ZERO TOLERANCE: Transfusion Free Total Joint Replacement

Mark A Snyder, MDKathryn Eten RN, CCM

Katy Loos, RNOrthopaedic Center of Excellence

Good Samaritan Hospital Cincinnati, Ohio

SEPT 22, 2012 SABM 2012

Consultancy▪ Smith & Nephew▪ Medtronic

Research Support▪ Smith & Nephew▪ Hatton Research Institute GSH▪ IDEs

Bayer Boehringer Cadence

Co-management Arrangements▪ Good Samaritan Hospital

Consultancy▪ Smith & Nephew▪ Medtronic

Research Support▪ Smith & Nephew▪ Hatton Research Institute GSH▪ IDEs

Bayer Boehringer Cadence

Co-management Arrangements▪ Good Samaritan Hospital

DISCLOSUREDISCLOSURE

Good Samaritan HospitalTriHealth System

Centralization

Obamacare

Standardization

The Solution:Consumer (patient)-

Driven Care

Consumer-driven insurers

Consumer-friendly hospitals

Consumer-friendly employers

Consumer-supportive laws

Consumer-driven market

TRANSPARENCY!“Americans Favor Transparency in Medicare, Physician Changes,” May 2, 2006, www.zogby.com

“How physicians can change the

future of health care.”Porter ME, Teisberg EO. JAMA

2007;297(10):1103.

PRINCIPLES:*Goal is value for

patients*Organization around

conditions and cycles of care

*Measuring of results, risk-adjusted outcomes, and costs

Returning medicine to its proper focus:Enabling health and providing effective care. “ZERO”, TJA, REGISTRY* * *

A powerful approach to cost reduction in health care!

“Adverse events are associated with significantly increased hospitalization costs and appropriate evidence-based interventions are justified to minimize AEs.”

Kondalsamy-Chennakesavan S, et al. Gynecol Oncol. 2011;121(1):70 “Risk-adjusted total, Medicare, and beneficiary healthcare

costs were significantly higher for both THR and TKR patients with VTE.”

Boser O, et al. Curr Med Res Opin. 2011;27(2):423

Radically reduce adverse events! Invest in initiatives to apply best evidence

literature to care processes. Believe that real change can happen and

that it is good for all stakeholders! PATIENT SAFETY!

Top 10 Most Costly, Frequent Medical Complications In the US

http://www.soa.org/files/pdf/research-econ-measurement.pdf

Error type

% of injuries that are errors

Count of injuries (2008)

Count of Errors (2008)

Medical cost per Error

In Hospital Mortality Cost per Error

STD Cost Error

Total Cost per Error

Total Cost of Error Millions

Pressure Ulcer (Medicare Never Event)

>90%394,66

9374,96

4$8,730 $1,133 $425

$10,288

$3858

Postoperative infection

>90% 265,995

252,695

$13,312

$-$1,23

6$14,54

8$3,676

Mechanical complication of device, implant or graft

10-35%268,35

360,380

$17,709

$426 $636$18,77

1$1,133

Postlaminectomy syndrome 10-35%

505,881

113,823

$8,739 $-$1,12

4$9,863 1,123

Hemorrhage complicating a procedure

35-65%156,43

378,216 $8,665 $2,838 $778

$12,272

$960

Infection following infusion, injection, transfusion, vacc

>90%9,321 8,855

$63,911

$14,172 $-$78,08

3$691

Pneumothorax 35-65%51,119 25,256

$22,256

$-$1,87

6$24,13

2$617

Infection due to central venous catheter

>90% 7,434 7,062$83,36

5$- $-

$83,365

$589

Other complications of internal biological, synthetic

<10%535,66

626,783

$14,851

$1,768 $614$17,23

3$462

Ventral hernia w/o mention of obstruction or gangrene

10-35%239,15

653,810 $6,359 $260

$1,559

$8,178 $440

Why Zero Tolerance?

It is the right thing to do!

A New Day Is Coming!

CMS in cooperation with the AAOS Dry-run September 2012 National transparency 2013 via

compare.gov RSCR and RARR What are the targets?

▪ Mechanical complication readmission 90 days▪ PJI 90 days▪ SSI 90 days▪ Surgical site bleeding, PE, death 30 days▪ AMI, pneumonia, sepsis/septicemia 7 days

The Truth Hurts!

RARR 5.7% nationalRSCR 3.6%GSH 5.0% and 3.6% respectively

Years 2008 to 2010

Zero in on ZeroClinical Focus

30 day readmission

Patient FallsDissatisfaction

Poor Discharge Handoff

Catheter Assoc UTI

Infected THA/TKADeath from VTE

Ineffective Pain Management Transfusions

Strive For 0%

Dislocation

Two Things!

No “silver bullet”

Mountain climbing

Using The Evidence

Causal analysis Heget JR, et al. Jt Comm J Qual Improv 2002;28(12):660 Nicolini D, et al. J Health Serv Res Policy 2011;16 Suppl 1:34

BEFORE…DURING…AFTER Randomized clinical trials Meta-analyses Cochrane reviews Available clinical practice guidelines

(CPG) BEST PRACTICE PROPOSALS (BPP)

Barbieri A, et al. BMC Med 2009;7:32 Rotter T, et al. Cochrane Database Syst Rev 2010;

(3):CD006632

For ExampleReducing Blood Transfusions

BEFORE: uncorrected pre-op anemia

DURING: unfettered bleeding and no inhibition of fibrinolysis

AFTER: mandated strong VTE chemoprophylaxis

Evidence: STRONG, MODERATE, WEAK, INCONCLUSIVE

BPPReducing Blood Transfusions

BEFORE DURING AFTERRecognition of anemia with CBC more than 4 weeks prior to surgery (S)

Regional anesthesia (M)

Avoidance of strong VTE chemoprophylaxis in low risk TKA patients (S)

Correction of HgB <13 in males and <12 in females with erythropoietin and iron supplements (S)

Hypotensive anesthesia for those requiring GA

Lovenox 40 mg daily in TKA. INR targets near 1.5 for coumadinized patients (M)

Referral to hematology if HgB < 10

Pre-op TXA given 15 mg/kg 15 minutes before incision (S)

Transfusion triggers 7/21 unless cardiac symptoms unstable (S)

Avoidance of autologous donation (M)

Decreased tourniquet time, bipolar cautery (I)

IV fluid correction of hypotension and mild postural changes (I)

Drain avoidance (M)

Teamwork is required to enable Zero in on Zero

SurgeonsStaffAdministra

tionPatients

and family

Eisenhower Strategy

Get broad buy-inCollegially help everyone move in the

same direction to achieve a solution!Hospital credentialing:

▪ Docs must participate in the Registry▪ Docs may use the OCE marketing plan IF they

follow established CPGs and new BPP protocols where CPGs do not yet exist

▪ While docs must decide what is best for their individual patients, disagreements with CPGs and BPP protocols must be in writing

Blood Transfusions

Salida JA, et al. Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: predictive factors. JBJS 2002 84:216

Bong MR, et al. Risks associated with blood transfusion after total knee arthroplasty. J Arthroplasty 2004;19:281

REMEMBER THAT THE TWO LEADING CAUSES OF BLEEDING SUFFICIENT TO REQUIRE TRANSFUSION ARE 1) PRE-OP ANEMIA AND 2) POTENT ANTICOAGULANTS

Despite a low transfusion rate, 20% TKA/THA patients exhibited

preoperative anemia

< 13 gm/L for men and < 12 gm/L for women

Patients unaware of anemia since fatigue is the predominant symptom.

PCP acceptance of anemia since surgical options not in their usual treatment algorithms.

Patients with severe OA of the hip and/or knee are more likely to undergo TJA if this option is discussed with their PCP, but few patients experience this conversation!

Schonberg MA, et al. J Am Geriatr Soc 2009;57(1):82

Total Blood Transfusions

Zero BPP designed and trialed

2009

AVG

2010

AVG

Jan

11Fe

b 11

Mar

11

Apr 1

1M

ay 1

1Ju

n 11

Jul-1

1Aug

-11

Sep-1

1O

ct-1

1Nov

-11

Dec-1

1Ja

n-12

Feb-

12M

ar-1

2

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

20.00%

Elective Hip and Knee Arthroplasty RBC % Trans-

fused

% Transfused

Linear (% Transfused)

In 2010, transfusion cost for 321

allogenic and autologous units was $321,000.

In 2011 and 2012, we have already

saved over$500,000!

Shander A, et al. Transfusion 2010;50(4):753

Orthopaedics was an area of practice ready for change!

Collaborative group with strong leadership

Supportive multidisciplinary teamZero in on Zero initiative with

strong body of evidence to support best practice initiatives

High usage of blood productsWide variation in blood

management practices

ORTHOPAEDICS

Example of physician blinding for elective total hip arthroplasties

A B C D E F G H I J K L M N O P Q R S0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

Hip Cases With Transfusions

% Hip Cases With Transfu-sions By Doctor

ORTHOPAEDICS

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

Pre-Surgical Anemia Protocol

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

Challenges: The Patient

Lack of knowledge about anemia

Overwhelmed when notified of anemic status

Feared surgery cancelation

Did not want to travel for additional doctor visits

Challenges: Physicians

Orthopedic surgeons tried to treat patients on a case by case basis only to meet resistance from PCP and third party payers.

PCP’s feared loss of control over patient care if patients were referred to a hematologist for mild anemia.

Speculation that the new process would delay surgery.

Communication gaps

Challenges: Hospital Process

Ownership of clinic process

Clinical exam space Departments wanted

new business but sometimes resisted implementation

Multi dept involvement

Verbal and electronic communication gaps between departments

How can a total joint registry enable blood conservation success?

Prospective, consecutive tracking of all total hip and knee arthroplasties enables physicians to see their own results in comparison with blood conservation best practices, and then choose to change their own practices.

The registry has “before/during/after” data that enables problem solving.

Patient ConsentIRB Approved

1)Early warning2)Influence MD behavior3)Decrease AE cost, M&M,

revTJA volume

REGISTRY BENEFITS!

August 1, 2011 to Sept 21, 2012405TJATotal AE 1.73%Transfusion 0%SSI 0%RSCR 0.49%RARR 0.49%

1/10 THE RAT

E

MAS DATA

BEFORE▪ Anemia detection▪ Anemia correction

DURING▪ Novel blood loss prevention▪ TXA administration▪ Avoidance of surgical drains

AFTER▪ TXA effect▪ Transfusion criteria 7/21▪ IV saline for minor postural hypotension and

lack if vigor

HOW WAS THIS ACCOMPLISHED?

TAKEHOME

MESSAGES

Part of a regional solution for an upcoming patient access crisis

Stellar safety and quality are win-wins for patients, providers, hospitals and society.

Physician leadership is critical to creating and sustaining patient-centered solutions for adverse event challenges in hip and knee replacement.

THE PATH

Center of Excellence

Zero in on Zero safety and quality initiative

Initiative deployment

Physician credentialing agreement

Registry

ZERO IN ON ZERO

Sir Winston Churchill Sir Winston Churchill

“SUCCESS IS NOT FINAL,FAILURE IS NOT FATAL: IT ISTHE COURAGE TO CONTINUE

THAT COUNTS.”