1. 1 Introducing Change: An Organizational Overview Tim Dickinson October 7, 2011

2. 2 Objectives Describe quality improvement program Reveal variation in clinical practices Tool & Resources Those who provide medical care must lead in changing medical care Robert Waller Mayo Foundation

3. 3 CPB & ATS Programs PerfusionATS

4. 4 Quality Improvement

5. 5 PIC Meeting Prospective Variance Database –Clinical and Product Quality Indicator Program Chief Medical Officer, Chair –Risk Manager –EVP Clinical Services –Director, Regulatory & Compliance –Director, Clinical Performance Improvement –Others

6. 6 Advisory Boards Medical Perfusion Technician

7. 7 Education Classroom –Leadership training Mock OR LMS (HealthStream ® ) Live Webinars

8. 8 Total Intraop RBCs n=14,424 isolated CABGs 2010

9. 9 Blood Management Practices

10. 10 Blood Management Practices

11. 11 Other Metrics

12. 12 Intraop RBC -units

14. 14 Autotransfusion Reduce ECC Prime - Autologous prime Ultrafiltration Microplegia AVOID ANEMIA Coated ECC Divert Pericardial Bld P.O.C. Lab testing Rx interventions PLT Sequestration Temperature? MINIMIZE BLOOD LOSS Perfusion Blood Management Influence

15. 15 SurgeonAnesthesiologistPerfusionist Patient History Lab Screening/Minimizing Blood Sampling Predict Likelihood for Transfusion Consider Drugs to Increase RBC mass (Iron) Avoid Fluid Overload Avoid/Suspend Anticoagulant Therapy Enforceable Transfusion Guidelines Consider Acute Normovolemic Hemodilution Avoid Hypertension Avoid Fluid Overload Consider Drugs to Reduce Bleeding (Amicar) Meticulous Surgical Technique Enforceable Transfusion Guidelines Cell Salvage Low Prime ECC Microplegia Ultrafiltration Point of Care Lab Testing Avoid Hypertension Consider Platelet Rich Plasma ECC Biopassive Surface Coating Divert Pericardial Blood Avoid Hypertension Avoid Fluid Overload Avoid Hypothermia Consider Drugs to Increase RBC Mass Enforceable Transfusion Guidelines Minimize Blood Sampling Point of Care Lab Testing Early Return to O.R. for Bleeding Consider Cell Salvage POSTOPERATIVEINTRAOPERATIVEPREOPERATIVE

16. 16 Generalizable Scientific Evidence +Context Improvement Keys to Performance Improvement Intelligent Action

17. 17 Reference Articles

18. 18 Dashboard Query

19. 19 Q.I. Run Chart

20. 20 Ad-hoc Query Tool

21. 21 Surgeon Data

22. 22 Intraop RBC vs. Net Prime Volume

23. 23 Flow Chart

24. 24 Action Plan

25. Relative Odds of Receiving Packed Red Blood Cells Transfusion p value <0.001 2003;97:958-63

26. 26 Procedure Volume vs. Prime Volume n=28,200 isolated CABGs 2009-2010

27. 27 Patient Gender vs. Prime Volume

28. 28 Patient Age vs. Prime Volume

29. 29 Preop HCT vs. Prime Volume

30. 30 Intraop RBC units vs. Prime Volume

31. 31 Nadir HCT on CPB vs. Intraop RBCs

32. 32 Summary Variation in clinical practice exists at many levels –Geographic –Top performers Varying practice methods appear to achieve similar RBC utilization rates Change is inevitable –except from a vending machine