1 introducing change: an organizational overview tim dickinson october 7, 2011
TRANSCRIPT
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Introducing Change:An Organizational Overview
Tim Dickinson
October 7, 2011
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ObjectivesDescribe quality improvement program
Reveal variation in clinical practices
Tool & Resources
“Those who provide medical care must lead in changing
medical care”
Robert Waller Mayo Foundation
3
CPB & ATS Programs
PerfusionATS
4
Quality Improvement
5
PIC MeetingProspective Variance Database
– Clinical and ProductQuality Indicator ProgramChief Medical Officer, Chair
– Risk Manager– EVP Clinical Services– Director, Regulatory & Compliance– Director, Clinical Performance Improvement– Others
6
Advisory Boards
Medical
Perfusion
Technician
7
EducationClassroom
– Leadership training
Mock OR
LMS (HealthStream®)
Live Webinars
8
Total Intraop RBCsn=14,424 isolated CABGs 2010
9
Blood Management Practices
43
64
57
36
0% 20% 40% 60% 80% 100%
Physician Champion
Blood Management Team
Yes No
10
Blood Management Practices
46
79
100
29
21
22
14
64
100
100
7
50
14
43
36
54
14
21
79
64
43
0% 20% 40% 60% 80% 100%
Microplegia
Antifibrinolytics
Cell Salvage
Divert Pericardial Blood
Viscoelastic Tests
Heparin Conc/Protamine Tit
Transfusion Guideline/Algorithm
Meticulous Surgical Technique
Residual Pump Blood Chased to CS
Biopasive Surface Coating
Always Sometimes Never
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Other Metrics
SC Best SC Average Nadir HCT on CPB 24.8 24.5 Preop HCT 38.9 35.1
Average Range Static Prime (mLs) 1320 ±306 750-1800 Autologous Prime (mLs) 457 ±295 0-900 Ultrafiltration (% use) 15 ±12 0-40 Anesthesia Volume (mLs) 1721 ±381 1000-2200 Lowest Core Temperature (°C) 33 ±1.0 32-34.5 Hbg Trigger (g/dL) 7.0 ±0.4 6.0-7.0
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Intraop RBC -units
00.20.40.60.8
11.21.41.61.8
Q3 2010
Q4 2010
Q1 2011
Q2 2011
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•Autotransfusion•Reduce ECC Prime
- Autologous prime•Ultrafiltration•Microplegia
AVOID ANEMIA
•Coated ECC•Divert Pericardial Bld •P.O.C. Lab testing•Rx interventions•PLT Sequestration•Temperature?
MINIMIZE BLOOD LOSS
Perfusion Blood Management Influence
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Surgeon Anesthesiologist Perfusionist
• Patient History• Lab Screening/Minimizing
Blood Sampling• Predict Likelihood for
Transfusion• Consider Drugs to Increase
RBC mass (Iron)• Avoid Fluid Overload• Avoid/Suspend Anticoagulant
Therapy• Enforceable Transfusion
Guidelines
• Consider Acute Normovolemic Hemodilution
• Avoid Hypertension• Avoid Fluid Overload• Consider Drugs to Reduce
Bleeding (Amicar)
• Meticulous Surgical Technique• Enforceable Transfusion
Guidelines
• Cell Salvage• Low Prime ECC• Microplegia• Ultrafiltration• Point of Care Lab Testing• Avoid Hypertension• Consider Platelet Rich Plasma• ECC Biopassive Surface
Coating• Divert Pericardial Blood
• Avoid Hypertension• Avoid Fluid Overload• Avoid Hypothermia• Consider Drugs to Increase
RBC Mass• Enforceable Transfusion
Guidelines• Minimize Blood Sampling• Point of Care Lab Testing• Early Return to O.R. for
Bleeding
• Consider Cell Salvage
POSTOPERATIVEINTRAOPERATIVEPREOPERATIVE
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GeneralizableScientific Evidence
+ Context Improvement
Keys to Performance Improvement
Intelligent
Action
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Reference Articles
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Dashboard Query
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Q.I. Run Chart
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Ad-hoc Query Tool
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Surgeon Data
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Intraop RBC vs. Net Prime Volume
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Flow Chart
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Action Plan
Relative Odds of Receiving Packed Red Blood Cells Transfusion
p value <0.001
Odds Ratio Adjusted* Low HCT 15.5 Use of pump 7.91 Female Gender 2.37 Lower Body Weight 2.18 Older Age 1.99
2003;97:958-63
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6294
10629
3928
2126
3778
1445
0
2000
4000
6000
8000
10000
12000
<1000mLs 1000-1499mLs >=1500mLs
Num
ber o
f Pro
cedu
res
male female
Procedure Volume vs. Prime Volumen=28,200 isolated CABGs 2009-2010
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Patient Gender vs. Prime Volume
74.8% 73.8% 73.1%
25.2% 26.2% 26.9%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
<1000mLs 1000-1499mLs >=1500mLs
male female
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Patient Age vs. Prime Volume
64.5 64.564.4
66.4 66.3 66.6
63
63.5
64
64.5
65
65.5
66
66.5
67
<1000mLs 1000-1499mLs >=1500mLs
AGE
-yea
rs
male female
p <0.0001
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39.7 39.939.8
35.736.3 36.0
33.0
34.0
35.0
36.0
37.0
38.0
39.0
40.0
41.0
<1000mLs 1000-1499mLs >=1500mLs
Preo
p H
CT
male female
p <0.0001
Preop HCT vs. Prime Volume
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0.370.49
0.68
1.2
1.50
1.80
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
2
<1000mLs 1000-1499mLs >=1500mLs
RBC
-uni
ts
male female
p <0.0001
Intraop RBC units vs. Prime Volume
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2.84
1.33
0.59
0.21 0.07
2.78
1.68
1.190.95
0.46
0.00
0.50
1.00
1.50
2.00
2.50
3.00
<18 18-21 22-25 26-29 >29
RBC
-uni
ts
male female
Nadir HCT on CPB vs. Intraop RBCs
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SummaryVariation in clinical practice exists at many levels
– Geographic
– Top performers
Varying practice methods appear to achieve similar RBC utilization rates
Change is inevitable –except from a vending machine