1. Today’s Webinar will begin at 11:00 2/9/12

2. Welcome from Barb DeBaun, RN, MSN, CIC

4. Introduction Please do not put your phone on hold; use the mute function or *6 Please type questions into text box If time permits, we will open up the phone lines at the conclusion of the presentation

5. Blood Conservation in CABG Surgery February 9, 2012

6. Participants Barry Johnson, MD –CV Surgery Anesthesiologist –barryjonsn@aol.com Pablo Zubiate, CCP –Cardiovascular Surgery Coordinator –Pablo.zubiate@enloe.orgPablo.zubiate@enloe.org Marcia Nelson, MD, FAAFP –Vice President, Medical Affairs –Marcia.nelson@enloe.orgMarcia.nelson@enloe.org

7. Perspective Historically, >50% of bypass surgeries transfused –Lundy’s hemoglobin threshold of 1942 Study recommended transfusion for Hb < 8-10 New studies focus on safety Enloe creating new evidence-based standards

8. The Public is Watching Wall Street Journal, October 19, 2010

9. Enloe Medical Center 298-bed Level II Trauma Center 14,500 admissions/year Planetree affiliate Hospital-owned Flight Care New Magnolia Tower Spring 2012 –New CV ICU –Doubles the number of OR suites

10. Quality at Enloe Created organizational focus in 2009 Annual Quality Summit Organizational quality initiatives Program-based poster presentations

11. Enloe Heart Program Blue Distinction for Cardiac Care STEMI Receiving Center Cardiology, Interventional Cardiology, Electrophysiology Cardiac Surgery

12. Cardiothoracic Surgery Team Surgeons Miguel Puig, MD Guy Lemire, MD Phil Faraci, MD Anesthesiologists Barry Johnson, MD Michael Hieb, MD Jeni Henrie, MD Robert Ertner, MD Roger Phillips, MD Physician Assistants Shari Miller, PA-C Michael Mohr, PA-C Todd Richter, PA-C Perfusionists Pablo Zubiate, CCP Bob Hayes, CCP Jack Reed, CCP

13. Background: CV Quality Initiative Model: Physician champion leading multi- disciplinary team Administration alignment Evidence-based decision making –2007 Guidelines published by the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologist Ann Thorac Surg 2007;83:27-86 –2011Guidelines Update published Ann Thorac Surg 2011;91:944–82

14. Project Design Transfusion Committee oversight Step 1: 2007-09 data analyzed Step 2: Opportunities for improvement identified and goals set Step 3: Physician champions established Step 4: Education provided including new predictors for blood usage

15. Special Considerations Advanced age Low pre-op RBC volume – anemia, small body size Pre-op antiplatelet or antithrombotic drugs Re-operative, complex procedures Emergency operations Non-cardiac co-morbidities Inherited coagulation abnormalities

16. Enloe Heart Program Volumes

17. Baseline Data: 2007-2009 In 2009, 65% of Enloe’s CABG patients received intra-operative blood Goal: Reduce intra- operative blood usage to meet STS benchmark

18. Methods: Role of the Team Multidisciplinary blood conservation program Surgeon role –Selective use of off-pump technique for CABG –Utilize evidence-based transfusion indications –Topical agents and tissue glues –Prophylaxis Interventions outside the OR

19. Methods: Role of the Team Anesthesiologist Role –Hemostatic drugs with anti-fibrinolytic properties Aprotinin, Amicar, Tranexamic acid –Erythropoietin ( EPO ) –DDAVP and Factor VIIA –Intra-operative autologous blood donation

20. Methods: Role of the Team Perfusionist Role –Minimize extracorporeal circuits –Use of bonded circuits –Use of cell savers –Pump salvage & intra-op auto- transfusion –Post-operative shed blood re-infusion –Retrograde autologous priming (RAP) –Hemofiltration

21. Methods: Role of the Team Physician Assistants –Endoscopic vein harvesting Latest equipment to prevent hemorrhage –Vein mapping –Post-op transfusion guidelines Nursing –ICU processes and practices

22. Actions Taken Reintroduction of guidelines –Review of blood utilization practices led to new protocols Acquisition of new cell savers Reduction of perfusion circuit Anesthesia reduced crystalloid use

23. CABG: On vs. Off Pump

24. Results: 2009-Current CABG blood use decreased by 57% from 2009

25. Next Steps February 13 pilot: Thromboelastograph (TEG) in CABG surgery Educate non-CV surgeons and OR staff around cell saver use

26. Challenges Evolution of protocols Dealing with high-risk profiles Introduction of new thrombin inhibitors

27. Thank you Any questions?

29. Next Cynosure ‘Beyond SCIP” and other events March 15 th : in-person meeting in San Francisco March 27 th : webinar with Dr. Heather Young from Colorado April 12 th : webinar with Sue Barnes from Kaiser Permanente May 21 st : Cynosure Summit: the great quality swap meet

30. Improvement Capacity Building

31. Contact Us www.Cynosurehealth.org Contact Barb DeBaun at bdebaun@cynosurehealth.org bdebaun@cynosurehealth.org Check in for updates on webinar and in-person meetings