1. Blood Utilization at VUMC: Developing Systems Which Shape High Quality Care Gina Whitney, M.D. Departments of Anesthesiology and Pediatrics

2. Beginnings Philosophical – o Developing a model by which postoperative outcomes inform intraoperative practice Practical o Giving a large quantity of blood products intra-operatively o “Empiric” transfusion practice o Epidemic of “capillary leak” and prolonged ventilator dependence post-operatively Perioperative Blood Product Utilization in Pediatric Cardiac Surgery

4. 5 units 6+ units

5. Koch, CG Ann Thorac Surg 2006; 81:1650-7.

6. Two ventricle repairs without arch reconstruction – April 1996 – July 2004 – 270 patients – Looked at intraoperative blood products 4-34 ml/kg LOW 35-67 ml/kg MEDIUM 68-364 ml/kg HIGH – Measured DMV

7. The Quality Case: PRBC transfusion is associated with dose- dependent increases in – surgical site infection – ventilator associated pneumonia – duration of mechanical ventilation – length of stay – mortality

8. Why (else) should we care about PRBC transfusion? FINANCIAL ALL BLOOD PRODUCTS >12, 700 TRANSFUSIONS in 2010 - VCH, ALL PRODUCTS ANNUAL FACTOR 7 UTILIZATION ~1 MILLION DOLLARS

9. Blood Product Utilization

10. Some problems are so complex that you have to be highly intelligent and well informed just to be undecided about them. -Laurence J. Peter

11. Standardization of Intraoperative Practice

12. Statistical Process Control

13. Total PRBC per case - Anesthesia

14. Red Cell Transfusion Implementation Period P=0.001

15. Total Cryo per Case - Anes

16. Implementation Period Cryoprecipitate Transfusion P<0.001

17. Total Blood Products per case - Anesthesia

18. Total Blood Products per Case – 12h ICU

19. Total Blood Products per Case Anes + 12h ICU

20. Balancing Measure – Chest Tube Output Age < 180 days Age > 180 days

21. Factor 7 Utilization

22. Touchpoint: OR Exit Criteria ABG within 30 min of leaving room – pH >7.3 – Lactate <10 CT Output < 3 cc/kg/15min Inotrope requirement – Epi <0.05 mcg/kg/min – Dopamine <10 mcg/kg/min Debriefing performed

23. Lessons Learned Creating standard practice establishes expectations about evidence based management and clinical course. Perfect is the enemy of the good. Move towards problems and not away from them. Replicate successes. Lynda.com

24. Moving Beyond the OR

26. Identifying Challenges Need for evidence-based algorithm to determine appropriateness of PRBC transfusion Metrics unclear Attribution of PRBC transfusion to the incorrect attending physicians “Drive by” transfusions Need for education regarding transfusion risk

27. Systems Support Good Practice

28. How important are systems? Ann Thorac Surg 2012 Oct 3 12 regional hospitals Transfusion practice following CAB from Jan 2008 – June 2011 – Surgeon identity accounted for 30% of practice variation – Institution identity accounted for 70% of variation in practice

29. Next steps Identified pilot ICU’s at both MCJCHV and VUH Literature Search Development of evidence based PRBC transfusion protocol (adult CVICU, trauma ICU) Modification of existing CPOE system – “Transfuse and reassess” practice – Warn provider of off protocol transfusion – Attribution of transfusion decision to the correct attending physician

31. Define Best Practice Implemented August 2011

32. CPOE Decision Support

35. Is our PRBC transfusion practice safer today than it was twelve months ago?

36. Future Directions Establish “True North” Metrics Mutual accountability – Blood utilization metrics are relevant, up to date – Ongoing collaboration with providers (feedback, data and refinement of existing practices) Establish partnerships with locations with high utilization and low adherence to established EB practices – Target resources to areas of greatest opportunity Transparency

37. Ordering Practice by Location - MCJCHV

38. How to Engage and Communicate?

39. Questions/discussion