rbc case study - ok heart hospital

RBC® InitiativeRETHINKING BLOOD CONSERVATION

Blood Conservation Improves ‘Total Care’ of Heart PatientsHow one heart hospital achieved cost savings and clinical benefit with a collaborative approach to blood conservation

CASE STUDY

“ Leaders across the hospital are needed because the patient is cared for by a team.”

— Goya Raikar, MD, FACS, FCCP, Director of Cardiovascular Surgery, Oklahoma Heart Hospital, South Campus

CASE STUDY Oklahoma Heart Hospital

Background: The Oklahoma Heart Hospital is a physician-owned heart hospital located in Oklahoma City, Oklahoma. In an effort to enhance the total care of patients across the hospital, Oklahoma Heart’s south campus partnered with Medtronic and their Rethinking Blood Conservation (RBC®) Initiative to implement a blood conservation program that would enhance the ‘total care’ of patients hospital-wide.

Methods: Goya Raikar, MD, FACS, FCCP, Director of Cardiovascular Surgery, engaged a multi-disciplinary care team from across the hospital, and leveraging the expertise and technologies of the RBC Initiative, implemented a blood conservation plan and new protocols that have achieved their initial goals and delivered impressive cost savings and clinical benefit.

Results: Oklahoma Heart demonstrated a savings of nearly $400,000 annually on transfusion-related costs as well as reduced length of stay and post-operative complications.

Blood Conservation is a Whole-Hospital Effort

From looking at blood conservation programs at other hospitals, Dr. Raikar knew that success would come from engaging leaders across several disciplines. “An effective blood conservation program isn’t just about a mini-circuit in the OR, with patients still receiving blood or blood products pre-op and post-op,” explains Dr. Raikar. “One department, like surgery, can’t be the only champion, because the patient is cared for by a team – from cardiology, to the pre-op nurse, to the cardiac surgeon and his team, the anesthesiologist, the perfusionist, and then an ICU physician and nurse, and through discharge.”

Dr. Raikar says that once the team at the south campus of Oklahoma Heart had the same epiphany about how a comprehensive blood conservation program could enhance the ‘total care’ of patients across the hospital, they were able to move quickly to develop blood conservation plans and new protocols and get approval from their Medical Executive Committee.

A blood conservation program would be successful if blood product usage was reduced without any negative impact to clinical measures. However, the team believed that there would also be clinical benefit to patients by reducing transfusions. The program was able to show a clear reduction in blood usage and administration costs. In addition, there are promising initial reductions in important measures of clinical benefit that will continue to be measured for improvement over time.

Oklahoma Heart Hospital South Campus At-A-Glance

• Based in Oklahoma City, OK

• Oklahoma’s 1st dedicated heart hospital

• Approx 400 annual cardiac surgeries

• 62 beds

• 3 open heart surgery suites

• 4 cardiac cath labs

• Physician owned hospital

• Oklahoma’s largest group of cardiovascular specialists

• Nation’s 1st all-digital hospital

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Blood Conservation Improves ‘Total Care’ of Heart PatientsHow one heart hospital achieved costs savings and clinical benefit with a collaborative approach to blood conservation

Blood Conservation Program Clinical ResultsIsolated CAB Patients

Annual Blood Administration Costs South Campus - All Patients

24.3%

6.0 Days5.0 Days

18.4%Post-Op AF

Surgery- Discharge

LOS

Pre-Implementation(N = 111)

1.8%0.9%

Post-Op Stroke

2.7%1.8%

ProlongedVentilation

Post-Implementation(N = 114)

Intra-op TransfusionNo Transfusion

$459K

$75K

Pre-programImplementation

Post-programImplementation

Based on information provided by Oklahoma Heart Hospital

“ One department, like surgery, can’t be the only champion. Leaders across the hospital are needed because the patient is cared for by a team.”



“ I don’t think anyone should work in a vacuum, which is why the site visit to Englewood Hospital was so useful. You have to listen to others who’ve already done this.”


KEY LEARNING ONE: Rethink Old Norms for Blood Use

“In the past, blood usage was just something you did,” says Jodi Tracy, RN, OR Manager. “If you had a patient scheduled for a heart surgery, you didn’t just order one unit of blood, you ordered two, and also some fresh frozen plasma and platelets, and so on. You ordered blood and blood products based on the procedure, not so much the clinical manifestations of the patients. No one thought about a different way of managing blood transfusions or administering blood products. So, our first step, was to rethink our ‘business as usual’ approach, and today, we’ve got a minimalist mindset to when and how we use blood.”

In the past, according to Teresa Nicholson, RN, Manager of CCU, ICU and PCCU, blood and blood products were more easily seen as a solution to hemodynamic instability when a cardiac surgery patient was recovering in the intensive care unit.

5 Key Learnings from Oklahoma Heart’s Experience

The process that Oklahoma Heart followed can be summarized in five key learnings that are critical to the success of any blood conservation program:

1) Rethink old norms for blood use

2) Learn from others

3) Track progress and results

4) Employ a multimodality approach

5) Communicate, communicate, communicate

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KEY LEARNING T WO: Learn From Others

According to Gretchen Beagles, Staff Perfusionist, a Grand Rounds presentation at Oklahoma Heart by Robert W. Emery, Jr., MD, Medical Consultant at the HealthEast Care System in St. Paul, MN, was a stepping-stone for her and many staff in understanding the value of a whole-hospital approach to blood conservation.

“When I listened to Dr. Emery talk about his experience at St. Joseph’s Hospital in St. Paul, I realized that all the pieces of the puzzle needed to fit together if we wanted to make blood conservation a success at Oklahoma Heart. I knew that we couldn’t have just one person, like our surgeon, Dr. Raikar, pushing for blood conservation. We all had to be convinced and be on board if we wanted to do what was best for our patients.”

Shoab Nazir, MD, an Intensivist/Pulmonologist at the south campus of Oklahoma Heart agrees on the impact of Dr. Emery’s presentation. “He gave a fantastic presentation about the retrospective studies and analyses on blood use and the negative consequences of blood use. Dr. Emery showed us convincing clinical evidence that sometimes, a lower hemoglobin level is just fine.”

“ Now we have a different approach. Having a lower pressure or a lower hemoglobin is sometimes ok. We don’t automatically think that blood is the solution when we are trying to help the patient.”

— Teresa Nicholson, RN Manager of CCU, ICU, PCCU Oklahoma Heart Hospital, South Campus

Jodi says that everyone at the hospital is smarter about blood use today. “We look at a unit of blood now as being like a liquid organ transplant. We think about blood use through each phase of patient care – from pre-op, to intra-op and through post-op and ICU. The new blood conservation protocols have definitely been a benefit to the patient and the hospital. Patients are having fewer complications, they are getting off the ventilator more quickly and leaving the hospital faster. And it’s benefitting the hospital financially as well.”

Dr. Raikar says that Dr. Emery’s talk, plus a site visit to the Englewood Hospital and Medical Center in Englewood, NJ, facilitated by the Medtronic RBC initiative, were instrumental in getting the team at the south campus of Oklahoma Heart on its way.

“The site visit to the Englewood Hospital was very helpful – it was a catalyst,” says Dr. Raikar. “When you’re out of your usual work environment, you’re more relaxed and open to thinking about new things, new ways of doing your work,” adds Dr. Raikar.

“We watched our peers work, heard about their results from their blood conservation program and their ‘bloodless surgery’ standard of care, which is nearly 20 years old now, and was born out of their practice of caring for Jehovah’s Witness patients, who don’t accept blood or blood products.”


Best practice technologies and techniques used at Oklahoma Heart Hospital:

• Smaller circuits with lower priming volume and integrated arterial filter in the oxygenator

• Perfusion lines that are smaller and shorter

• Properly performing retrograde/antegrade autologous priming of the perfusion circuit

• Appropriate cannulae selection

• Using a cell saver for shed surgical field blood and flushing of the perfusion circuit to return the autologous blood back to the patient

• Limiting surgical bleeding as much a possible

• TEG testing pre- and post-operatively

KEY LEARNING THREE: Track Progress and ResultsThe key to any lasting change is measurement, and the south campus of Oklahoma Heart Hospital has shown positive clinical and financial outcomes from the cardiac patients they track in a blood conservation registry supported by the Medtronic RBC Initiative since July 2013.

“We were pleased to have Medtronic help us set up the registry software and train our staff to use it,” says Dr. Raikar. “Our perfusionist enters data into the registry after every case and we get reports from Medtronic that give us a clear view of how our blood conservation efforts are doing. Also, the software is customizable to our needs, so we are considering adding some additional metrics to track, like some renal function parameters.”

The registry also offers hospitals real-time tracking of clinical data pre-, intra- and post-operatively, rationale for transfusions, longitudinal analysis and trend information, as well as an array of custom reporting capabilities. These data support clinical and behavioral changes for patient blood management.

KEY LEARNING FOUR: Employ a Multimodality Approach

Another key to a successful blood conservation program is having a multimodality approach, says Gretchen Beagles. “There are several techniques, tests and technologies that all have a part to play in a successful blood conservation program,” explains Gretchen. “Each one is important, but if you can align all of them, you’ll make exponential improvement in overall patient care and in reaching your blood conservation goals.”

According to Dr. Lau, Staff Anesthesiologist at Oklahoma Heart Hospital, surgical technique is also important to blood use. “I know it sounds basic, but if the surgeon isn’t able to stop every bleeder, or if he or she allows a lot of bleeding in the field, you’ll lose blood and you’re more likely to give blood. So, even the surgeon’s technique is important to achieving your goals.”

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Transfusion Rate ReductionAll Phases of Care

“ Since we implemented our blood conservation program, we are saving nearly $400,000 per year on transfusion-related costs.”


Blood Conservation Program Clinical ResultsIsolated CAB Patients

24.3%

6.0 Days5.0 Days

18.4%Post-Op AF

Surgery- Discharge

LOS

Pre-Implementation(N = 111)

1.8%0.9%

Post-Op Stroke

2.7%1.8%

ProlongedVentilation

Post-Implementation(N = 114)

Intra-op TransfusionNo Transfusion

Pre-Implementation

(N = 157)49.1%

10.8%Post-Implementation

(N = 166)

Based on information provided by Oklahoma Heart Hospital

A thromboelastography (TEG) test is another important element of blood conservation, according to both Gretchen and Teresa. “We use TEG testing pre-operatively to anticipate any coagulation issues due to drug therapies the patient is on and to address any platelet dysfunction prior to surgery,” says Gretchen.

“In the ICU,” says Teresa, “the TEG test is important to help us determine what to do when a patient is bleeding. Is it due to a mechanical issue that requires a return to surgery, a need for blood products and what products are appropriate or is it something else we can do like reversing their heparin?”

Oklahoma Heart HospitalCASE STUDY

Advice for OthersNow that the team at the south campus of Oklahoma Heart Hospital has fully implemented their blood conservation program and seen positive clinical and financial benefits, what advice do they have for other hospitals considering a blood conservation program?

1. Have Champions From Each Hospital Discipline“I don’t think I can emphasize enough how important it is for each hospital function to be on board with blood conservation, from cardiology, to cardiac surgery, nursing, anesthesiology, perfusion, critical care, etc., otherwise you won’t see the optimal benefits for the patient,” explains Dr. Raikar. “Having a single, engaged leader from each team helps to ensure that all caregivers in the hospital who touch the patient will have a positive impact on blood conservation.”

According to Dr. Lau, it’s critical to ensure that your surgeons are aligned with blood conservation. “Get your surgeon on board. That’s key. And after that, your intensivist – those are the two areas where we tend to give blood and blood products,” says Dr. Lau.

Jodi also sees the benefit of cross-discipline collaboration. “You really have to make sure every discipline has a blood conservation mindset. For example, you can’t have a patient coming into the day of surgery and someone starts an IV and opens it wide up and run a liter and a half of fluid and dilute them out before surgery,” says Jodi. “We’ve been able to align all departments to make blood conservation the standard of care in our hospital for all of our cardiac patients.”

Advice From Oklahoma Heart Hospital

1. Have champions in each discipline

2. Benchmark other hospitals

3. Align, educate and train before roll-out

4. Work with an industry partner

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KEY LEARNING F IVE:

Communicate Communicate Communicate

An obvious low-tech method to improve their blood conservation outcomes at the south campus of Oklahoma Heart was a focus on better communication.

“Today, we talk back and forth a lot more in the OR about our goals,” says Dr. Lau. “For example, where do we want to set the pressures, or how much fluid are we going to give? And it’s not just better communication with the surgeon, it’s with the perfusionist, the nurses, the scrub techs—everyone in the OR.”

Dr. Nazir says that there’s also more communication in patient handoffs between care settings. “We’re communicating more orally and in the records about what happened in the OR when ICU is getting the patient – things like how much fluid was given, how much blood or blood products were used, where the hemoglobin levels are. It makes a difference in how we care for the patient after surgery.”

One unexpected surprise and a lesson they learned, according to Teresa, was how far some staff took limiting volume after surgery. “When we rolled it out, we said we wanted to be careful about fluid administration, but I think we went a little too far in one direction of holding back fluids. We had to clarify and educate,” Teresa explains, “that sometimes it’s OK to give fluid and if ordered, blood to patients, but to do it always thinking about what each individual patient needs. So, if a patient needs fluid, that’s what they should receive.”

“The blood conservation program has brought our team closer together

and has helped us progress faster in providing a higher level of ‘total care’

for our heart patients.”— Goya Raikar, MD, FACS, FCCP, Director of Cardiovascular Surgery,

Oklahoma Heart Hospital, South Campus

Oklahoma Heart HospitalCASE STUDY

2. Benchmark Other HospitalsThe team at the south campus of the Oklahoma Heart Hospital is unanimous in its agreement on the positive value of the peer-to-peer site visit to the Englewood Hospital in New Jersey, and that hospital’s example as a benchmark. “The Medtronic RBC Initiative,” says Teresa, “added a lot of value for us by connecting us with the team at Englewood. It gave us a real-life example of how blood conservation can work in a hospital system.”

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3. Align, Educate and Train Before You Roll OutTime invested in aligning all hospital functions and in educating and training staff is well spent to help ensure a rapid and smooth rollout.

“Have a lot of conversations upfront with all stakeholders at the table,” Jodi says. “Make sure everyone has the same mindset about blood conservation. Then, focus on some quick wins as you tackle the longer-term cultural obstacles.”

Teresa adds, “As we found out, if you don’t clarify the goals of the program, there may be a chance for misinterpretation.”

4. Work With an Industry Partner Dr. Raikar says the collaboration mindset from industry was critical to the success of their blood conservation efforts. “We are all so busy caring for our patients and tracking our outcomes,” says Dr. Raikar. “So, to have a partner like Medtronic help facilitate a site visit to another hospital, offer a registry software package and provide training to the head of nursing, anesthesia, etc., all of these educational efforts, in addition to the products, have been valuable.”

“We’ve been able to align all departments to make blood

conservation the standard of care in our hospital for

all of our cardiac patients.”— Jodi Tracy, RN, OR Manager, Oklahoma Heart Hospital, South Campus

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Oklahoma Heart Hospital, South Campus

The Rethinking Blood Conservation (RBC®) Initiative is from the suite of innovative solutions offered by the Cardiac and Vascular Group at Medtronic that are designed to drive value across the care continuum.

Solutions

The Rethinking Blood Conservation (RBC®) Initiative is a fee-based service from Medtronic. This case study is not intended to be a recommendation by Medtronic for Oklahoma Heart Hospital. It is provided for general educational purposes only and should not be considered the exclusive source for this type of information. At all times, it is the professional responsibility of the practice or clinical practitioner to exercise independent judgment in a particular situation and treat patients based on their judgment and medical necessity. Results may vary.

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rbc case study - ok heart hospital

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