ZERO TOLERANCE: Transfusion Free Total Joint Replacement

1. Mark A Snyder, MD Kathryn Eten RN, CCM Katy Loos, RN Orthopaedic Center of Excellence Good Samaritan Hospital Cincinnati, Ohio ZERO TOLERANCE: Transfusion Free Total Joint Replacement sept 22, 2012 SABM 2012

2. DISCLOSURE • Consultancy • Smith & Nephew • Medtronic • Research Support • Smith & Nephew • Hatton Research Institute GSH • IDEs • Bayer • Boehringer • Cadence • Co-management Arrangements • Good Samaritan Hospital

3. Good Samaritan HospitalTriHealth System

4. Obamaca r e Standardization Centralization

5. The Solution:Consumer (patient)-Driven Care • Consumer-driven insurers • Consumer-friendly hospitals • Consumer-friendly employers • Consumer-supportive laws • Consumer-driven market Transparency! “Americans Favor Transparency in Medicare, Physician Changes,” May 2, 2006, www.zogby.com

6. “How physicians can change the future of health care.”Porter ME, Teisberg EO. JAMA 2007;297(10):1103. Returning medicine to its proper focus: Enabling health and providing effective care. PRINCIPLES: • *Goal is value for patients • *Organization around conditions and cycles of care • *Measuring of results, risk-adjusted outcomes, and costs * * * “ZERO”, TJA, registry

7. A powerful approach to cost reduction in health care! • “Adverse events are associated with significantly increased hospitalization costs and appropriate evidence-based interventions are justified to minimize AEs.” • Kondalsamy-Chennakesavan S, et al. GynecolOncol. 2011;121(1):70 • “Risk-adjusted total, Medicare, and beneficiary healthcare costs were significantly higher for both THR and TKR patients with VTE.” • Boser O, et al. Curr Med Res Opin. 2011;27(2):423 • Radically reduce adverse events! • Invest in initiatives to apply best evidence literature to care processes. • Believe that real change can happen and that it is good for all stakeholders! Patient safety!

8. Top 10 Most Costly, Frequent Medical Complications In the US http://www.soa.org/files/pdf/research-econ-measurement.pdf

9. Why Zero Tolerance? It is the right thing to do!

10. A New Day Is Coming! • CMS in cooperation with the AAOS • Dry-run September 2012 • National transparency 2013 via compare.gov • RSCR and RARR • What are the targets? • Mechanical complication readmission 90 days • PJI 90 days • SSI 90 days • Surgical site bleeding, PE, death 30 days • AMI, pneumonia, sepsis/septicemia 7 days

11. The Truth Hurts! • RARR 5.7% national • RSCR 3.6% • GSH 5.0% and 3.6% respectively • Years 2008 to 2010

13. Two Things! • No “silver bullet” • Mountain climbing

14. Using The Evidence • Causal analysis • Heget JR, et al. JtComm J QualImprov 2002;28(12):660 • Nicolini D, et al. J Health Serv Res Policy 2011;16 Suppl 1:34 • BEFORE…DURING…AFTER • Randomized clinical trials • Meta-analyses • Cochrane reviews • Available clinical practice guidelines (CPG) • BEST PRACTICE PROPOSALS (BPP) • Barbieri A, et al. BMC Med 2009;7:32 • Rotter T, et al. Cochrane Database Syst Rev 2010;(3):CD006632

15. For ExampleReducing Blood Transfusions • BEFORE: uncorrected pre-op anemia • DURING: unfettered bleeding and no inhibition of fibrinolysis • AFTER: mandated strong VTE chemoprophylaxis • Evidence:STRONG, MODERATE, WEAK, INCONCLUSIVE

16. BPPReducing Blood Transfusions

17. Teamwork is required to enable Zero in on Zero Surgeons Staff Administration Patients and family

18. Eisenhower Strategy • Get broad buy-in • Collegially help everyone move in the same direction to achieve a solution! • Hospital credentialing: • Docs must participate in the Registry • Docs may use the OCE marketing plan IF they follow established CPGs and new BPP protocols where CPGs do not yet exist • While docs must decide what is best for their individual patients, disagreements with CPGs and BPP protocols must be in writing

19. Blood Transfusions

20. REMEMBER THAT THE TWO LEADING CAUSES OF BLEEDING SUFFICIENT TO REQUIRE TRANSFUSION ARE 1) PRE-OP ANEMIA AND 2) POTENT ANTICOAGULANTS • Salida JA, et al. Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: predictive factors. JBJS 2002 84:216 • Bong MR, et al. Risks associated with blood transfusion after total knee arthroplasty. J Arthroplasty 2004;19:281

21. Despite a low transfusion rate, 20% TKA/THA patients exhibited preoperative anemia • < 13 gm/L for men and < 12 gm/L for women • Patients unaware of anemia since fatigue is the predominant symptom. • PCP acceptance of anemia since surgical options not in their usual treatment algorithms. • Patients with severe OA of the hip and/or knee are more likely to undergo TJA if this option is discussed with their PCP, but few patients experience this conversation! • Schonberg MA, et al. J Am GeriatrSoc 2009;57(1):82

22. Total Blood Transfusions Zero BPP designed and trialed

24. In 2010, transfusion cost for 321 allogenic and autologous units was $321,000. In 2011 and 2012, we have already saved over$500,000! Shander A, et al. Transfusion 2010;50(4):753

25. Orthopaedics was an area of practice ready for change! • Collaborative group with strong leadership • Supportive multidisciplinary team • Zero in on Zero initiative with strong body of evidence to support best practice initiatives • High usage of blood products • Wide variation in blood management practices

26. ORTHOPAEDICS Example of physician blinding for elective total hip arthroplasties

27. ORTHOPAEDICS • Blinded physician-specific transfusion data • Presented at Section meeting • Extensive literature review for evidence based best practice • New practice initiatives for pre, intra, and post-operative conservation • Amended order sets to reflect changes • Established Anemia Clinic • Orthopedic Center of Excellence (OCE) • Quality measure: Preoperative anemia • Established metrics • Posted on OCE dashboard

28. Pre-Surgical Anemia Protocol

29. Anemia Prevention • Anemia Clinic with automatic treatment of patients by hematologist • Education of residents, and individual services • Go to each section meeting and deliver the message that is pertinent to their practice • Let other services know about the successes gained by others • Empower staff nurses as your advocates

30. Challenges: The Patient • Lack of knowledge about anemia • Overwhelmed when notified of anemic status • Feared surgery cancelation • Did not want to travel for additional doctor visits

31. Challenges: Physicians • Orthopedic surgeons tried to treat patients on a case by case basis only to meet resistance from PCP and third party payers. • PCP’s feared loss of control over patient care if patients were referred to a hematologist for mild anemia. • Speculation that the new process would delay surgery. • Communication gaps

32. Challenges: Hospital Process • Ownership of clinic process • Clinical exam space • Departments wanted new business but sometimes resisted implementation • Multi dept involvement • Verbal and electronic communication gaps between departments

33. How can a total joint registry enable blood conservation success? • Prospective, consecutive tracking of all total hip and knee arthroplasties enables physicians to see their own results in comparison with blood conservation best practices, and then choose to change their own practices. • The registry has “before/during/after” data that enables problem solving.

34. Patient Consent IRB Approved

35. REGISTRY BENEFITS! Early warning Influence MD behavior Decrease AE cost, M&M, revTJAvolume

39. MAS DATA • August 1, 2011 to Sept 21, 2012 • 405TJA • Total AE 1.73% • Transfusion 0% • SSI 0% • RSCR 0.49% • RARR 0.49% 1/10 the rate

40. How was this accomplished? • BEFORE • Anemia detection • Anemia correction • DURING • Novel blood loss prevention • TXA administration • Avoidance of surgical drains • AFTER • TXA effect • Transfusion criteria 7/21 • IV saline for minor postural hypotension and lack if vigor

41. TAKEHOMEMESSAGES ZERO in on zero THE PATH Center of Excellence Zero in on Zero safety and quality initiative Initiative deployment Physician credentialing agreement Registry • Part of a regional solution for an upcoming patient access crisis • Stellar safety and quality are win-wins for patients, providers, hospitals and society. • Physician leadership is critical to creating and sustaining patient-centered solutions for adverse event challenges in hip and knee replacement.

42. Sir Winston Churchill “Success is not final, Failure is not fatal: it is The courage to continue That counts.”