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

Welcome from Barb DeBaun, RN, MSN, CIC

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

Blood Conservation in CABG Surgery

February 9, 2012

Participants • Barry Johnson, MD – CV Surgery Anesthesiologist – [email protected]

• Pablo Zubiate, CCP – Cardiovascular Surgery Coordinator – [email protected]

• Marcia Nelson, MD, FAAFP – Vice President, Medical Affairs – [email protected]

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

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

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

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

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

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

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

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

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

Enloe Heart Program Volumes

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

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

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

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

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

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

CABG: On vs. Off Pump

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

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

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

Thank you Any questions?

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

Improvement Capacity Building

Quality Improvement 101

An introduction to quality improvement in healthcare.

Excel for Quality Improvement: Beyond the Basics

Understanding more advanced functions, database management, and Pivot tables.

Quality Improvement for Physicians

Core concepts of quality improvement for physician leaders/champions.

Excel for Quality Improvement

Learning to create databases, automate calculations, and build graphs.

Project Management 101

Skill building class for leading meetings and improvement efforts.

Compass

Multi-month class designed to take student through a performance improvement project.

Contact Us • www.Cynosurehealth.org

• Contact Barb DeBaun at [email protected]

• Check in for updates on webinar and in-person meetings