Blood Health Consultations
Background:
Pre-operative anemia is a problem of process, and it has significant negative implications for
the patient and the hospital. Pre-operative anemia alone increases the risk for surgical
complications, length of hospital stays, risk for surgical site and other infections, and increases
risk for pulmonary and/or kidney injuries at a rate three times the non-anemic surgical person.
Traditionally, patients have pre-operative exams too close to the day of surgery, making it
difficult for the primary care physician to correct low blood counts pre-operatively.
Blood transfusion is common in surgical patients, particularly in those with anemia on the day
of surgery. Twenty-five percent of individuals having elective joint replacement surgeries are
anemic. Too often, clinicians proceed to the operating room with anemic patients, having the
mindset that post-operative transfusions will be used to assist recovery. As many as thirty
percent of these “total joint” patients receive blood post-operatively, generally with two or
more units of blood. Surgeon-specific transfusion rates range from 5% to 95% when controlled
for same procedure types. Transfusion overuse has become so common place, that in 2012,
the Joint Commission and the American Medical Association both designated the reduction of
blood use as one of their collective top five care improvement initiatives.
Innovation:
In 2012, Fairview Southdale Hospital launched a pilot project in cooperation with pathologist,
Katherine Frey, MD, and surgeons, John Anderson, MD, Edward Szalapski, MD, Joseph Teynor,
MD, and Michael Nemanich, MD, all of Twin Cities Orthopedics. These surgeons collaborated
to obtain pathologist driven blood health consultations and peri-surgical blood and anemia
needs-planning for patients preparing to have elective joint replacement surgeries. Together
they used a proprietary, IT-based, algorithmic program Dr. Frey developed, aimed at virtually
assessing and managing these surgical candidates with pre-operative anemia and minimizing
their need for post-operative blood transfusions. The program also provided outcomes
reporting capabilities.
In this pilot, all patients had their laboratory blood values assessed by Dr. Frey, and all patients
received inpatient blood health care plans including a transfusion risk score. Pre-operative
patients who were found to be anemic were also contacted to have additional lab tests
obtained at lab sites closely located to the person’s home. When needed, anemia treatment
was often accomplished pre-operatively via infusion therapy, again at convenient locations for
the patient. Pathology consultations were also generated for the primary care physician, the
surgeon, the hospital, and the patient, recommending best practice interventions to achieve
optimum “blood health” peri-operatively.
Results:
Fairview Southdale Hospital implemented this pilot with a focus on improving patient care, on
safely minimizing blood transfusions, on minimizing complications from poor blood health, and
on avoiding unnecessary transfusion costs during one’s inpatient stay.
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Pre-Pilot Baseline:
o 15.88% of patients with joint replacement surgeries at Fairview Southdale
Hospital received transfusions and averaged 1.8 units per transfusion.
Pilot results for 2012 - 2013:
o Two hundred forty-six patients used this consultation service in 2012 through
2013.
o 3.2% received blood transfusions and averaged 1.5 units per transfusion
o Thirty-one fewer patients received blood than would have been expected
o Fifty-eight fewer units of blood were used than would have been expected
o Blood use appropriateness was reviewed and found to be at 100% vs. at 80%
pre-study
o There were no anemia related post-operative complications
o Length of stay changes were not tracked in this pilot
o Fairview Southdale Hospital realized a cost avoidance of $58,000 in this pilot
group
o Potential cost savings of $356,000 annually if all patients having joint
replacement procedures were taken through this consultation process.
Potential for Replication:
Given these early results, and the fact that no additional physical space is needed to conduct
this process, discussions are ongoing related to expanding this virtual pathology consultative
service across the Fairview Health System.
Nationwide, greater than three million patients having surgeries might benefit from such
services. Conducting pre- and peri-operative blood health consultations has the potential to
markedly reduce blood use across not only orthopedic surgery cases, but it may also benefit
those individuals having certain, elective cardio-thoracic, gastro-intestinal, and gynecologic
procedures. Using blood health consultation services as described here, could also assist
hospitals in realizing improved quality outcomes, in lessening co-morbidities, and in enhancing
cost savings.