Todays Webinar will begin at 11 00 2912

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

Welcome from Barb De. Baun, 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

Blood Conservation in CABG Surgery February 9, 2012

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

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

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

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

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

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

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

Background: CV Quality Initiative • Model: Physician champion leading multidisciplinary 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 – 2011 Guidelines Update published Ann Thorac Surg 2011; 91: 944– 82

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

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

Enloe Heart Program Volumes

Baseline Data: 2007 -2009 • In 2009, 65% of Enloe’s CABG patients received intra -operative blood • Goal: Reduce intraoperative blood usage to meet STS benchmark

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

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

Methods: Role of the Team • Perfusionist Role – – Minimize extracorporeal circuits Use of bonded circuits Use of cell savers Pump salvage & intra-op autotransfusion – Post-operative shed blood -infusion – Retrograde autologous priming (RAP) – Hemofiltration re

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

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

CABG: On vs. Off Pump

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

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

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

Thank you Any questions?

Next Cynosure ‘Beyond SCIP” and other events • March 15 th: in-person meeting in San Francisco • March 27 th: webinar with Dr. Heather Young from Colorado • April 12 th: webinar with Sue Barnes from Kaiser Permanente • May 21 st: Cynosure Summit: the great quality swap meet

Improvement Capacity Building Quality Improvement 101 An introduction to quality improvement in healthcare. Excel for Quality Improvement: Beyond the Basics Understanding more advanced functions, database management, and Pivot tables. Quality Improvement for Physicians Core concepts of quality improvement for physician leaders/champions. Excel for Quality Improvement Learning to create databases, automate calculations, and build graphs. Project Management 101 Skill building class for leading meetings and improvement efforts. Compass Multi-month class designed to take student through a performance improvement project.

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