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Today’s Webinar will begin at 11:00

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.

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Today’s Webinar will begin at 11:00

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  1. Today’s Webinar will begin at 11:00 2/9/12

  2. Welcome from Barb DeBaun, RN, MSN, CIC

  3. 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

  4. Blood Conservation in CABG Surgery February 9, 2012

  5. Participants • Barry Johnson, MD • CV Surgery Anesthesiologist • barryjonsn@aol.com • Pablo Zubiate, CCP • Cardiovascular Surgery Coordinator • Pablo.zubiate@enloe.org • Marcia Nelson, MD, FAAFP • Vice President, Medical Affairs • Marcia.nelson@enloe.org

  6. 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

  7. The Public is Watching Wall Street Journal, October 19, 2010

  8. 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

  9. Quality at Enloe • Created organizational focus in 2009 • Annual Quality Summit • Organizational quality initiatives • Program-based poster presentations

  10. Enloe Heart Program • Blue Distinction for Cardiac Care • STEMI Receiving Center • Cardiology, Interventional Cardiology, Electrophysiology • Cardiac Surgery

  11. 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

  12. 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

  13. 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

  14. 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

  15. Enloe Heart Program Volumes

  16. 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

  17. 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

  18. 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

  19. 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

  20. 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

  21. 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

  22. CABG: On vs. Off Pump

  23. Results: 2009-Current CABG blood use decreased by 57% from 2009

  24. Next Steps • February 13 pilot: Thromboelastograph (TEG) in CABG surgery • Educate non-CV surgeons and OR staff around cell saver use

  25. Challenges • Evolution of protocols • Dealing with high-risk profiles • Introduction of new thrombin inhibitors

  26. Thank you Any questions?

  27. 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

  28. Improvement Capacity Building

  29. Contact Us • www.Cynosurehealth.org • Contact Barb DeBaun at bdebaun@cynosurehealth.org • Check in for updates on webinar and in-person meetings

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