8 (from 1.5) Oncology subset with decreased triggers

ONCOLOGYONCOLOGY

General Oncology Meeting

OPCC, 14CD, CNS, and Physicians

Show them their practice and opportunity to improve

Task force to review best practice

Always give literature to support changes

Oncology Order sets revised

Decreased RBC trigger to HGB 7 or HCT 21

Decreased daily automatic transfusion to 1 unit RBC if

indicated by trigger (was 2 units)

Decreased Platelet trigger to 10,000 (from 20,000)

Strategies to Decrease or Eliminate Strategies to Decrease or Eliminate Transfusions Transfusions

Anemia is treated as a laboratory value, not a

diagnosis

Overlooked in the presurgical History and

Physical

Total Joint Replacement surgeries (TJA) on the

rise – especially in the elderly

TJAs have some of the highest rates of

transfusion

Preoperative anemia is the greatest predictor of

peri-operative transfusion !!!

Regional anesthesia 

Hypotensive anesthesia for those requiring

general anesthesia

Pre-op Tranexamic acid

Decreased tourniquet time

Reinfusion system

Bipolar cautery

Avoidance of drains

Avoidance of strong VTE chemoprophylaxis in low risk Total Knee Arthroplasy (TKA) patients.

Lovenox 40 mg daily in TKA. INR targets near 1.5 for patients on Coumadin. Prolonged knee flexion >70 degrees the day of

surgery Transfusion triggers HGB 7 / HCT 21 unless

cardiac symptoms or unstable IV fluid correction of hypotension and postural

changes

OUTCOMES IN ORTHOPEDICSOUTCOMES IN ORTHOPEDICS

Since May 2011, overall transfusions of red blood cells have

decreased by over 50% to a rate of 2-6% in elective total joint

procedures

Transfusion rates during total hip replacements decreased

No adverse patient outcomes resulted

Decreased length of stay of 1 day on average

2011 PRBC Orthopedic purchase cost savings of $5,700 per

month average compared to 2010 average

Anemia Prevention Anemia Prevention

Anemia Clinic with automatic treatment of patients by hematologist

Education of residents, and individual services Go to each section meeting and deliver the

message that is pertinent to their practice Let other services know about the

successes gained by others Empower staff nurses as your advocates

Pre-Surgical Anemia ProtocolPre-Surgical Anemia Protocol

Hospital Purchase CostsHospital Purchase Costs

Oncology DataOncology Data

Thank YouThank You Katy Loos RN, MSN Katy Loos RN, MSN

Katy_Loos@trihealth.comKaty_Loos@trihealth.com

(CartCartoon source: http://bloodbankpartners.com)

ReferencesReferences

Alexandrov, A. W., & Brewer, B. B. (2011). The Role of Outcomes in Evaluating Practice

Change. In B. M. Melnyk, & E. Fineout-Overholt, Evidence Based Practice in Nursing and

Healthcare . Philadelphia: Wolters Kluwer/ Lippencott Williams & Wilkins.

American Society of Anesthesiologists, Inc. (2006). Practice guidelines for perioperative

blood transfusion and adjuvant therapies. Anesthesiology, 198 - 208.

 Farris, P., Ritter, M., & Abels, R. (1996). The Effects of Recombinant Human

Erythropoietin on Perioperative Transfusion Requirements in Patients Having a Major

Orthopedic Operation. The Journal of Bone and Joint Surgery, 62 - 72.

Goodnough, L. T., Maniatis, A., Earnshaw, P., Benon, G., P. B., Bisbe, E., et al. (2011).

Detection, evaluation, and management of preoperative anemia in the elective orthopedic

patient: NATA guidelines. British Journal of Anaesthesia, 13 - 22.

References, cont.References, cont.

Kumar, A. (2009, November). Perioperative management of anemia: Limits of blood

transfusion and alternatives to it. Cleveland Clinic Journal of Medicine, pp. S112 - S118.

Liumbruno, G., Bennardello, F., Lattanzio, A., Piccoli, P., & Rossetti, G. (2011).

Recommendations for the transfusion management of patients in the peri-operative

period. III. The post-operative period. Blood Transfusion, 320 - 335.

Martinez, V., Monsaingeon-Lion, A., Cherif, K., Judet, T., Chauvin, M., & Fletcher, D. (2007).

Transfusion strategy for primary knee and hip arthroplasty: Impact of an algorithm to lower

transfusion rates and hospital costs. British Journal of Anesthesia, 794 - 800.

Spahn, D. (2010, August). Anemia and patient blood management in hip and knee surgery:

A systematic review of the literature. Anesthesiology, pp. 482 - 495.

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