1. 1 How we Managed to change Blood Usage with Q.I. Charles B. Yarnall Bs, CCP, LP Clinical Manager National Clinical Specialist

2. 2 Blood Management back ground  Chief Perfusionist at: – Pennsylvania Hospital - 2002 to 2006 –Temple University Hospital -2006 to 2008 –Morristown Memorial 2008 to 2010  National Clinical Specialist –Abington Memorial Hospital 2010 to Present. –Our Lady of Lourdes Medical Center.

3. 3 3 Enabling Change for Blood Management 101  Before you begin anything, find the starting line. –Focusing on Intra-Operative Data was the best bet for a successful collection.  Most blood banks are not setup for mass data searches bases on specific parameters such as: –Who gave and ordered the blood –What was the reason it was given –Where was the blood given –When the blood was given –Why that amount was given.

4. 4 4 Enabling Change for Blood Management 101  Get your medical record numbers together.  Go out and gather all available information –Your Blood Bank Administrator. –Director of Pathology –Hospitals STS Data base –Hospitals Blood management Committee  This is a great opportunity to start building your extended support team.  You need a multimodality approach for change to: –Start, Take Hold and Survive.

5. 5 5 Enabling Change for Blood Management 101  Make the Data collection and entry as simple as possible. –The more information you get, the easier the answers will come. –Motivation is key: Additional work at the end of the case is never fun. –Accuracy is Paramount: Take the time to audit cases weekly, be supportive. – Review the list with your team and ask for feed back.

6. 6 2011 Adult CPB Quality Indicators  Intraop Blood Products? Yes/No –Intraop Red Cell Units –Red Cell Units on CPB –Fresh Frozen Plasma Units –Cryoprecipitate Units –Platelet Units  Red Cell Expire Date  Highest Intraop Glucose  Type of Procedure  CPB Time  Preop HCT  First HCT in O.R.  Post Heparin HCT  Lowest on CPB HCT  Last HCT in O.R.  Anesthesia Volume  Dynamic (Net) Priming Volume

7. 7 Enabling Change for Blood Management 101  Once you have 90 days of Data  Compile your findings –Graphing the result speaks volumes. –It’s the best way to gain a true perspective  Share the data with your team every week: Pick a day and time of the week and stick to it.  Talk about challenging cases. Review what was done, or not done, to help conserve the patients blood components.

8. 8 We are Talking about a lot of numbers Procedure Date AgeWeightHeightBSALowest HCT on CPB Tot Intraop Red Cell Tot Red Cells on CPB Total Intraop FFP Total Intraop Cryo Sep 201074.3377.22166.561.8624.221.000.890.780.00 Oct 201063.2787.05171.821.9925.911.641.360.820.00 Nov 201069.40110.30165.902.0224.901.100.750.400.00 Dec 201070.1688.16170.361.9925.740.64 0.00 Jan 201171.0485.54166.461.9428.140.290.210.00 Feb 201167.1679.20164.561.8525.900.280.400.160.00 Mar 201169.0376.24170.391.8724.910.710.560.060.00 Apr 201172.6173.78159.871.7825.300.39 0.00 May 201168.7881.09167.221.9127.570.13 0.00 Jun 201168.3881.44166.881.8924.630.310.190.00 Jul 201169.2078.84171.041.8626.280.800.560.400.08 Procedure Date Highest Intraop Gluc Net Prime Volume Total CPB Time Preop HCT1st HCT in O.R. Post Heparin HCT Last HCT in O.R. Anesthesia Volume Tot Intraop Platelet Sep 2010209.00833.3394.6734.7033.1130.5026.331,300.000.67 Oct 2010247.27890.91100.5038.8737.8136.2328.951,659.000.64 Nov 2010233.55884.3593.2536.9234.7031.3827.531,075.000.10 Dec 2010224.68839.08100.1236.3036.3434.6029.521,244.000.00 Jan 2011204.86942.86101.6140.0138.7138.6030.141,035.710.36 Feb 2011235.88948.00111.2436.3735.9235.2528.281,420.000.16 Mar 2011201.18873.53118.4137.4834.9733.3828.381,182.350.03 Apr 2011183.22865.2298.7838.0836.6134.0028.301,478.260.04 May 2011153.86960.8797.4340.1539.0936.4530.091,373.910.00 Jun 2011164.75912.50106.5637.4336.2533.7930.131,612.500.00 Jul 2011152.441,116.16107.2835.9836.4233.7430.401,548.000.32

9. 9 Abington Memorial Hospital 3 Year running blood component usage - Only half the story -

10. 10 Benchmark your findings - The other half -  Intra-Op RBC 0.990.831.51  Intra-Op PLT 0.830.180.87  Intra-Op FFP 0.640.130.97  Intra-Op CRYO 0.220.000.12 National Top 10% Abington

11. 11 Don’t Keep It a Secret  Share your information –Most people have no idea of:  A Departments actual usage  Their ranking with Benchmarking  The cost associated with a poor ranking –????????????? –Your either rising above, or digging a hole.

12. 12 Enabling Change for Blood Management 101  Find a CHAMPION. –It might not be you! –It should be someone you can access easily.  Cardiothoracic Surgeon  Cardiac Anesthesiologist  Director of Blood Bank. –COMUNICATION skills are PARAMOUNT! –A proven team builder will carry the process forward at a faster rate

13. 13 The bottom line – Hard Dollars  Each unit of blood products cost around: –$250 for PRBC’s –$56 for FFP –$700 for Single Donor Platelets –$500 each for Pooled Platelets

14. 14 Duration of Blood Storage Basran et al Anesth Analg 2006;103(1):15-20 Hovav et al Transfusion 1999;39(3):277-81 Mortality

15. 15 RBC Transfusion Associated with Mortality and Morbidity Koch CG, et al. Crit Care Med 2006;34(6):1-9

16. 16 Total cost of postoperative complications Rich J.B., et al., Am Heart Hosp J. 2006;4:142-7

17. 17 Biopassive Surface Coating  STS & SCA Blood Conservation Practice Guideline 1 & CPB Practice Guidelines 4  Heparin bonded circuits: 13 –Decreased incidence of RBC transfusion by 20% –Decreased resternotomy by 40% –Decreased ICU LOS by 9.3 hours and Total LOS by 0.5 days 1.STS Blood Conservation Guideline. Ann Thorac Surg 2007;83(5 Suppl):S27-86 4.Shann KG, et al. J Thor Cardiovasc Surg 2006;132(2):283-90 13.Mangoush O, et al. Eur J Cardiothorac Surg 2007;31(6):1058-69

18. 18 Reduce ECC Prime  STS & SCA Blood Conservation Practice Guideline 1 & CPB Practice Guidelines 4  Exposure to allogeneic RBC significantly reduced in low prime group as compared to standard (full) prime group. 5,6  Lowest HCT on bypass significantly higher in low prime group. 5 1.STS Blood Conservation Guideline. Ann Thorac Surg 2007;83(5 Suppl):S27-86 4.Shann KG, et al. J Thor Cardiovasc Surg 2006;132(2):283-90 5.Shapira OM., et al. Ann Thorac Surg 1998:65(3):724-30 6.Perthel M., et al. Perfusion 2007;22(1):9-14

19. 19 Ultrafiltration  Ultrafiltration is associated with a significant reduction in postoperative blood transfusions as well as reduce bleeding in adults undergoing cardiac surgery. 7  Post-bypass ultrafiltration significantly reduced morbidity by 43%. 8  Hemobag ® demonstrated a 64% reduction in allogeneic RBC units transfused (SC –Florida Hospital) 9 7.Boodhwani M., et al. Eur J Cardiothorac Surg 2006;30(6):892-7 8.Luciani GB., et al. Circulation 2001;104(12 Suppl 1):I253-9 9.Results on file

20. 20 Abington Memorial Hospital 11 month running blood component usage - Hard Work will lead to rewarding outcomes -

21. 21 Abington Memorial Hospital 3 Year running blood component usage - Only half the story -

22. 22 Benchmark your findings - let the numbers speak for themselves -  Intra-Op RBC 0.99 0.831.51 0.41  Intra-Op PLT 0.83 0.180.87 0.13  Intra-Op FFP 0.64 0.130.97 0.03  Intra-Op CRY 0.22 0.000.12 0.11 National Top 10% Before After Abington Intra-Op RBC 73% reduction Intra-Op PLT 85% reduction Intra-Op FFP 97% reduction Intra-Op CRY 8% reduction

23. 23 Case Studies  Morristown

24. 24 P.O.C. Coagulation Testing  STS & SCA Blood Conservation Practice Guideline 1  Heparin concentration(HMS) 15 –Significantly reduced platelets, FFP and cryoprecipitate transfusions  Platelet Works –RBC transfusions declined by 19% –Non-RBC transfusions declined by 50% 1.STS Blood Conservation Guideline. Ann Thorac Surg 2007;83(5 Suppl):S27-86 15.Despotis GJ., et al. J Thorac Cardiovasc Surg 1995;110(1):46-54

25. 25 Three Main Components 1.Education with Constant Communication. 2.Change Management 3.Metrics with Accountability

26. Thank You

27. 27 References 1)Scott B.H., et al., Blood use in patients undergoing coronary artery bypass surgery: Impact of cardiopulmonary bypass pump, hematocrit, gender, age and body weight. Anesth Analg 2003;97:958-63. 2)Williamson L.M., et al., Serious hazards of transfusions (SHOT) initiative: analysis of the first two annual reports. BMJ 1999;319:16-9. 3)DeFoe G. R., et al., Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group. Annals of Thoracic Surgery 2001; 71(3):769-76. 4)Habib, R.H., et al., Adverse effects of low hematocrit during cardiopulmonary bypass in the adult: should current practice be changed? J Thorac Cardiovasc Surg 2003;125(6):1438-50. 5)Fang W.C., et al., Impact of minimum hematocrit during cardiopulmonary bypass on mortality in patients undergoing coronary artery surgery. Circulation 1997;96(9):II-194-99. 6)Karkouti K., et al., Low hematocrit during cardiopulmonary bypass is associated with increased risk of perioperative stroke in cardiac surgery. Ann Thorac Surg 2005;80(4):1381-7. 7)Habib R.H., et al., Role of hemodilutional anemia and transfusion during cardiopulmonary bypass in renal injury after coronary revascularization: implications on operative outcome. Crit Care Med. 2005;33(80):1749-56. 8)Dial S., et al., Hemodilution and surgical hemostasis contribute significantly to transfusion requirements in patients undergoing coronary artery bypass. J Thorac Cardiovasc Surg 2005;130(3):654-61. 9)Speiss, B.D., Transfusion and outcome in heart surgery. Ann Thorac Surg 2002;74(4):986-7. 10)Koch C.G., et al., Morbidity and mortality risk associated with red cell and blood-component transfusion in isolated coronary artery bypass grafting. Crit Care Med 2006;34(6):1-9. 11)Koch C.G., et al., Transfusion in coronary artery bypass grafting is associated with reduced long-term survival. Ann Thorac Surg 2006;81(5):1650-7. 12)Cormack J. E., et al., Size makes a difference: use of a low-prime cardiopulmonary bypass circuit and autologous priming in small adults. Perfusion 2000;15(2):129-35. 13)Shapira O. M., et al., Reduction of allogeneic blood transfusions after open-heart operations by lowering cardiopulmonary bypass prime volume. Ann Thorac Surg 1998;65(3):724-30. 14)McCusker K., et al., MAST system: a new condensed cardiopulmonary bypass circuit for adult cardiac surgery. Perfusion 2001;16(6):447- 52. 15)Beholz, S., et al., A new PRECiSe (Priming Reduced Extracorporeal Circulation Setup) minimized the need for blood transfusions. First clinical results in coronary artery bypass grafting. Heart Surgery Forum 2004;8(3):E132-135. 16)Rich J.B., et al., Making a business case for quality by regional information sharing involving cardiothoracic surgery. Am Heart Hosp J. 2006;4:142-7. 17)Riley J.B., et al., Results from the Perfusion.com cardiac surgery hematocrit trend survey.; Observations and evidence-based recommendations. Perfusion.com Jan 2006. 18)Alghamadi A.A., et al., Development and validation of Transfusion Risk Understanding Scoring Tool (TRUST) to stratify cardiac surgery patients according to their blood transfusion needs Transfusion 2006;46;1120-9.