Quality Data Collection and
Interpretation from the Masses
Tim Dickinson, MS
September 9, 2011
1
Objectives
Review Autotransfusion clinical practice data
Hospitals that achieve remarkable blood utilization
rates –what blood conservation practices have they
adopted?
Association of ECC prime volume with intraop RBC
use
2
CPB & ATS Programs
3
ATS
Perfusion
Autotransfusion
4
2011: Published ahead of print
BACKGROUND: Intraoperative blood salvage is the process whereby shed red blood cells (RBCs) are
collected and returned to the patient. We analyzed the trends in the volume of returned RBCs by our
blood salvage program across a 12-hospital regional health care system over a 5-year period.
STUDY DESIGN AND METHODS: All quality control, RBC recovery, and patient demographic data relating
to blood salvage are stored in a large database covering these 12 hospitals. Cases in which blood salvage
was performed over a 5-year period were stratified based on patient demographics, hospital, type of
surgery, and volume of RBCs recovered.
RESULTS: There were 19,867 surgeries performed during the study period in which blood salvage was
used. The median volume of blood returned to each patient was 405 mL (25th-75th percentile, 135-750
mL). Defining the volume of an RBC unit as 200 mL, this represented a median of 1.1 RBC unit
equivalents (25th-75th percentile, 0.37-2.1 units) returned to each patient. For the majority of patients,
not more than 1 RBC unit equivalent was recovered. Overall, the ratio of cases where at least 1 RBC unit
equivalent was recovered to cases where less than 1 RBC equivalent was recovered was 2.5:1; this ratio
varied considerably between surgical procedures.
CONCLUSIONS: Although overall the mean volumes of RBCs returned to the patients by intraoperative
blood salvage were high, the actual volumes returned depended on the case mix. There appears to be
an opportunity to use blood salvage more selectively to improve efficiency.
5
Comparative Data
6
Procedure Volume by Procedure Type
30000
26805
25000
20785
20000
15000
10000
5000
3352
2577
1034
666
General
Neuro
0
CPB
7
OPCAB
Orthopedic
Vascular
Volume Returned by Procedure Type
700
626
mLs (median)
600
400
300
200
100
0
8
490
500
405
400
375
250
458
230
Volume Returned by Type of
Orthopedic
Procedure
300
mLs (median)
250
250
205
210
Knee
Hip
200
150
100
50
0
Spine
9
RBC Unit Equivalents
RBC Equivalents by Procedure Type
10
2.0
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
0.0
1.8
1.4
1.1
1.1
1.1
0.7
1.3
0.6
Potential Cost Avoidance
$25,000,000
$23,491,902
$20,000,000
$15,000,000
$10,000,000
$6,692,770
$5,000,000
$1,443,120
$542,850
$233,100
General
Neuro
$2,299,472
$0
CPB
11
OPCAB Orthopedic Vascular
RBC Unit Equivalents Comparison
35.0%
30.0%
25.0%
28.0%
22.1%
21.8%
20.0%
16.6%
15.0%
10.0%
6.1%
5.0%
2.6%
1.1%
0.5%
0.4%
0.2%
0.2%
0.5%
0.0%
0
<1
1-2
2-3
3-4
SC
12
4-5
5-6
UPMC
6-7
7-8
8-9 9-10 >10
Rate of Return by Procedure Type
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
94%
79%
67%
59%
64%
83%
62%
42%
CPB
13
78%
General Neuro OPCAB Ortho
Other Vascular
ALL
UPMC
ATS Device Comparison -Rate
100%
88%
90%
80%
77%
77%
82%
67%
70%
60%
50%
40%
30%
20%
10%
0%
Sorin Brat
14
Fresenius
CATS
Haemonetics
Cell Saver
Medtronic
Autolog
Other
ATS Device Comparison -mLs
600
500
525
500
450
mLs (median)
405
375
400
300
200
100
0
Sorin Brat
15
Fresenius
CATS
Haemonetics
Cell Saver
Medtronic
Autolog
Other
Cardiopulmonary Bypass
16
Perfusion Blood Management Influence
AVOID ANEMIA
• Autotransfusion
• Reduce ECC Prime
- Autologous prime
• Ultrafiltration
• Microplegia
17
MINIMIZE BLOOD
LOSS
• Coated ECC
• Divert Pericardial Bld.
• P.O.C. Lab testing
• Rx interventions
• PLT Sequestration
• Temperature?
18
19
20
21
22
23
24
25
26
27
28
29
Other Metrics
Static Prime (mLs)
Autologous Prime (mLs)
Ultrafiltration (% use)
Anesthesia Volume (mLs)
Lowest Core Temperature (°C)
Hbg Trigger (g/dL)
Nadir HCT on CPB
Preop HCT
30
Average
1320 ±306
457 ±295
15 ±12
1721 ±381
33 ±1.0
7.0 ±0.4
Range
750-1800
0-900
0-40
1000-2200
32-34.5
6.0-7.0
SC Best
24.8
38.9
SC Average
24.5
35.1
ECC Net Prime Volume
31
Relative Odds of Receiving Packed Red Blood Cells Transfusion
Low HCT
Use of pump
Female Gender
Lower Body Weight
Older Age
Odds Ratio Adjusted*
15.5
7.91
2.37
2.18
1.99
p value <0.001
2003;97:958-63
Procedure Volume vs. Prime Volume
n=28,200 isolated CABGs 2009-2010
Number of Procedures
12000
10629
10000
8000
6294
6000
3778
4000
2126
3928
1445
2000
0
<1000mLs
1000-1499mLs
male
33
female
>=1500mLs
Patient Demographics
Age (years)
<1000mLs
n=8420
65.0 ±10.7
1000-1499mLs
n=14,407
65.0 ±10.6
≥1500mLs
n=5373
65.0 ±10.8
p value
0.9939
Weight (kg)
88.0 ±19.6
87.7 ±22.0
88.9 ±20.0
0.0021
2.00 ±0.24
2.00 ±0.25
2.01 ±0.24
0.0023
74.7
73.7
73.1
0.0896
2
BSA (m )
Gender (% male)
34
Intraop RBC units vs. Prime Volume
2
1.8
1.80
1.6
1.50
RBC -units
1.4
1.2
1.2
1
p <0.0001
0.8
0.68
0.6
0.4
0.2
0.49
0.37
0
<1000mLs
1000-1499mLs
male
35
female
>=1500mLs
Intraop RBC -% vs. Prime Volume
70.0%
66.4%
60.0%
RBC -%
50.0%
59.5%
53.5%
p <0.0001
40.0%
30.0%
29.4%
21.8%
20.0%
10.0%
16.9%
0.0%
<1000mLs
1000-1499mLs
male
36
female
>=1500mLs
Nadir HCT on CPB vs. Prime Volume
30
26.2
25.4
22.4
21.7
naidr HCT on CPB
25
20
25.6
21.9
p <0.0001
15
10
5
0
<1000mLs
1000-1499mLs
male
37
female
>=1500mLs
Preop HCT vs. Prime Volume
41.0
40.0
39.9
39.7
39.8
Preop HCT
39.0
38.0
p <0.0001
37.0
36.0
35.0
36.3
36.0
35.7
34.0
33.0
<1000mLs
1000-1499mLs
male
38
female
>=1500mLs
Nadir HCT on CPB vs. Intraop RBCs
3.00
2.84
2.78
RBC -units
2.50
2.00
1.68
1.50
1.19
1.33
0.95
1.00
0.59
0.50
0.46
0.21
0.00
<18
18-21
male
39
22-25
female
26-29
0.07
>29
Nadir HCT on CPB vs. Intraop RBC %
100.0%
88.9%
90.0%
80.0% 88.5%
70.7%
RBC -%
70.0%
60.0%
57.3%
50.0%
48.7%
40.0%
39.7%
30.0%
26.9%
20.0%
20.5%
10.0%
10.2%
0.0%
<18
18-21
male
40
22-25
female
26-29
3.5%
>29
Summary
ATS utilization rates vary by type of surgery and cell
salvage device
Practice variation exists amongst hospitals
achieving exceptional blood utilization results
Incremental decreases in net ECC prime volume is
associated with less RBC use
41