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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 as autotransfusion); • 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 White Paper
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) system efforts.
• 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 on transfusions." 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 White Paper
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
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. The SpecialtyCare 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.
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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
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 COPYRIGHT 2014 SPECIALTYCARE



PD Dr med WP Bieger NeuroStress Guide EINLEITUNG Der vorliegende NeuroScience-Guide ist als Anleitung für Patienten, Ärzte und Therapeuten gedacht. Er soll einen Einblick in die Funktionsweise des Neuroendokriniums und in die Grundlagen neuroendokriner Funktionsstörungen und deren Behandlung vermitteln. Die von uns entwickelte „NeuroStress"-Diagnostik wird vorgestellt und physiologische Behandlungsformen besprochen. Schon lange gibt es hochwirksame Substanzen für die natürliche Behandlung psychoneurovegetativer Störungen, die allerdings durch die Entwicklung der modernen Psychopharmaka verdrängt wurden. Die unbefriedigenden Ergebnisse der Antidepressiva haben die traditionellen Behandlungskonzepte jedoch wieder ins Bewusstsein gerückt. Unser aktuelles ganzheitliches diagnostisch-therapeutisches Konzept greift die bewährten Verfahren auf und verbindet sie mit innovativen Diagnose- und Behandlungsformen aus den USA. Eingangsüberlegungen: 1. Die Zahl neurovegetativer Störungen und psychischer Krankheiten nimmt weltweit stark zu. Damit auch die Nachfrage nach neuen diagnostischen Möglichkeiten und effzienten, gut verträglichen Behandlungen. Seit Jahren steigt die Zahl psychischer Störungen in den westlichen Industrieländern. Man geht davon aus, dass bis zu 60% der Krankheitsfälle in der täglichen ärztlichen Praxis psychischer Natur sind bzw. eng mit psychischen Belastungen verbunden sind. Schon heute entfallen viele Krankheitstage auf psychische Störungen, ihre Zahl nimmt ständig zu, während die Gesamtzahl krankheitsbedingter Fehltage seit Jahren zurückgeht. Besonders gravierend ist die Zunahme der Depressionen. Während Herz-Kreislauferkrankungen, Herzinfarkt, sogar die häufigsten Krebserkrankungen (Lungen-, Brust- und Prostatakrebs) seit einigen Jahren abnehmende Tendenz zeigen, nimmt der Anteil von Depressionen ständig zu. Die WHO geht in einem ihrer jüngsten Gesundheitsberichte (2006) davon aus, dass bereits in den nächsten 5-10 Jahren Depressionen die zweithäufigste medizinische Krankheitsursache überhaupt sein werden. 2. Psychopharmaka werden heute in enormem Maße eingesetzt, sie sind mit >65 Mrd € die umsatzstärkste pharmazeutische Präparategruppe. Ihre Wirksamkeit, vor allem die der Antidepressiva, ist jedoch begrenzt. Die Nebenwirkungen sind zahlreich und zum Teil lebensbedrohlich. Immer wieder werden Zweifel am Aussagewert von Psychopharmakastudien geäußert, die Publikation von klinischen Studien mit Antidepressiva erfolgt offensichtlich nach willkürlichen Kriterien (NEJM, 2008). In einer kürzlichen Metaanalyse wurde die fehende Wirksamkeit von Antidepressiva bei leichten bis mittelschweren Depressionen konstatiert (PloS Medicine, 2008). Nur bei schweren Depressionen findet sich ein Vorteil von Antidepressiva gegenüber Placebos. 3. Die Neurobiologie psychischer Störungen wird seit Jahren intensiv untersucht, neue Untersuchungsverfahren wie MRT, PET, SPECT, Immunologie oder Molekulargenetik haben das Verständnis der zentralen Prozesse enorm verbessert. Neue Diagnose- und Behandlungsverfahren können daher stärker auf Wissen und weniger auf Zufallsbeobachtungen wie bisher basiert werden. STRESS Als eines der zentralen Geschehen gilt chronischer Stress, der vielfach zu bleibenden psychovegetativen Störungen führt. Ein kürzlich erschienenes Buch des Bonner Psychiaters Prof. Benkert (2006) hat den Begriff der „StressDepression" geprägt und damit „Stress" als ganz wesentlichen Grund für psychische Störungen einschließlich Depressionen in den Mittelpunkt

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