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
– barryjonsn@aol.com
• Pablo Zubiate, CCP
– Cardiovascular Surgery
Coordinator
– Pablo.zubiate@enloe.org
• Marcia Nelson, MD, FAAFP
– Vice President, Medical Affairs
– Marcia.nelson@enloe.org
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 multidisciplinary 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 intraoperative 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
autotransfusion
– 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 15th: in-person meeting in San
Francisco
• March 27th: webinar with Dr. Heather
Young from Colorado
• April 12th: webinar with Sue Barnes
from Kaiser Permanente
• May 21st: Cynosure Summit: the great
quality swap meet
Improvement Capacity
Building
Quality Improvement 101
An introduction to quality
improvement in healthcare.
Excel for Quality Improvement
Learning to create databases,
automate calculations, and build
graphs.
Excel for Quality Improvement:
Beyond the Basics
Understanding more advanced
functions, database management,
and Pivot tables.
Project Management 101
Skill building class for leading
meetings and improvement
efforts.
Quality Improvement for
Physicians
Core concepts of quality
improvement for physician
leaders/champions.
Compass
Multi-month class designed to
take student through a
performance improvement project.
Contact Us
• www.Cynosurehealth.org
• Contact Barb DeBaun at
bdebaun@cynosurehealth.org
• Check in for updates on webinar and
in-person meetings