1 introducing change: an organizational overview tim dickinson october 7, 2011

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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

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Advisory Boards

Medical

Perfusion

Technician

7

EducationClassroom

– Leadership training

Mock OR

LMS (HealthStream®)

Live Webinars

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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

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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