Today’s Webinar will begin at 11 PST

1. Today’s Webinar will begin at 11 PST 7/19/12

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 or comments into text box • If time permits, we will open up the phone lines at the conclusion of the presentation

4. Katy Loos, RN, MSN

5. Best Practice Initiatives PATIENT BLOOD MANAGEMENT Katy Loos RN, MSN GOOD SAMARITAN HOSPITAL CINCINNATI, OH

6. OBJECTIVES • Identify areas of practice ready for change • Implement strategies to decrease or eliminate allogenic transfusions • Identify strategies to manage anemia

7. BLOOD MANAGEMENT AT GSH • Started Early 2010 • Identified 3 largest users of Blood Products • Focused on Orthopedics, ICU, and Oncology • Other areas were rising to the top in usage by remaining static giving us our next area to tackle

8. BASIC TENETS • Anemia is a treatable medical condition • Red cells should not be used to treat anemias that can be corrected with medications (AABB, American Blood Centers, American Red Cross) • Always document reason for transfusion • Use one unit whenever possible • Recheck labs before ordering more blood products

9. IDENTIFY AREAS NEEDING CHANGE • Know your data! • Target key problem areas first • Celebrate and congratulate all gains • Know your practices !

10. Data Dives… • Blood utilization by MSDRG • Physician practice • Premier benchmarking …drive the focus

11. Top 10 MSDRGs by Blood Case Count for Discharges January 2009 to December 2009 - Inpatient

12. Transfusion Practice at GSH by DRGPEER Data

13. Transfusion Practice by Top 10 MDs

14. ORTHOPEDICS Example of physician blinding for elective total hip arthroplasties

15. Orthopedics • 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

16. Orthopedic Recommendations • Document Reason for Transfusion: • HGB ≤7, HCT ≤ 21, Hypoxia, Weakness, or other signs of decreased oxygen carrying capacity. • Reasons and Triggers for Autologous transfusion same as allogenic. • While autologous transfusion is safer, it is not without risk • Limit autologous donations for indications such as known antibodies on T&S, complex surgery, or patient refusal of blood products. • Check HGB or HCT before automatically transfusing, thereby documenting lab value, and reason for transfusion • Do not give PRBCs in PACU without lab results. • Transfuse ONE unit at a time. Then recheck labs, re-evaluate patient. Give second unit only if needed.

17. INTENSIVE CARE • Physician and Resident education • Newsletter • E- LEARN • Mandatory transfusion order set usage • Audited for compliance • Established ICU transfusion dashboards • Intensivist scorecards delivered quarterly • Transfusion order sets revised • Decreased H/H trigger to 7/21 • Decreased number of PRBCs to 1 • Increased INR trigger on FFP to 1.8 (from 1.5) • Oncology subset with decreased triggers

18. ONCOLOGY • General Oncology Meeting • OPCC, 14CD, CNS, and Physicians • Show them their practice and opportunity to improve • Task force to review best practice • Always give literature to support changes • Oncology Order sets revised • Decreased RBC trigger to HGB 7 or HCT 21 • Decreased daily automatic transfusion to 1 unit RBC if indicated by trigger (was 2 units) • Decreased Platelet trigger to 10,000 (from 20,000)

19. Strategies to Decrease or Eliminate Transfusions PREOPERATIVE GUIDELINES • Pre-admission testing 14 – 45 days prior to surgery – allowing time to treat anemia • Oral agents of Iron, Folic Acid and Vitamin C for all patients • Avoid drugs that promote bleeding • Use Procrit - an erythropoesis stimulating agent (ESA), and IV Iron for more severe anemia

20. PREOPERATIVE GUIDELINES RATIONALE • Anemia is treated as a laboratory value, not a diagnosis • Overlooked in the presurgical History and Physical • Total Joint Replacement surgeries (TJA) on the rise – especially in the elderly • TJAs have some of the highest rates of transfusion • Preoperative anemia is the greatest predictor of peri-operative transfusion !!!

21. PERI-OPERATIVE GUIDELINES • Regional anesthesia  • Hypotensive anesthesia for those requiring general anesthesia • Pre-op Tranexamic acid • Decreased tourniquet time • Reinfusion system • Bipolar cautery • Avoidance of drains

22. POST-OPERATIVE GUIDELINES • Avoidance of strong VTE chemoprophylaxis in low risk Total Knee Arthroplasy (TKA) patients. • Lovenox 40 mg daily in TKA. • INR targets near 1.5 for patients on Coumadin. • Prolonged knee flexion >70 degrees the day of surgery • Transfusion triggers HGB 7 / HCT 21 unless cardiac symptoms or unstable • IV fluid correction of hypotension and postural changes

23. OUTCOMES IN ORTHOPEDICS • Since May 2011, overall transfusions of red blood cells have decreased by over 50% to a rate of 2-6% in elective total joint procedures • Transfusion rates during total hip replacements decreased • No adverse patient outcomes resulted • Decreased length of stay of 1 day on average • 2011 PRBC Orthopedic purchase cost savings of $5,700 per month average compared to 2010 average

24. 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

25. Pre-Surgical Anemia Protocol

26. Hospital Purchase Costs

28. Oncology Data

29. Thank You Katy Loos RN, MSN Katy_Loos@trihealth.com (CartCartoon source: http://bloodbankpartners.com)

30. References • Alexandrov, A. W., & Brewer, B. B. (2011). The Role of Outcomes in Evaluating Practice Change. In B. M. Melnyk, & E. Fineout-Overholt, Evidence Based Practice in Nursing and Healthcare . Philadelphia: Wolters Kluwer/ Lippencott Williams & Wilkins. • American Society of Anesthesiologists, Inc. (2006). Practice guidelines for perioperative blood transfusion and adjuvant therapies. Anesthesiology, 198 - 208. •  Farris, P., Ritter, M., & Abels, R. (1996). The Effects of Recombinant Human Erythropoietin on Perioperative Transfusion Requirements in Patients Having a Major Orthopedic Operation. The Journal of Bone and Joint Surgery, 62 - 72. • Goodnough, L. T., Maniatis, A., Earnshaw, P., Benon, G., P. B., Bisbe, E., et al. (2011). Detection, evaluation, and management of preoperative anemia in the elective orthopedic patient: NATA guidelines. British Journal of Anaesthesia, 13 - 22.

31. References, cont. • Kumar, A. (2009, November). Perioperative management of anemia: Limits of blood transfusion and alternatives to it. Cleveland Clinic Journal of Medicine, pp. S112 - S118. • Liumbruno, G., Bennardello, F., Lattanzio, A., Piccoli, P., & Rossetti, G. (2011). Recommendations for the transfusion management of patients in the peri-operative period. III. The post-operative period. Blood Transfusion, 320 - 335. • Martinez, V., Monsaingeon-Lion, A., Cherif, K., Judet, T., Chauvin, M., & Fletcher, D. (2007). Transfusion strategy for primary knee and hip arthroplasty: Impact of an algorithm to lower transfusion rates and hospital costs. British Journal of Anesthesia, 794 - 800. • Spahn, D. (2010, August). Anemia and patient blood management in hip and knee surgery: A systematic review of the literature. Anesthesiology, pp. 482 - 495.

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34. Upcoming Webinars • August 9th 11:00am-noon PST • September 13th 11:00am-noon PST

35. Thanks for joining us today