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7/19/12
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Katy Loos, RN, MSN
PATIENT BLOOD MANAGEMENT
Katy Loos RN, MSN
GOOD SAMARITAN HOSPITAL
CINCINNATI, OH
OBJECTIVES
 Identify areas of practice ready for change
 Implement strategies to decrease or
eliminate allogenic transfusions
 Identify strategies to manage anemia
6
BLOOD MANAGEMENT AT GSH
 Started Early 2010
 Identified 3 largest users of Blood Products
 Focused on Orthopedics, ICU, and Oncology
 Other areas were rising to the top in usage
by remaining static giving us our next area
to tackle
7
BASIC TENETS
 Anemia is a treatable medical condition
 Red cells should not be used to treat
anemias that can be corrected with
medications
(AABB, American Blood Centers, American Red Cross)
 Always document reason for transfusion
 Use one unit whenever possible
 Recheck labs before ordering more blood
products
IDENTIFY AREAS NEEDING CHANGE
 Know your data!
 Target key problem areas first
 Celebrate and congratulate all gains
 Know your practices !
Data Dives…
Blood utilization by MSDRG
Physician practice
Premier benchmarking
…drive the focus
10
Top 10 MSDRGs by Blood Case Count for Discharges January 2009
to December 2009 - Inpatient
Blood Products
MS
DRG DRG Description
470
Major joint replacement or
reattachment of lower extremity w/o
MCC
765
Cases
No Blood Products
Avg
Chrgs
ALOS
Avg
ALOS Chrgs
Cases
Var Yes vs. No
Avg
Chrgs
ALOS
206
3
59,188
735
2 55,120
1
4,067
Cesarean section w CC/MCC
79
8
39,301
960
6
23,264
2
16,037
377
G.I. hemorrhage w MCC
77
5
34,336
23
4
21,902
1
12,434
378
G.I. hemorrhage w CC
Extreme immaturity or respiratory distress
syndrome, neonate
62
3
23,686
27
3
19,555
0
4,131
60
67
399,723
100
59
3
95,448
232
2
70,354
1
25,094
871
Spinal fusion except cervical w/o MCC
Septicemia or severe sepsis w/o MV 96+
hours w MCC
53
8
50,043
306
6
33,643
2
16,400
812
Red blood cell disorders w/o MCC
47
3
16,936
11
1 12,491
2
4,446
811
Red blood cell disorders w MCC
Major joint replacement or
reattachment of lower extremity w MCC
34
4
31,336
7
2 16,391
2
14,946
34
7
91,471
29
5 64,869
2
26,602
790
460
469
Hospital Average
23%
77%
28 152,825
39 246,898
37,106
11
Transfusion Practice at GSH by DRG
PEER Data
HOSPITAL (OH)) And (({Community Status} = Urban) And ({Council of Teaching Hospitals} = COTH) And ({Bed-Size} = Facilities w/ 501 Beds or More)) And ({Perspective
Clinical Summary} = BLOOD PRODUCTS)
Patient
Patient
Pat Pop Util
MGSH-Top 15 MSDRGS by Blood Product
Patient
Pop
Population
Rate
Cases
Populatio
Patient
Utilization
Utilization
Variance
MS-DRG
Blood Cases for Blood Cases
n for
Populatio
Rate for
Rate for
(FacilityFacility
for Peer
Facility
n for Peer
Facility
Peer
Peer)
Total
826
16,916
4,720
103,823
17.50%
16.29%
1.21%
MJR JNT RPLCMNT/RTTHMNT
470
197
3,052
908
22,973
21.70%
13.29%
8.41%
OF LWR ET W/OMCC
377
GI HEMORRHAGE WITH MCC
75
1,279
100
3,130
75.00%
40.86%
34.14%
765
812
460
790
378
871
469
811
945
774
481
329
742
CESAREAN SECTION WITH CC/MCC
RED BLOOD CELL DISORDERS
WITHOUT MCC
SPINAL FUSION EXCEPT CERVICAL
W/O MCC
EXT IMMATUR OR RESP DISTRESS
SYN NEONATE
G.I. HEMORRHAGE W CC
SEPTICEMIA/SEVR SEPSIS W/OMV
96+HRS WMCC
MAJ JOINT REPLACE/REATTACH
LOW EXT W MCC
RED BLOOD CELL DISORDERS
WITH MCC
REHABILITATION W CC/MCC
VAGINAL DELIVERY W
COMPLICATING DX
HIP & FEMUR PROC EXC MAJOR
JOINT W CC
MAJOR SMALL & LARGE BOWEL PX
W MCC
UTERINE&ADNEXA PX
NONMALIGNANCY WCC/MCC
68
596
1,005
13,618
6.77%
4.38%
2.39%
66
2,640
83
6,681
79.52%
39.52%
40.00%
62
518
286
6,041
21.68%
8.57%
13.10%
60
947
163
3,047
36.81%
31.08%
5.73%
54
1,977
80
5,538
67.50%
35.70%
31.80%
46
1,719
321
11,477
14.33%
14.98%
-0.65%
31
429
53
1,329
58.49%
32.28%
26.21%
31
964
41
2,095
75.61%
46.01%
29.60%
30
350
536
9,891
5.60%
3.54%
2.06%
29
158
867
8,908
3.34%
1.77%
1.57%
28
1,022
48
3,241
58.33%
31.53%
26.80%
25
900
57
2,976
43.86%
30.24%
13.62%
24
365
172
2,878
13.95%
12.68%
1.27%
Transfusion Practice by Top 10 MDs
Blood Products
Attend MD
Cases
ALOS
No Blood Products
Avg Chrgs
Cases
ALOS
Var Yes vs. No
Avg Chrgs
ALOS
Avg Chrgs
1
159
4
37,131
983
0
8,031
4
29,100
2
93
53
336,243
606
17
88,146
36
248,096
3
70
6
45,824
768
3
22,702
3
23,122
4
61
6
40,356
778
2
20,504
4
19,852
5
55
6
31,756
4769
1
5,970
5
25,787
6
53
7
121,419
435
1
24,366
6
97,052
7
43
3
25,601
680
0
8,116
3
17,485
8
43
8
64,414
278
3
26,218
5
38,196
9
40
4
91,258
211
0
17,306
4
73,953
10
40
3
60,370
481
2
45,024
1
15,346
ORTHOPEDICS
Hip Cases With Transfusions
120.00%
100.00%
80.00%
% Hip Cases
With
Transfusions
By Doctor
60.00%
40.00%
20.00%
0.00%
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
Example of physician blinding for elective total hip arthroplasties
Orthopedics
 Blinded physician-specific transfusion data
 Presented at Section meeting
 Extensive literature review for evidence based best
practice
 New practice initiatives for pre, intra, and postoperative conservation
 Amended order sets to reflect changes
 Established Anemia Clinic
 Orthopedic Center of Excellence (OCE)
 Quality measure: Preoperative anemia
 Established metrics
 Posted on OCE dashboard
Orthopedic Recommendations
 Document Reason for Transfusion:
 HGB ≤7, HCT ≤ 21, Hypoxia, Weakness, or other signs of decreased
oxygen carrying capacity.
 Reasons and Triggers for Autologous transfusion
same as allogenic.
 While autologous transfusion is safer, it is not without risk
 Limit autologous donations for indications such as
known antibodies on T&S, complex surgery, or
patient refusal of blood products.
 Check HGB or HCT before automatically transfusing,
thereby documenting lab value, and reason for
transfusion
 Do not give PRBCs in PACU without lab results.
 Transfuse ONE unit at a time. Then recheck labs, reevaluate patient. Give second unit only if needed.
INTENSIVE CARE
 Physician and Resident education
 Newsletter
 E- LEARN
 Mandatory transfusion order set usage
 Audited for compliance
 Established ICU transfusion dashboards
 Intensivist scorecards delivered quarterly
 Transfusion order sets revised
 Decreased H/H trigger to 7/21
 Decreased number of PRBCs to 1
 Increased INR trigger on FFP to 1.8 (from 1.5)
 Oncology subset with decreased triggers
ONCOLOGY
 General Oncology Meeting
 OPCC, 14CD, CNS, and Physicians
 Show them their practice and opportunity to improve
 Task force to review best practice
 Always give literature to support changes
 Oncology Order sets revised
 Decreased RBC trigger to HGB 7 or HCT 21
 Decreased daily automatic transfusion to 1 unit RBC if
indicated by trigger (was 2 units)
 Decreased Platelet trigger to 10,000 (from 20,000)
Strategies to Decrease or Eliminate
Transfusions
Pre-admission testing 14 – 45 days prior to
surgery – allowing time to treat anemia
Oral agents of Iron, Folic Acid and Vitamin C for
all patients
Avoid drugs that promote bleeding
Use Procrit - an erythropoesis stimulating
agent (ESA), and IV Iron for more severe anemia
 Anemia is treated as a laboratory value, not a
diagnosis
 Overlooked in the presurgical History and
Physical
 Total Joint Replacement surgeries (TJA) on the
rise – especially in the elderly
 TJAs have some of the highest rates of
transfusion
 Preoperative anemia is the greatest predictor of
peri-operative transfusion !!!
 Regional anesthesia
 Hypotensive anesthesia for those requiring
general anesthesia
 Pre-op Tranexamic acid
 Decreased tourniquet time
 Reinfusion system
 Bipolar cautery
 Avoidance of drains
 Avoidance of strong VTE chemoprophylaxis in
low risk Total Knee Arthroplasy (TKA) patients.
 Lovenox 40 mg daily in TKA.
 INR targets near 1.5 for patients on Coumadin.
 Prolonged knee flexion >70 degrees the day of
surgery
 Transfusion triggers HGB 7 / HCT 21 unless
cardiac symptoms or unstable
 IV fluid correction of hypotension and postural
changes
OUTCOMES IN ORTHOPEDICS
 Since May 2011, overall transfusions of red blood cells have
decreased by over 50% to a rate of 2-6% in elective total
joint procedures
 Transfusion rates during total hip replacements decreased
 No adverse patient outcomes resulted
 Decreased length of stay of 1 day on average
 2011 PRBC Orthopedic purchase cost savings of $5,700 per
month average compared to 2010 average
Anemia Prevention
 Anemia Clinic with automatic treatment of
patients by hematologist
 Education of residents, and individual
services
 Go to each section meeting and deliver the
message that is pertinent to their practice
 Let other services know about the
successes gained by others
 Empower staff nurses as your advocates
Pre-Surgical Anemia Protocol
Hospital Purchase Costs
RBC COSTS
$130,000.00
$120,000.00
$110,000.00
$100,000.00
$90,000.00
$80,000.00
$70,000.00
$60,000.00
$50,000.00
Elective Hip and Knee Arthroplasty RBC
% Transfused
20.00%
% Transfused
18.00%
16.00%
14.00%
12.00%
10.00%
8.00%
6.00%
4.00%
2.00%
0.00%
Linear (%
Transfused)
Oncology Data
Hgb > 7
Unknown
RBC Transfusion Triggers in Oncology (14CD & OPCC)
60
RBC UNITS TX
50
40
30
20
10
0
Hgb ≤ 7
Thank You
Katy Loos RN, MSN
Katy_Loos@trihealth.com
(CartCartoon source: http://bloodbankpartners.com)
References
Alexandrov, A. W., & Brewer, B. B. (2011). The Role of Outcomes in Evaluating Practice
Change. In B. M. Melnyk, & E. Fineout-Overholt, Evidence Based Practice in Nursing and
Healthcare . Philadelphia: Wolters Kluwer/ Lippencott Williams & Wilkins.
American Society of Anesthesiologists, Inc. (2006). Practice guidelines for perioperative
blood transfusion and adjuvant therapies. Anesthesiology, 198 - 208.
Farris, P., Ritter, M., & Abels, R. (1996). The Effects of Recombinant Human Erythropoietin
on Perioperative Transfusion Requirements in Patients Having a Major Orthopedic
Operation. The Journal of Bone and Joint Surgery, 62 - 72.
Goodnough, L. T., Maniatis, A., Earnshaw, P., Benon, G., P. B., Bisbe, E., et al. (2011).
Detection, evaluation, and management of preoperative anemia in the elective orthopedic
patient: NATA guidelines. British Journal of Anaesthesia, 13 - 22.
References, cont.
Kumar, A. (2009, November). Perioperative management of anemia: Limits of blood
transfusion and alternatives to it. Cleveland Clinic Journal of Medicine, pp. S112 - S118.
Liumbruno, G., Bennardello, F., Lattanzio, A., Piccoli, P., & Rossetti, G. (2011).
Recommendations for the transfusion management of patients in the peri-operative
period. III. The post-operative period. Blood Transfusion, 320 - 335.
Martinez, V., Monsaingeon-Lion, A., Cherif, K., Judet, T., Chauvin, M., & Fletcher, D. (2007).
Transfusion strategy for primary knee and hip arthroplasty: Impact of an algorithm to lower
transfusion rates and hospital costs. British Journal of Anesthesia, 794 - 800.
Spahn, D. (2010, August). Anemia and patient blood management in hip and knee surgery:
A systematic review of the literature. Anesthesiology, pp. 482 - 495.
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