Presentation on theme: "ZERO TOLERANCE: Transfusion Free Total Joint Replacement"— Presentation transcript:
1 ZERO TOLERANCE: Transfusion Free Total Joint Replacement Mark A Snyder, MDKathryn Eten RN, CCMKaty Loos, RNOrthopaedic Center of ExcellenceGood Samaritan HospitalCincinnati, Ohiosept 22, 2012SABM 2012
2 DISCLOSURE Consultancy Research Support Co-management Arrangements Smith & NephewMedtronicResearch SupportHatton Research Institute GSHIDEsBayerBoehringerCadenceCo-management ArrangementsGood Samaritan Hospital
4 Obamaca r e Standardization Centralization ObamaCare's core philosophies are standardization and centralization, which in practice will mean higher costs for everyone caused by suffocating price competition. The share of insurance industry revenue that comes from government now stands at 42%, up from 36% just three years ago, and that's before the new entitlement kicks in. And a wave of ObamaCare-promoted provider consolidation is creating hospital monopolies that can demand higher-than-competitive prices.
5 The Solution: Consumer (patient)-Driven Care Consumer-driven insurersConsumer-friendly hospitalsConsumer-friendly employersConsumer-supportive lawsConsumer-driven marketUS HC consumers must have the information that will enable them to shop intelligently for providers and treatment. They need it and want it, and they have shown they will use it when it’s available. Zogby Poll, “Americans Favor Transparency in Medicare, Physician Changes,” May 2, 2006,Transparency!“Americans Favor Transparency in Medicare, Physician Changes,” May 2, 2006,
6 “ZERO”, TJA, registry * * * PRINCIPLES: *Goal is value for patients “How physicians can change the future of health care.” Porter ME, Teisberg EO. JAMA 2007;297(10):1103.Returning medicine to its proper focus:Enabling health and providing effective care.PRINCIPLES:*Goal is value for patients*Organization around conditions and cycles of care*Measuring of results, risk-adjusted outcomes, and costsPatient ACCESS ACCESS ACCESS!A possible way to improve against the future issues is to regionally provide through centers of excellence where operative throughput, safety and quality, cost controls, physician resourcing and potential gain-sharing, attraction of patients to get the surgery done, etc.Cost savings through AE reductionPatient satisfaction with ZeroPain managementNot implant-drivenNot surgical technique-drivenPhysician and patient-centered driven by focusing on what HC needs to do. The JAMA articleZero, registry, etc.Root Cause Analysis and its relationship to Zero…* * *“ZERO”, TJA, registry
7 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):423Radically 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!Curr Med Res Opin Feb;27(2):423-9Gynecol Oncol Apr;121(1):70-5.Patient safety!
8 Top 10 Most Costly, Frequent Medical Complications In the US Error type% of injuries that are errorsCount of injuries (2008)Count ofErrors (2008)Medical cost per ErrorIn Hospital Mortality Cost per ErrorSTD Cost ErrorTotal Cost per ErrorTotal Cost of Error MillionsPressure Ulcer (Medicare Never Event)>90%394,669374,964$8,730$1,133$425$10,288$3858Postoperative infection265,995252,695$13,312$-$1,236$14,548$3,676Mechanical complication of device, implant or graft10-35%268,35360,380$17,709$426$636$18,771Postlaminectomy syndrome505,881113,823$8,739$1,124$9,8631,123Hemorrhage complicating a procedure35-65%156,43378,216$8,665$2,838$778$12,272$960Infection following infusion, injection, transfusion, vacc9,3218,855$63,911$14,172$78,083$691Pneumothorax51,11925,256$22,256$1,876$24,132$617Infection due to central venous catheter7,4347,062$83,365$589Other complications of internal biological, synthetic<10%535,66626,783$14,851$1,768$614$17,233$462Ventral hernia w/o mention of obstruction or gangrene239,15653,810$6,359$260$1,559$8,178$440
9 It is the right thing to do! Why Zero Tolerance?It is the right thing to do!
10 A New Day Is Coming! CMS in cooperation with the AAOS Dry-run September 2012National transparency 2013 via compare.govRSCR and RARRWhat are the targets?Mechanical complication readmission 90 daysPJI 90 daysSSI 90 daysSurgical site bleeding, PE, death 30 daysAMI, pneumonia, sepsis/septicemia 7 daysAbout the measures Under the measure for Risk-Standardized Complication Rate Following THA and/or TKA, complications that can be reported will be identified during the index admission or associated with a readmission that occurs up to 90 days after the index admission date, depending on the complication. The follow-up period for complications from date of index admission is as follows:Mechanical complications—90 daysPeriprosthetic joint infection—90 daysWound infection—90 daysSurgical site bleeding—30 daysPulmonary embolism—30 daysDeath—30 daysAcute myocardial infarction—7 daysPneumonia—7 daysSepsis/septicemia—7daysThe measures were developed by a team of clinical and statistical experts from Yale New Haven Health Services Corporation – Center for Outcomes Research and Evaluation under contract to CMS. They were developed with extensive input from leading hip and knee surgeons, including Daniel J. Berry, MD, and Robert H. Bucholz, MD, both past presidents of the AAOS, and Kevin J. Bozic, MD, MBA, current chair of the AAOS Council on Research and Quality. A technical expert panel, which included Jay Lieberman, MD, third vice president of the American Association of Hip and Knee Surgeons, also contributed to the development of the final measures. The National Quality Forum (NQF) has endorsed both measures.CMS will actively support hospitals in understanding their results via:A national provider call on September 14, 2012Responses to questions via during the test period (September 4-October 3, 2012)A Hospital-Specific Report containing detailed hospital results, state and national benchmarks, information about how to interpret the results, and an overview of the measures’ methodologyAn Excel® file containing the hospital’s patient-level data and risk factor informationInformation about the measures posted onThe AAOS encourages fellows to seek out performance measurement data from their hospitals as an educational tool, since it will soon be made available to the public through the hospital compare.gov website. Any questions can be directed to Dr. Bozic, chair of the AAOS Council on Research and Quality Chair, at or William Martin III, MD, AAOS medical director, at
11 The Truth Hurts! RARR 5.7% national RSCR 3.6% GSH 5.0% and 3.6% respectivelyYears 2008 to 2010CMS is preparing to begin publishing the following orthopedic-specific measures:§ Hospital-Level 30-Day All-Cause Risk-Standardized Readmission Rate (RSRR) following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)Hospital-Level Risk-Standardized Complication Rate (RSCR) following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)Attached are the findings from a dry run using data from calendar year 2010. The severity adjusted readmission rate of 5.0% for Good Samaritan is modestly below the 5.7% National Rate. However, the severity adjusted readmission rate of 7.8% for Bethesda is significantly higher than the National Rate and amongst the worst 6 hospitals in the State (out of 158) and the worst 52 hospitals in the Nation (out of 3497).The severity adjusted complication rates of 3.7% for Bethesda and 3.6% for Good Samaritan are both no different than the National Rate of 3.6%.
14 Using The Evidence Causal analysis BEFORE…DURING…AFTER Heget JR, et al. Jt Comm J Qual Improv 2002;28(12):660Nicolini D, et al. J Health Serv Res Policy 2011;16 Suppl 1:34BEFORE…DURING…AFTERRandomized clinical trialsMeta-analysesCochrane reviewsAvailable clinical practice guidelines (CPG)BEST PRACTICE PROPOSALS (BPP)Barbieri A, et al. BMC Med 2009;7:32Rotter T, et al. Cochrane Database Syst Rev 2010;(3):CD006632
15 For Example Reducing Blood Transfusions BEFORE: uncorrected pre-op anemiaDURING: unfettered bleeding and no inhibition of fibrinolysisAFTER: mandated strong VTE chemoprophylaxisEvidence: STRONG, MODERATE, WEAK, INCONCLUSIVEBEFORE: uncorrected pre-op anemiaDURING: unfettered bleeding and no inhibition of fibrinolysisAFTER: mandated VTE chemoprophylaxisEvidence: STRONG, MODERATE, WEAK, INCONCLUSIVE.Simple protocolBEFORE: recognition of anemia with CBC more than 4 weeks prior to surgery (S), Correction of HgB <13 with erythropoietin and iron supplements (S), referral to hematology if HgB < 10. Avoidance of autologous donation (M).DURING: Regional anesthesia (M), hypotensive anesthesia for those requiring GA, pre-op TXA given 15 mg/kg 15 minutes before incision (not if active intracranial bleeding or thrombosis, known seizure disorder, h/o VTE, allergy to TXA) (S), decreased tourniquet time, bipolar cautery (I), avoidance of drains in many cases (M).AFTER: Avoidance of strong VTE chemoprophylaxis in low risk TKA patients (S). Lovenox 40 mg daily in TKA. INR targets near 1.5 for Coumadinized patients. Prolonged knee flexion > 70 degrees DOS (M). Transfusion triggers 7/21 unless cardiac symptoms unstable (S). IV fluid correction of hypotension and mild postural changes (I).
16 BPP Reducing Blood Transfusions BEFOREDURINGAFTERRecognition 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 GALovenox 40 mg daily in TKA. INR targets near 1.5 for coumadinized patients (M)Referral to hematology if HgB < 10Pre-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)This is a BPP
17 Teamwork is required to enable Zero in on Zero SurgeonsStaffAdministrationPatients and family
18 Eisenhower Strategy Get broad buy-in Collegially help everyone move in the same direction to achieve a solution!Hospital credentialing:Docs must participate in the RegistryDocs may use the OCE marketing plan IF they follow established CPGs and new BPP protocols where CPGs do not yet existWhile docs must decide what is best for their individual patients, disagreements with CPGs and BPP protocols must be in writing
20 REMEMBER THAT THE TWO LEADING CAUSES OF BLEEDING SUFFICIENT TO REQUIRE TRANSFUSION ARE 1) PRE-OP ANEMIA AND 2) POTENT ANTICOAGULANTSSalida JA, et al. Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: predictive factors. JBJS :216Bong MR, et al. Risks associated with blood transfusion after total knee arthroplasty. J Arthroplasty 2004;19:281
21 Despite a low transfusion rate, 20% TKA/THA patients exhibited preoperative anemia < 13 gm/L for men and < 12 gm/L for womenPatients 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
22 Total Blood Transfusions Zero BPP designed andtrialed
24 In 2011 and 2012, we have already saved over$500,000! 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
25 Orthopaedics was an area of practice ready for change! Collaborative group with strong leadershipSupportive multidisciplinary teamZero in on Zero initiative with strong body of evidence to support best practice initiativesHigh usage of blood productsWide variation in blood management practices
26 ORTHOPAEDICSExample of physician blinding for elective total hip arthroplasties
27 ORTHOPAEDICS Blinded physician-specific transfusion data Presented at Section meetingExtensive literature review for evidence based best practiceNew practice initiatives for pre, intra, and post-operative conservationAmended order sets to reflect changesEstablished Anemia ClinicOrthopedic Center of Excellence (OCE)Quality measure: Preoperative anemiaEstablished metricsPosted on OCE dashboard
29 Anemia PreventionAnemia Clinic with automatic treatment of patients by hematologistEducation of residents, and individual servicesGo to each section meeting and deliver the message that is pertinent to their practiceLet other services know about the successes gained by othersEmpower staff nurses as your advocatesEdu. Services examples: ( i.e. anesthesia, hospitalists, renal…)Letting other services know example: (Our CT surgeons are now using Tranexamic acid after hearing about the success in ortho)Empowering nurse example: (give them the literature and rationale as to why this is better for the patient; they will then talk to the MD when the order is being written)
30 Challenges: The Patient Lack of knowledge about anemiaOverwhelmed when notified of anemic statusFeared surgery cancelationDid not want to travel for additional doctor visits
31 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
32 Challenges: Hospital Process Ownership of clinic processClinical exam spaceDepartments wanted new business but sometimes resisted implementationMulti dept involvementVerbal and electronic communication gaps between departments
33 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.
35 REGISTRY BENEFITS! Early warning Influence MD behavior Decrease AE cost, M&M, revTJA volumeThey provide an early warning system for early implant failure.They provide evidence that, if delivered to physicians in a timely and understandable fashion, will positively influence physician behavior to the benefit of patients and society.They have the power to ultimately decrease the burden of disease and cost associated with surgical morbidity and mortality, and reduce the volume of premature revision procedures.
39 MAS DATA 1/10 the rate August 1, 2011 to Sept 21, 2012 405TJA Total AE 1.73%Transfusion 0%SSI 0%RSCR 0.49%RARR 0.49%1/10 the rate3 falls, 2 DVT, I dislocation, 1 PJI
40 How was this accomplished? BEFOREAnemia detectionAnemia correctionDURINGNovel blood loss preventionTXA administrationAvoidance of surgical drainsAFTERTXA effectTransfusion criteria 7/21IV saline for minor postural hypotension and lack if vigor
41 ZERO in on zeroTAKE HOME MESSAGESTHE PATHCenter of ExcellenceZero in on Zero safety and quality initiativeInitiative deploymentPhysician credentialing agreementRegistryPart of a regional solution for an upcoming patient access crisisStellar 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.
42 Failure is not fatal: it is The courage to continue “Success is not final,Failure is not fatal: it isThe courage to continueThat counts.”Sir Winston Churchill