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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
BloodConservationin CABG Surgery
February 9, 2012
Participants• Barry Johnson, MD
– CV Surgery Anesthesiologist– [email protected]
• Pablo Zubiate, CCP– Cardiovascular Surgery Coordinator– [email protected]
• Marcia Nelson, MD, FAAFP– Vice President, Medical Affairs– [email protected]
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 multi-disciplinary 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 intra-operative 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 auto-
transfusion– 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 youAny 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
Contact Us
• www.Cynosurehealth.org
• Contact Barb DeBaun at [email protected]
• Check in for updates on webinar and in-person meetings