QRC Improving Blood Component Utilization in Cardiac Surgery

QRC Improving Blood Component Utilization in Cardiac Surgery with Teamwork and Audits with Feedback Nadia B. Hensley MD Assistant Professor

Objectives • Demonstrate how JHH’s cardiac surgery program has higher blood component utilization compared to other academic institutions • Discuss how we chose to intervene through audits with feedback and a new protocol • Compare pre- and post-intervention

Joint Commission’s Overuse Summit • Blood transfusion is one of top 5 most overused medical procedures according to the Joint Commission • 9 RCTs- liberal Hb transfusion trigger only adds risks and costs, without benefit, and potential harm • Substantial heterogeneity in blood transfusion practices

Maryland Cardiac Surgery Quality Initiative JHH

MCSQI comparison for PRBC transfusions JHH June 9, 2021 5

BLOOD UTILIZATION CAB ONLY – CY 16 June 9, 2021 7

Quarterly Joint Cardiac Surgery, Cardiac Anesthesia Meeting • 11/30/17 • Stakeholders- cardiac surgeons 3 new hires, cardiac anesthesia, perfusionists, mid-level providers, ICU intensivists • Immediately prior to meeting- anesthesia only- showed rank order bar graphs

Rank bar graphs presented to anesthesia RBC (units/case) PLTS (units/case) HENSLEY, NADIA BLAKEMORE (n=128) KOSTIBAS, MEGAN PRESLEY (n=84) BRADY, MARY BETH (n=36) BROWN IV, CHARLES HUGH (n=122) GAO, WEI DONG (n=134) FARADAY, NAUDER (n=47) BUSH, BRIAN PETER (n=11) JOHNS, ROGER ANTHONY (n=39) BERKOWITZ, DAN EZRA (n=117) LESTER, LAEBEN CHOLA (n=138) BARODKA, VIACHASLAU M (n=154) GRANT, MICHAEL CONRAD (n=88) SHEINBERG, ROSANNE (n=125) KOCH, COLLEEN GORMAN (n=11) JOSHI, BRIJEN L (n=41) NYHAN, DANIEL (n=94) GOEDDEL, LEE ANDREW (n=4) ABERNATHY III, JAMES HARRY (n=13) STEPPAN, JOCHEN (n=57) DODD-O, JEFFREY MICHAEL (n=47) HENSLEY, NADIA BLAKEMORE (n=128) BUSH, BRIAN PETER (n=11) KOSTIBAS, MEGAN PRESLEY (n=84) LESTER, LAEBEN CHOLA (n=138) JOSHI, BRIJEN L (n=41) BROWN IV, CHARLES HUGH (n=122) GAO, WEI DONG (n=134) SHEINBERG, ROSANNE (n=125) FARADAY, NAUDER (n=47) GRANT, MICHAEL CONRAD (n=88) KOCH, COLLEEN GORMAN (n=11) JOHNS, ROGER ANTHONY (n=39) ABERNATHY III, JAMES HARRY (n=13) BRADY, MARY BETH (n=36) NYHAN, DANIEL (n=94) BERKOWITZ, DAN EZRA (n=117) BARODKA, VIACHASLAU M (n=154) DODD-O, JEFFREY MICHAEL (n=47) STEPPAN, JOCHEN (n=57) GOEDDEL, LEE ANDREW (n=4) 0 June 9, 2021 0. 5 1 1. 5 2 2. 5 3 0 0. 2 0. 4 0. 6 0. 8 1 1. 2 9

Rank bar graphs (units/case) FFP (units/case) CRYO (units/case) BUSH, BRIAN PETER (n=11) HENSLEY, NADIA BLAKEMORE (n=128) KOSTIBAS, MEGAN PRESLEY (n=84) JOHNS, ROGER ANTHONY (n=39) BARODKA, VIACHASLAU M (n=154) LESTER, LAEBEN CHOLA (n=138) GAO, WEI DONG (n=134) BROWN IV, CHARLES HUGH (n=122) BRADY, MARY BETH (n=36) FARADAY, NAUDER (n=47) SHEINBERG, ROSANNE (n=125) JOSHI, BRIJEN L (n=41) BERKOWITZ, DAN EZRA (n=117) GRANT, MICHAEL CONRAD (n=88) KOCH, COLLEEN GORMAN (n=11) NYHAN, DANIEL (n=94) DODD-O, JEFFREY MICHAEL (n=47) STEPPAN, JOCHEN (n=57) GOEDDEL, LEE ANDREW (n=4) ABERNATHY III, JAMES HARRY (n=13) KOSTIBAS, MEGAN PRESLEY (n=84) HENSLEY, NADIA BLAKEMORE (n=128) BUSH, BRIAN PETER (n=11) ABERNATHY III, JAMES HARRY (n=13) BROWN IV, CHARLES HUGH (n=122) LESTER, LAEBEN CHOLA (n=138) GOEDDEL, LEE ANDREW (n=4) FARADAY, NAUDER (n=47) JOHNS, ROGER ANTHONY (n=39) SHEINBERG, ROSANNE (n=125) BARODKA, VIACHASLAU M (n=154) BRADY, MARY BETH (n=36) GAO, WEI DONG (n=134) KOCH, COLLEEN GORMAN (n=11) BERKOWITZ, DAN EZRA (n=117) GRANT, MICHAEL CONRAD (n=88) JOSHI, BRIJEN L (n=41) NYHAN, DANIEL (n=94) STEPPAN, JOCHEN (n=57) DODD-O, JEFFREY MICHAEL (n=47) 0 June 9, 2021 0. 5 1 1. 5 2 2. 5 3 0 0. 05 0. 15 0. 25 0. 35 0. 4 10 0. 45

Rank bar graphs- percent patients transfused % Tx Intraop RBCs GOEDDEL, LEE ANDREW (n=4) BRADY, MARY BETH (n=36) JOSHI, BRIJEN L (n=41) BROWN IV, CHARLES HUGH (n=122) HENSLEY, NADIA BLAKEMORE (n=128) GRANT, MICHAEL CONRAD (n=88) ABERNATHY III, JAMES HARRY (n=13) KOCH, COLLEEN GORMAN (n=11) KOSTIBAS, MEGAN PRESLEY (n=84) NYHAN, DANIEL (n=94) All attendings (n=1, 490) SHEINBERG, ROSANNE (n=125) LESTER, LAEBEN CHOLA (n=138) BERKOWITZ, DAN EZRA (n=117) FARADAY, NAUDER (n=47) BUSH, BRIAN PETER (n=11) BARODKA, VIACHASLAU M (n=154) DODD-O, JEFFREY MICHAEL (n=47) GAO, WEI DONG (n=134) JOHNS, ROGER ANTHONY (n=39) STEPPAN, JOCHEN (n=57) % Tx Intraop PLTS BUSH, BRIAN PETER (n=11) KOCH, COLLEEN GORMAN (n=11) LESTER, LAEBEN CHOLA (n=138) KOSTIBAS, MEGAN PRESLEY (n=84) JOSHI, BRIJEN L (n=41) HENSLEY, NADIA BLAKEMORE (n=128) BROWN IV, CHARLES HUGH (n=122) BRADY, MARY BETH (n=36) GRANT, MICHAEL CONRAD (n=88) All attendings (n=1, 490) SHEINBERG, ROSANNE (n=125) GAO, WEI DONG (n=134) FARADAY, NAUDER (n=47) NYHAN, DANIEL (n=94) ABERNATHY III, JAMES HARRY (n=13) BERKOWITZ, DAN EZRA (n=117) DODD-O, JEFFREY MICHAEL (n=47) JOHNS, ROGER ANTHONY (n=39) GOEDDEL, LEE ANDREW (n=4) BARODKA, VIACHASLAU M (n=154) STEPPAN, JOCHEN (n=57) 0 June 9, 2021 10 20 30 40 50 60 70 80 0 10 20 30 40 50 60 11

Rank bar graphs- percent patients transfused % Tx Intraop FFP KOSTIBAS, MEGAN PRESLEY. . . BUSH, BRIAN PETER (n=11) JOSHI, BRIJEN L (n=41) LESTER, LAEBEN CHOLA (n=138) BERKOWITZ, DAN EZRA (n=117) BROWN IV, CHARLES HUGH. . . SHEINBERG, ROSANNE (n=125) GRANT, MICHAEL CONRAD. . . All attendings (n=1, 490) NYHAN, DANIEL (n=94) BARODKA, VIACHASLAU M. . . BRADY, MARY BETH (n=36) HENSLEY, NADIA BLAKEMORE. . . JOHNS, ROGER ANTHONY (n=39) FARADAY, NAUDER (n=47) GOEDDEL, LEE ANDREW (n=4) GAO, WEI DONG (n=134) DODD-O, JEFFREY MICHAEL. . . KOCH, COLLEEN GORMAN (n=11) ABERNATHY III, JAMES HARRY. . . STEPPAN, JOCHEN (n=57) 0 10 20 30 40 50 % Tx Intraop CRYO GOEDDEL, LEE ANDREW (n=4) KOSTIBAS, MEGAN PRESLEY (n=84) HENSLEY, NADIA BLAKEMORE (n=128) LESTER, LAEBEN CHOLA (n=138) JOHNS, ROGER ANTHONY (n=39) BROWN IV, CHARLES HUGH (n=122) All attendings (n=1, 490) BUSH, BRIAN PETER (n=11) KOCH, COLLEEN GORMAN (n=11) SHEINBERG, ROSANNE (n=125) BERKOWITZ, DAN EZRA (n=117) BARODKA, VIACHASLAU M (n=154) BRADY, MARY BETH (n=36) ABERNATHY III, JAMES HARRY (n=13) GAO, WEI DONG (n=134) JOSHI, BRIJEN L (n=41) GRANT, MICHAEL CONRAD (n=88) FARADAY, NAUDER (n=47) NYHAN, DANIEL (n=94) STEPPAN, JOCHEN (n=57) DODD-O, JEFFREY MICHAEL (n=47) 0 June 9, 2021 5 10 15 20 25 12 30

Intraoperative hemoglobin triggers (July-October, 2017) Provider ID 1228 1317 1439 1480 200169 200702 200840 200844 200925 202932 202953 203219 2080 2227 2766 3728 4449 55698 Provider Name BARODKA, VIACHASLAU M BERKOWITZ, DAN EZRA BRADY, MARY BETH BROWN IV, CHARLES HUGH HENSLEY, NADIA BLAKEMORE STEPPAN, JOCHEN GRANT, MICHAEL CONRAD KOSTIBAS, MEGAN PRESLEY LESTER, LAEBEN CHOLA GOEDDEL, LEE ANDREW JOSHI, BRIJEN L BUSH, BRIAN PETER FARADAY, NAUDER GAO, WEI DONG JOHNS, ROGER ANTHONY NYHAN, DANIEL SHEINBERG, ROSANNE KOCH, COLLEEN GORMAN

Revisions – 2 to 3 times more units/Pt. Isolated CAB/Valve Intra Operative Other Cardiac Surgeries Intra Operative 6 10 5 8 4 6 3 4 2 2 1 0 0 RBC FFP Primary RBC PLTS FFP Primary Revision Isolated CAB/Valve Whole Hospital PLTS Revision Other Cardiac Surgeries Whole Hospital 20 30 25 15 20 10 15 10 5 5 0 0 RBC FFP Primary PLTS Revision CRYO

% Redo Sternotomy Case Complexity (% Redo) ABERNATHY III, JAMES HARRY (n=13) KOSTIBAS, MEGAN PRESLEY (n=84) BRADY, MARY BETH (n=36) DODD-O, JEFFREY MICHAEL (n=47) JOHNS, ROGER ANTHONY (n=39) KOCH, COLLEEN GORMAN (n=11) STEPPAN, JOCHEN (n=57) HENSLEY, NADIA BLAKEMORE (n=128) FARADAY, NAUDER (n=47) BARODKA, VIACHASLAU M (n=154) All Attendings (n=1, 498) LESTER, LAEBEN CHOLA (n=138) GRANT, MICHAEL CONRAD (n=88) BERKOWITZ, DAN EZRA (n=117) BROWN IV, CHARLES HUGH (n=122) JOSHI, BRIJEN L (n=41) SHEINBERG, ROSANNE (n=125) NYHAN, DANIEL (n=94) GAO, WEI DONG (n=134) GOEDDEL, LEE ANDREW (n=4) BUSH, BRIAN PETER (n=11) 0 2 4 6 8 10 12 14 16 18

Cardiac Surgeons % Tx Intraop RBC 0 0 10 5 20 10 15 30 % Tx Intraop PLTS 40 50 % Tx Intraop FFP 20 25 60 0 5 10 15 20 25 30 35 40 45 % Tx Intraop CRYO 30 35 40 45 0 2 4 6 8 10 12 14

Cardiac Anesthesia data- by name and public space Posted on the inside of the door to the cardiac anesthesia suite

March 1 st 2018 combined cardiac surgical/cardiac anesthesia meeting • • Intraoperative interventions 1) Transfusion trigger of Hb 7 2) Why Give 2 When 1 Will Do on Pump? 3) Formula dilutional Hct on pump <21% 4) Communicate with perfusion re: cell saver 5) Ultrafiltration/Hemoconcentration 6) Retrograde autologous prime 7) Consider acute normovolemic hemodilution

March 1 st 2018 combined cardiac surgical/cardiac anesthesia meeting • Consider preop platelet functional assay (Verify. Now P 2 Y 12) to determine % inhibition • Post-bypass- utilize TEG, fibrinogen, platelet count algorithm to guide treatment of coagulopathy

ly 2 Au 016 g 2 (n = Se 016 92) pt ( 20 n=9 Oc 16 2 t 2 (n ) No 016 =99 v 2 (n ) 01 =10 De 6 8 c 2 (n ) 01 =11 Ja 6 (n 3) n 20 =11 Fe 17 5) b ( 20 n=7 M 17 6) ar ( 20 n=9 Ap 17 0) r 2 (n= M 0 9 ay 17 7) 20 (n= 1 8 Ju 7 (n 7) n 20 =10 Ju 17 4) ly ( 20 n=8 Au 17 6) g 2 (n = Se 017 72) pt ( 20 n=6 Oc 17 6) t 2 (n= No 017 84) v 2 (n 0 = De 17 72) c 2 (n = Ja 017 78) n 20 (n= 1 Fe 8 ( 76) n b 20 =10 Ap 18 4) r 2 (n= M 0 9 ay 18 3) 20 (n= 18 69 (n ) =1 08 ) Ju Percent of Patients 50 45 30 25 15 % Tx RBC % Complex Cases 40 R 2 = 0. 2114 35 Joint Meeting 20 R 2 = 0. 0001 10 5 0

6 01 6 (n 2) =9 (n 2 = Oc 016 92 t 2 (n ) No 016 =99 v 2 (n ) 0 = De 16 108 c 2 (n ) 01 =11 Ja 6 (n 3) n 20 =11 Fe 17 5) b ( 20 n=7 M 17 6) ar ( 20 n=9 Ap 17 0) r 2 (n= M 0 9 ay 17 7) 20 (n= 1 8 Ju 7 (n 7) n 20 =10 Ju 17 4) ly ( 20 n=8 Au 17 6) g 2 (n = Se 017 72) pt ( 20 n=6 Oc 17 6) t 2 (n= No 017 84) v 2 (n 01 =72 De 7 ) c 2 (n = Ja 017 78) n 20 (n= 1 Fe 8 ( 76) n b 20 =10 Ap 18 4) r 2 (n= M 0 9 ay 18 3) 20 (n= 18 69 (n ) =1 08 ) pt Se g 2 01 ly 2 Au Ju Percent of Patients 50 45 % Tx FFP % Tx PLT % Complex Cases 40 35 R 2 = 0. 2658 30 25 20 R 2 = 0. 2258 Joint Meeting 15 10 5 R 2 = 0. 0001 0

30%

1. 73 41% 1. 02

Parameter Age (per unit increase) Gender (Female) ASA (per unit increase) OR (95% CI) P-Value 1. 02 (1. 02 – 1. 03)) <0. 0001 3. 32 (2. 65 – 4. 16) <0. 0001 2. 34 (1. 96 – 2. 80) <0. 0001 1. 08 (1. 07 – 1. 10) <0. 0001 2. 55 (1. 78 – 3. 69) <0. 0001 0. 99 (0. 77 – 1. 26) 0. 91 2. 18 (1. 65 – 2. 90) <0. 0001 Anesthesia Minutes (per 15 -minute increase) Complex Case Cell Saver Blood Given Pre- vs. Post-Initiative Multivariate Analysis- Independent Predictors of RBC Transfusion

Percentage of patients transfused FFP and platelets intraop in cardiac surgery over time

=plts =FFP

Table 1. Multivariate analysis (Outcome: Transfused PLTs or FFP intraoperatively) Outcome: Transfused PLTs Intraop Parameter Age (per unit increase) Gender (Female) ASA (per unit increase) Anesthesia Minutes (per 15 -minute increase) Complex Case Cell Saver Blood Given Pre- vs. Post-Initiative Outcome: Transfused FFP Intraop OR (95% CI) P-Value 1. 02 (1. 01 – 1. 03) <0. 0001 1. 01 (1. 00 – 1. 02) 0. 03 1. 25 (0. 99 – 1. 57) 0. 06 1. 45 (1. 14 – 1. 83) 0. 002 1. 87 (1. 55 – 2. 25) <0. 0001 9. 73 (5. 47 – 17. 48) <0. 0001 1. 09 (1. 08 – 1. 11) <0. 0001 1. 10 (1. 08 – 1. 11) <0. 0001 3. 19 (2. 23 – 4. 60) <0. 0001 4. 00 (2. 78 – 5. 80) <0. 0001 1. 16 (0. 90 – 1. 49) 0. 26 1. 37 (1. 06 – 1. 79) 0. 02 2. 51 (1. 85 – 3. 44) <0. 0001 1. 99 (1. 47 – 2. 72) <0. 0001

Summary • Cardiac surgery is one of the highest blood component utilizers in the hospital • Blood transfusion is one of the top 5 most overused medical procedures (by TJC) • 9 RCTs all showing “less is more” • Audits with feedback and building consensus around solution can be effective in changing behavior • In future, utilizing text messaging or other smart phone apps to serve as reminders

Acknowledgements • Dr. Steven M. Frank, Director, Johns Hopkins Health System Blood Management Program • Armstrong Institute for Patient Safety and Quality • Vince De. Mario B. S. – Data manager • Mereze Visagie B. A. – Data manager, report writer • Tyler Wintermeyer – Clinical Analytics