today’s webinar will begin at 11:00 2/9/12. welcome from barb debaun, rn, msn, cic
TRANSCRIPT
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Today’s Webinar will begin at 11:00
2/9/12
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Welcome from Barb DeBaun, RN, MSN, CIC
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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
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BloodConservationin CABG Surgery
February 9, 2012
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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]
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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
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The Public is Watching
Wall Street Journal, October 19, 2010
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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
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Quality at Enloe
• Created organizational focus in 2009
• Annual Quality Summit• Organizational quality initiatives• Program-based poster presentations
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Enloe Heart Program
• Blue Distinction for Cardiac Care
• STEMI Receiving Center
• Cardiology, Interventional Cardiology, Electrophysiology
• Cardiac Surgery
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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
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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
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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
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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
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Enloe Heart Program Volumes
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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
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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
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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
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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
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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
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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
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CABG: On vs. Off Pump
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Results: 2009-Current
CABG blood use decreased by 57% from 2009
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Next Steps
• February 13 pilot: Thromboelastograph (TEG) in CABG surgery
• Educate non-CV surgeons and OR staff around cell saver use
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Challenges
• Evolution of protocols
• Dealing with high-risk profiles
• Introduction of new thrombin inhibitors
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Thank youAny questions?
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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
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Improvement Capacity Building
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Contact Us
• www.Cynosurehealth.org
• Contact Barb DeBaun at [email protected]
• Check in for updates on webinar and in-person meetings