Blood Management Strategies, No Bones About It

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Blood Management Strategies
– No Bones About it.
By Andrea C. Peters, AA, BS, CPBMT
Perfusion.com, Inc.
St. Francis Hospital, Columbus, GA
September 10,2011
Purpose
 Identify and promote safe, appropriate and evidence-based
interventions that are likely to be helpful in blood
management.
 Encompass all aspect of blood management from patient
evaluation, through clinical indicators and management of a
decision-making process..
 Establishing guidelines that provide balance between
efficacy, safety, and regulatory constraints.
The Magnitude of Blood Management
1. One in twenty American’s will receive a transfusion at some point in
their lives.
2. About 12 million units of red blood cells and whole blood, 8 million
platelet units and 3 million plasma units are transfused annually.
3. Every three seconds someone needs blood.
4. People older than 65 use 43 percent of all donated blood. The
demand for blood will increase as the population ages.
5. Approximately 40,000 units of blood are used each day in the
United States
http://www.bloodtransfusion.com/facts.asp
What is Blood Management?
 Blood management is a comprehensive,
multidisciplinary process that is designed to
promote the optimal use of blood products
thoughout the hospital.
 The goal of blood management is to ensure
the safe and efficient use of the many
resources involved in the complex process of
blood component therapy.
What is Blood Management?
 An approach to medical treatments where the patient’s
blood is managed thereby reducing or eliminating the need
for blood transfusion.
More than
 Tightening of transfusion practice
 Bloodless medicine
Advantages of Blood Management
 By using the patient’s own blood reduces risk of infection,
autoimmune and or hemolytic reactions
 Reduced rate of complications reduces possible hospital stay
 Reduction in cost for the patient, their insurance company and
the hospital.
Why is This Important?
1. Increases your facility’s competitive advantage
2. Reduces out-of-pocket expense to patients
3. Reduces cost to payers
4. Attracts patients who prefer not to receive banked blood
5. Red blood cell products are continually becoming more scarce and more expensive
6. Blood transfusions are not consistently reimbursed
7. It is safer for the patient to receive salvaged autologous blood than pre-deposited
autologous or banked blood
8. Donor blood does not carry oxygen for the first 24 hours after transfusion, and
transfused patients consistently experience immuno-suppression
The more allogeneic blood you give, the
greater the risk of complications
The more allogeneic blood you give, the
greater the risk of infection
The more allogeneic blood you give, the
greater the risk of increased length of stay
Stored allogeneic blood is an imperfect
substitute for endogenous hemoglobin!
 Ineffective Exchange
 Impaired tissue oxygen delivery
due to storage defects
 Excess Baggage
 Adverse effects and immune
system changes as a consequence
of allogeneic transplantation
Techniques
 Manage blood
 Control bleeding
 Stimulate growth of new blood cells
 Minimize blood sampling
 Ensure that every unit of blood
transfused is appropriate
 Minimize transfusion,
complications and anemia
 Efficient use of all resources
(drugs, devices)
 Organizational principles
 Attention to detail
 Multidisciplinary approach
 Utilization of evidence-based
guidelines and clinical best
practices1
 Reduce risk exposure
 Proactive patient management
systems2
Adjusted hazard ratio
Applied Blood Management
1.8
1.7
1.6
1.5
1.4
1.3
1.2
1.1
1
serious bacterial
infection
pneumonia
1
2
3
4
Units Transfused
2
5+
The Role of Blood Utilization in Blood
Management
 Transfusion safety is much more than blood safety
 Efforts to reduce blood demand should parallel efforts to increase
the blood supply
 Blood utilization committees are the key to optimal blood
management
 Right patient
 Right product
 Right dose
A Smart Approach to
Blood Management
Patient centered, evidence-based, systems
oriented, data driven
Strategies for Change
Team creation and leadership
Educate
Engage, dialogue and challenge
Data management
Improve the transfusion permit
Create the blood component order
Identify high risk populations
Creating an Environment
 This is centered around teamwork & communication.
 It helps maintain consistent and standardized practices in
blood management therapy.
 It is essential for managing the complexities of transfusion
processes – complexities that often exceed the
capabilities of individual clinical disciplines in the
organization
 It improves patient safety by allowing departments to
learn from each other’s mistakes and proactively
implement necessary improvements consistently across
the organization .
Multidisciplinary Blood
Management Team
Director
(Surgeon)
Departmental
Champions
Pharmacist
• Surgery
Physician
Champions
Manager
(Perfusionist)
•Ortho
•Vascular
•Trauma
•Oncology
•Neuro
•Cardiac
Lab
Blood Bank
Quality Control
Nursing
Hospital Physician
Champions
Pathology
Intensivist
Hospitalist
Administration
Blood Management & Action
Items
AABB
STS
Physicians
Letters
Documentation
&
Blood
Bank
ICEBP
Organization
Data
Quality
Study
Results
Data
IBBM
SABM
Blood Management & Action
Items
Hgb Pro
Epocal
Point of
Care
Systems
Hepcon
CardioPat
TEG Sonoclot
Capitol
Equipment
Perfusion
Equipment
Platelet
Gel
Blood Management & Action
Items
Speakers
Consent
Studies
Creden-
Physician
tialing
Orders
Forms
Education
Evidence
Based
literature
Polices
Protocols
Webinars
&
Procedures
CME
Programs
Blood
Mgmt
Meetings
Blood Management Overview in
the Orthopedic Surgical Arena
I have been asked to provide an orthopedic surgeon's point of
view and perspective on blood management for this newsletter
issue. I am a hip and knee surgeon with a large total joint
arthroplastic practice in a community-based hospital and serve as a
director of the The American Osteopathic Academy of Orthopedics
(AOAO). Over the last 12-18 months, I have become very interested
in developing and implementing a comprehensive blood
conservation program to decrease surgical blood loss and reduce
blood transfusions after total joint surgery. Patients undergoing
total hip and knee surgery often sustain a significant blood loss
related to surgery, secondary to multiple reasons. The
postoperative anemia may have numerous deleterious effects on
the patients to include delayed rehabilitation, higher complication
rates, limited pain control, and poor postoperative outcomes. The
ability to limit postoperative bleeding may reduce this problems
and ultimately result in better patient satisfaction and a more
positive surgical result. With this in mind, we have taken into
account preoperative, intraoperative, and postoperative measures
to develop a multimodal blood conservation strategy to decrease
complications, increase patient safety, and improve our
postsurgical results.
Unwashed Autotransfusion
Disadvantages
Low Hematacrit Product:
Approximately 30%
Biologic Response Modifiers:
Un-washed RBC
product
Washed RBC
product
Post transfusion
 cytokines
Within normal limits
Within normal limits
 IL 6 & 8
Within normal limits
Within normal limits
 TNF-Alpha
Within normal limits
Within normal limits
Source: Acta Orthop. Scand 1995;66:334-8
Unwashed Autotransfusion
Disadvantages (cont.)
Consequences of Biologic Response Modifiers:




Fever1
Acute respiratory failure2
Hypotension3
Upper airway edema4
Sources:
1Clement S.D.H.,
Sculco T, et al J Bone Joint Surg (Am) 1992;74:646-51
H, Spies S, et al. J Arthroplasyt 1994;9:351-8
3Heath K, McFadzean W. JR Army Med Corps 19956;141:105-106
4Woda R, Tetzlaff JE, Can J Anaesth 1992; 39:290-2
2Wixson RL, Kwaan
Brat2 with Blood Management
Post-op blood salvage
via wound drain
Original Study to Utilize as a Base
for an Evaluation
“Platelet-Rich Plasma Application During Closure
Following Total Knee Arthroplasty”
By William J. Berghoff, MD; William S. Pietrzak, PhD;
Richard D. Rhodes, MD
ORTHOPEDICS 2006; 29:590
July 2006
Platelet treatment appears to improve several short-term outcomes following total knee arthroplasty.
Total knee arthroplasty (TKA) is one of the most common orthopedic procedures
performed, restoring function and reducing pain in the arthritic knee.1 In general, results
are excellent with reported survival rates as high as 90%-95% at 10-15 year follow-up.2
Complications are infrequent, with reoperations occurring in approximately 1% of patients
per year.3 With an aging population, elective TKA rates are steadily increasing. In
addition, there is a trend toward earlier hospital discharge during a more acute phase of
recovery in an effort to reduce hospital costs. . .
PRP Evaluation Data Sheet
Staff Education &
Patient Communication
 To insure competency, in-servicing should be completed and
signed off by each individual involved in their respective
areas.
 Review patient chart for labs, current medications and
medical history.
 Discuss with the patient why you are doing this blood draw.
 Benefits
 Results
 Answer questions from the patient
Angel with processed products
OR Staff Communication
 Once the patient is in the room and before decanting, verify
correct product and patient with the circulating nurse.
 Explain applicator assembly as tech is drawing up
components.
 Don’t accidently mix components to prevent clotting the tip
of the applicator. Wipe away any excess.
 Gently agitate syringes to re-suspend platelets just before
application.
PRP/PPP with Recothrom/Ca
Ready for Application
PRP Completed Eval Data
A Champion for Success
 Utilizing Platelet Rich and Platelet
Poor Plasma …”We were able to
show a significantly less use of
narcotics, a higher functional
range of motion, and had better
postoperative hemoglobins and a
significant decrease in the need
for blood transfusions. We believe
the use of autologous platelet gels
and fibrin sealants has enhanced
the efficacy of our total joint
arthroplasty surgeries.”
 Dr. George W. Zimmerman,
D.O.
 Orthopedic Surgeon, specializing in
Knee and Hip
Quality Issues: Failure to Adopt Evidence-based
Transfusion Guidelines
“A restrictive strategy of red cell transfusions
is at least as effective as and possibly
superior to a liberal strategy in critically ill
patients, with the possible exception of
with studyacute
myocardial
Ranked as thepatients
#1 landmark
that has
changed the practice of
1
infarction
or how many
unstable
angina.”
2 but
transfusion medicine
physicians
are familiar with it?
1 Hébert
et al- NEJM 1999;340(6)
2 Blajchman- Transfusion 2005:45
A multicenter, randomized controlled clinical trial of
transfusion strategies in critical care
Hebert et al, NEJM 1999:340(6)
 Results
 Overall, the adjusted multi-organ dysfunction score
and in-hospital mortality were significantly higher in
the liberal transfusion group than in the restrictive
transfusion group.
 No sub-group of these critically ill patients
demonstrated an added benefit of higher Hbg
levels, and most patients in the liberal transfusion
group had worse outcomes.
Variations in Transfusion Practices
 Transfusion rates of plasma and platelets have
been reported to vary from 0% to 100% of bypass
patients.
 Among 18 tertiary-care institutions




8 transfused 10% or less patients with platelets
4 transfused > 50% of patients with platelets
28% of patients platelet-related risk factors received platelets
17% of patients without platelet-related risk factors received
platelets
 In addition to intra-institution variability in
transfusion practice, it has been reported
that 26% of perioperative transfusions are
given inappropriately.
The “Transfusion Trigger” Controversy
10/30?
8.5/26?
7/21?
Transfusion paradigms
.
1 Spiess, Ann
Thorac Surg 2002;74
Transfusion trigger:
“a particular
hemoglobin level of
discomfort in the
prescribing physician,
not defined by clear
physiologic
parameters”1
Establishing Evidence-based
Transfusion Trigger
 “All in all, I feel the most significant alteration in our practice
that has decreased the use of blood products, is an alteration in
our perioperative transfusion trigger. We have employed strict
evidence-based transfusion criteria and have gone from the
"10/30 rule" to a more aggressive hemoglobin of 7 and
hematocrit of 20 before transfusion. With our alterations in
practice and our blood conservation means preoperatively,
intraoperatively, and postoperatively, we have significantly
decreased the blood product usage at our institution.”
Orthopedic Amicar Review
Incorporating Additional
Therapies: Tranexamic Acid
 “We have begun administering 20 mg per kg 1 time
intravenous bolus dose before surgery to our "highrisk for postoperative anemia" patients, but now
consider providing this pharmacologic agent to all
patients undergoing total joint surgery.”
Benefits
 More blood collected
perioperatively may reduce reliance
on stored blood
 Less reliance on stored blood may
reduce hospital costs
High Quality RBC Product
 High hematocrit RBC product
 High RBC recovery
 High free hemoglobin removal
 High albumin removal
 High heparin removal
Transfusion Costs
 “Hanging costs” are substantially more than the
cost of acquisition
 Total cost to the hospital includes accounting for a
variety of resources that are consumed:
 Direct Materials
 Variable Labor
 Fixed Labor
 Overhead
RBC Year Over Cost Savings for
Perioperative Autotransfusion
DIRECT RBC UNIT COST
$200,000
DIRECT COST SAVINGS
COST
$150,000
Average Monthly Savings
$37,776
$50,000
$0
1
2009
2
3
4
5
6 7 8
MONTH
9 10 11 12
2010
COBCON COST
COST
COBCON Cost Savings
Average Monthly Savings
$219,400
$100,000
$1,000,000
$800,000
$600,000
$400,000
$200,000
$0
1
2009
2
2010
3
4
5
6 7 8
MONTH
9 10 11 12
Blood Product Costs
RBC
PPH
FFP
Additional Strategies to
Incorporate
TEG Platelet
Mapping Assay
Platelet function, prothrombotic state and
platelet inhibition
The TEG Hemostasis System
Helps You Assess:
 Bleeding risk
 Ischemic risk
 Need for antiplatelet therapy
Use of the TEG in Interventional
Radiology
Epocal Blood Gas Analyzer
All that’s required is a 100 microliter
blood sample.
A true Point-of-Care analyzer, yielding
results within 30 seconds.
Utilizing blue-tooth technology and
bar-code reading.
Joint Commission 2011
 Patient Blood Management Performance Measures
Project
•PBM-01 Transfusion Consent
•PBM-02 RBC Transfusion Indication
•PBM-03 Plasma Transfusion Indication
•PBM-04 Platelet Transfusion Indication
•PBM-05 Blood Administration
Documentation
•PBM-06 Preoperative Anemia Screening
•PBM-07 Preoperative Blood Type
Testing and Antibody
Screening
Preoperative anemia is associated with increased morbidity and mortality after
surgery as well as exposure to allogeneic blood transfusions. Previously
undiagnosed anemia was identified in 5%-75% of elective surgery patient in certain
populations and a national audit demonstrated that 35% of patients scheduled for
joint replacement therapy have a hgb<13 g/dL on preadmission testing. Blood
transfusions are associated with several postsurgical complications, including
surgical site infections, pneumonia, slower wound healing, prolonged ventilator
use and increased length of stay.
Establish a Quality Team
Blood Bank
Director
Perfusion
Director
Oncology
Conduct Pre-construction Analysis
 Measure
your environment
 Is there an overlap of services?
 Evaluate your strengths
 How many modalities are already offered at your institution?
 Discover your areas for performance improvement
 Challenge the medical and surgical staff to new levels of
care
Begin Data Collection Now
 User friendly format
 Blood usage and costs
 OR blood salvage and costs
 Analyze
 How are we doing today?
 What opportunities exist?
 Track accomplishments
 Publish results
Establish Policies and Procedures
 Clinical policies and procedures:
 Program and equipment validation
 Update existing manuals
 Identify admission and discharge processes
 Ethics Committee policies and procedures
 Create organizational awareness of policies & procedures
Summary
 Blood products remain a precious, scarce, expensive
and HAZARDOUS resource
 Although anemia carries risks in the patient
population, there is little to no evidence
demonstrating improved outcomes with transfusion
 For years the medical community has overestimated
the benefits of transfusion and underestimated the
risks
 Clinicians must take an active role in supporting a
multidisciplinary blood management program
Conclusions
 Clinical application exists in many areas, and is expanding to
many others
 Providers have the opportunity to do well financially, but in
the same breath provide superior benefits on patient care.
 Providers need to seize this opportunity, but have the clinical
knowledge and documentation.
 We need to adapt
Questions?
“I believe in the old and sound rule that an ounce of sweat can
save a gallon of blood.”
General George Patton
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