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Doing Everything to Conserve Blood
Allina Health Hits Benchmarks in a System-wide Effort; Strives for Best in Class
Minneapolis Heart Institute
AT A GLANCE
knew that Pathology could not just mandate new practices
Not-for-profit Allina Health serves patients throughout
through the system; she needed allies among the providers
Minnesota and western Wisconsin at 12 hospitals, 90 clinics
who used the most blood products. That meant gaining the
and three ambulatory care centers. The system provided
support of physicians, especially cardiac surgeons, and other
105,057 inpatient hospital admissions, 1.2 million outpatient
clinicians such as perfusionists, who operate the heart-lung
admissions and 35,373 inpatient surgical procedures last year.
machines that support the patient during open-heart surgery.
It consistently ranks high on U.S. News and World Report's
When Dirck Rilla, SpecialtyCare's director of clinical
Best Hospitals list.
perfusion operations, arrived at Allina, he noticed that
The Minneapolis Heart Institute at Allina's flagship, Abbott
transfusions following open-heart surgery were far too
Northwestern Hospital, is recognized internationally as one
commonplace. "There was not really any effort to conserve
of the world's leading providers of heart and vascular care.
blood. The rate of platelet transfusions was running 65
Through the institute, advanced cardiac surgery is performed
percent to 70 percent. We were using 2 to 3.25 units of red
at Abbott Northwestern; United Hospital in St. Paul, Minn.;
blood cells per patient. The national benchmark at that time
and Mercy Hospital in Coon Rapids, Minn.
In 2011, senior clinical leaders at Allina, including Chief
Eventually, Allina adopted an ambitious system-wide blood
Clinical Officer Penny Wheeler, MD and Lauren Anthony,
MD, medical director of Allina Medical Laboratories, began
The project included:
discussions on how to reduce the use of blood products across the system. According to national benchmarks, Allina
• changing cardiac bypass protocols to reduce the use of
had a transfusion rate that was 25 percent above average.
priming volume for the heart-lung machine and use of
Wheeler was intrigued after attending national health care
the patient's own blood for priming purposes;
meetings where she heard presentations on the value of blood
• reducing postoperative blood loss for cardiac and
conservation for better clinical outcomes and significant
orthopedic surgery by collecting blood from surgical
sites, concentrating it, washing it and then reinfusing
Dr. Anthony had prior experience with a successful blood
the blood to the patient (a process commonly referred to
management program and was asked to lead the project. She
• adding a device to invasive
monitoring lines to reduce the
Figure 1: Intraoperative RBC Use
Al ina System Open-Heart Procedures
amount of blood lost from multiple draws for laboratory tests;
• reducing the default transfusion
order across the system from two units of red blood cells to one; and
• basing transfusion decisions not
just on lab results for hemoglobin but also on an in-person evaluation of the patient's overall condition.
The results have been strong:
• The frequency of intraoperative
RBC units decreased from 32 percent to 22 percent from 2011
to 2012, while the last hematocrit in the OR and the
if done hospital by hospital.
lowest hematocrit on CPB remained stable.
Dr. Anthony believes Allina is the largest health system to
• Red blood cells, which account for 70 percent of all
have adopted a comprehensive blood conservation program.
transfusions, fell from 300 units per 1,000 admissions
To make the program succeed, the Allina Transfusion
to 200 units at a savings of $1 million annually. But that
Care Council was created with Dr. Anthony as its chair
is based on the blood center's acquisition cost alone.
and members from all specialties and hospitals. Smaller
Published studies have shown that when adding in costs
work groups were formed around clinical areas with
of lab compatibility tests, maintaining blood inventory
representatives from each hospital and staff, such as
and nursing time to administer, the total cost is closer to
perfusionists, nurses and medical technicians, included.
four times the acquisition cost; and, hence, the savings
There were also hospital specific groups that mirrored the
would likely be four times higher. (see Figure 1)
• Overall blood utilization is down 25 to 30 percent
across the system.
• Net prime volume of cardiopulmonary bypass circuit is
Among others, Dr. Anthony credits John Grehan, MD,
down nearly fourfold to about 800 milliliters per case.
attending cardiothoracic surgeon at United Hospital, for
being a force for clinical integration on blood management. "A lot of doctors don't care about other hospitals, other
• In a pilot test, use of a device to reclaim blood from
specialties, but as system chair of the Cardiovascular
chest tubes postoperatively reduced transfusions from
Workgroup and chair of United Hospital's Transfusion Care
69 percent of patients to 36 percent.
Council, he has really worked across the system to implement
How Allina achieved those results is the real story, one that
clinical practice guidelines," she says.
involved overcoming ingrained habits in daily practice as
She also credits an anesthesiologist at Mercy Hospital,
well as debunking the folklore surrounding the use of blood
Joshua Martini, MD, as a key champion. Blood management,
and blood products.
as a movement, started with anesthesiologists, who provided
THE BACK STORY
transfusions during and after complex surgeries.
Early on, Allina brought in two experts to provide
Also, Dr. Anthony credits Rilla as being one of the first
perspective to physicians and other clinicians on blood
people to volunteer as a champion for blood management. "I
management and best practices. "They brought the message
knew Dirck and SpecialtyCare had already done programs
that proper blood conservation is good medicine, that blood
like ours, and he had made presentations at national
is not a benign substance, that you should only give it when
SpecialtyCare meetings on this topic, so he gave us some
it's needed and that you can cause a lot of harm when it's not,"
really good insight as to what was going on in other hospitals,
Dr. Anthony says. "Doctors don't get much education on this
what resources they were using, and helped us build an
in the field because it's kind of its own subject area. You learn
approach to what we needed to do to get our program
about it in the lab but not so much in areas like OB-GYN or
launched," Dr. Anthony says.
general surgery, where they aren't so focused
That approach included adopting all recommended
practices in the 2011 Society of Thoracic Surgeons' Blood
While blood transfusions can be lifesaving, they are not
Conservation Guidelines. The first project was to revamp the
risk-free. Furthermore, recent research shows that allogeneic
cardiopulmonary bypass circuit to reduce priming volume. "So
blood transfusions (donor blood) are far from benign. Large,
we shortened up the lines; we made things a lot smaller, a lot
multicenter studies have found significantly higher rates
tighter," Rilla says. Exposing blood to the surfaces within the
of death, kidney failure, heart attacks, surgical site infections,
heart-lung machine provokes an inflammatory response that
postoperative bleeding and other complications among
can cause the patient to dilate and lose fluid from blood vessels
transfused patients compared with those who didn't
to the tissues. To reduce intravascular depletion, the patient
often receives crystalloid volume administration, which carries the risk of hemodilution and subsequent blood transfusion.
The program was rolled out system-wide because Allina
has had complete electronic medical records since 2003,
The shorter circuit enabled the other big change—the
so it can't make a change to order sets for transfusions
switch to retrograde autologous priming technique (RAP).
without having all of its hospitals involved. Also, advocates
Prior to that point, the heart-lung pump was primed only
said it would work against the goal of clinical integration
with an isotonic crystalloid solution. Essentially, this solution
maintains sufficient blood volume between the machine and
"She is due to start rehab, so we will need to tank her up."
the patient for survival during surgery. The downside is that
The video includes "evidence," such as a screenshot of the
this fluid also dilutes the patient's blood, often to the point
transfusion guidelines from the American Association of
where needed blood components, including clot forming
Blood Banks, which recommends:
proteins, are ineffective, resulting in excessive bleeding and acute anemia.
• making transfusion decisions for all patients based on
symptoms as well as hemoglobin levels and
The RAP procedure allows for the patient's own blood to
be brought into the circuit to displace a significant amount
• using a hemoglobin level of 7 g/dL to 8 g/dL as a
of the IV fluid. "Essentially, the patient's own blood primes
threshold for hospitalized patients who are stable.
the circuit, and once on bypass, we don't see a huge drop
"When I made up the dialogue, I used all the objections
in hemoglobin and hematocrit like we used to, so we are
I have heard in all the meetings and presentations on the
not diluting them out significantly," Rilla says. "When we
blood program," Dr. Anthony says. "I had heard the phrase
are done with surgery, we have a lot of that blood left in the
‘the blood police' so many times, I thought we should use it
circuit, which we can then chase back up to the patient."
to our advantage."
United Hospital has made those pump practices standard,
"Administrators who would be totally bored with blood
and Dr. Grehan says perfusionists played a big role in taking
management watch this video and they get it," she adds. "It
the data on improved outcomes to the other two hospitals
has enabled us to get more buy-in from leadership."
that perform cardiac surgery. "Perfusionists have a home base, but they travel to other hospitals and can bring it to the
The logo for the Allina program is a red blood drop with the
attention of younger doctors who might be amenable to it.
word "THINK" in it. "Our message is not ‘Don't transfuse'; it
In turn, we hope they can build a critical mass so that more
is ‘Think,'" Dr. Anthony says. "There is a lot of folklore around
senior surgeons will take a look at this data, which is pretty
blood, and people who would otherwise order the minimum
compelling. But after 30 years of doing a pretty complex
effective dose of any medication automatically order two units
surgery and doing it well, many are still not ready for it."
of blood. We are asking them to stop and think first."
911: A CALL TO THE BLOOD POLICE
SALVAGING BLOOD POST-OP
Allina has tried a novel approach to spread the word about
Another major area of blood conservation involves
blood conservation. Dr. Anthony wrote and Rilla and Dr.
anesthesia technician services. Bruce Bjelland, vice president
Martini starred in a 12-minute "Law and Order"-style video
of SpecialtyCare's Autotransfusion Clinical Services, worked
called "The Blood Police: The Case of Too Much Blood."
with the Iatrogenic Blood Loss Committee to implement a
In it, a surgeon played by Dr. Martini is called by a nurse
venous arterial blood management protection (VAMP) system,
about a joint replacement patient whose blood work result
which encompasses a closed blood sampling system. The
suggests anemia, with a hemoglobin level of 8.0 grams per
VAMP system is designed to reduce blood waste associated
deciliter (g/dL). The doctor orders two units of blood, adding,
with blood sampling. Patients with a conventional (nonVAMP)
arterial line can often lose up to a unit of blood in the days following
Figure 2: Net (Pump) Prime Volume
a procedure from blood sampling procedures.
autotransfusion team also took the lead in postoperative blood salvage in joint replacement and cardiac surgery cases. These involved the OrthoPAT and CardioPAT devices, specialized autotransfusion devices for orthopedic and cardiovascular surgeries. These highly mobile devices follow patients through the recovery process, such as the cardiac care unit, and significantly reduce red blood cell transfusions.
medications], they need surgery right away, which causes
Allina has met its first goal of reaching the benchmark
us to use a lot of blood products," he says. The Society of
average of the national database for blood transfusion. Now
Thoracic Surgeons' guidelines recommend that stable
the task becomes more targeted, unmasking variation in
patients wait three or four days to allow the drug to dissipate
use by hospital, department and provider. "So if we look at
and platelet function to recover prior to surgery.
knee replacement, we'll want to know why at one hospital
The cardiovascular team is working on new dashboards
you may virtually be guaranteed to get a transfusion, yet at
that join data on blood use with outcomes and performance
another, virtually nobody gets one," Dr. Anthony says. "Is it
data. "Now we want to move beyond benchmarks to adopting
differences in patient population or just physician practice?"
all best practices," Dr. Grehan says.
Dr. Grehan wants to develop new protocols around the
Allina is not done with educating physicians. "We are doing
use of anti-clotting medication. Patients who present to the
transfusion medicine grand rounds, focusing on topics the
ER with suspected myocardial infarction are often given
doctors want to hear about," Dr. Anthony says. "We are using
Clopidogrel even before knowing the underlying cause of
videoconferencing, so the speaker can reach all 12 hospitals.
symptoms. "Also, cardiologists are of the mindset that if they
We are trying different modalities, really every means we can
can't stent a patient, even though he's loaded with [antiplatelet
find to spread this message of using less blood."
ALLINA HEALTH is dedicated to the prevention and
through its 90+ clinics, 12 hospitals, 15 pharmacies, specialty
treatment of illness and enhancing the greater health of
care centers and specialty medical services that provide
individuals, families and communities throughout Minnesota
home care, senior transitions, home oxygen and medical
and western Wisconsin. A not-for-profit health care system,
equipment, and emergency medical transportation services.
Allina Health cares for patients from beginning to end of life
Learn more at allinahealth.org.
SPECIALTYCARE, a Joint Commission-certified
Our client hospitals benefit from exceptional resources and
corporation, provides one or more of our six service lines
our annual caseload experience of more than 350,000 surgical
in perfusion, autotransfusion, minimally invasive surgical
procedures. SpecialtyCare provides perfusion services in more
support, sterile processing department management, surgical
than 50,000 open-heart surgeries each year. One in every
assist or intraoperative neuromonitoring in more than 820
nine open-heart surgeries performed in the US this year uses
hospitals across a broad geographical area that includes 44
SpecialtyCare for perfusion services.
states, the District of Columbia, Puerto Rico, and Germany.
One American Center 3100 West End Ave. Suite 800 Nashville, TN 37203 615-345-5400 615-345-5405 facsimilé www.specialtycare.net
COPYRIGHT 2014 SPECIALTYCARE
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