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ZERO TOLERANCE: Transfusion Free Total Joint Replacement

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Presentation on theme: "ZERO TOLERANCE: Transfusion Free Total Joint Replacement"— Presentation transcript:

1 ZERO TOLERANCE: Transfusion Free Total Joint Replacement
Mark A Snyder, MD Kathryn Eten RN, CCM Katy Loos, RN Orthopaedic Center of Excellence Good Samaritan Hospital Cincinnati, Ohio sept 22, 2012 SABM 2012

2 DISCLOSURE Consultancy Research Support Co-management Arrangements
Smith & Nephew Medtronic Research Support Hatton Research Institute GSH IDEs Bayer Boehringer Cadence Co-management Arrangements Good Samaritan Hospital

3 Good Samaritan Hospital TriHealth System

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 insurers Consumer-friendly hospitals Consumer-friendly employers Consumer-supportive laws Consumer-driven market US 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 costs Patient 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 reduction Patient satisfaction with Zero Pain management Not implant-driven Not surgical technique-driven Physician and patient-centered driven by focusing on what HC needs to do. The JAMA article Zero, 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):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! Curr Med Res Opin Feb;27(2):423-9 Gynecol 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 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% 394,669 374,964 $8,730 $1,133 $425 $10,288 $3858 Postoperative infection 265,995 252,695 $13,312 $- $1,236 $14,548 $3,676 Mechanical complication of device, implant or graft 10-35% 268,353 60,380 $17,709 $426 $636 $18,771 Postlaminectomy syndrome 505,881 113,823 $8,739 $1,124 $9,863 1,123 Hemorrhage complicating a procedure 35-65% 156,433 78,216 $8,665 $2,838 $778 $12,272 $960 Infection following infusion, injection, transfusion, vacc 9,321 8,855 $63,911 $14,172 $78,083 $691 Pneumothorax 51,119 25,256 $22,256 $1,876 $24,132 $617 Infection due to central venous catheter 7,434 7,062 $83,365 $589 Other complications of internal biological, synthetic <10% 535,666 26,783 $14,851 $1,768 $614 $17,233 $462 Ventral hernia w/o mention of obstruction or gangrene 239,156 53,810 $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 2012 National transparency 2013 via 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 About 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 days Periprosthetic joint infection—90 days Wound infection—90 days Surgical site bleeding—30 days Pulmonary embolism—30 days Death—30 days Acute myocardial infarction—7 days Pneumonia—7 days Sepsis/septicemia—7days The 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, 2012 Responses 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’ methodology An Excel® file containing the hospital’s patient-level data and risk factor information Information about the measures posted on The 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 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% respectively Years 2008 to 2010 CMS 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%.


13 Two Things! No “silver bullet” Mountain climbing

14 Using The Evidence Causal analysis BEFORE…DURING…AFTER
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

15 For Example Reducing 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 BEFORE: uncorrected pre-op anemia DURING: unfettered bleeding and no inhibition of fibrinolysis AFTER: mandated VTE chemoprophylaxis Evidence: STRONG, MODERATE, WEAK, INCONCLUSIVE. Simple protocol BEFORE: 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
BEFORE DURING AFTER Recognition 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) This is a BPP

17 Teamwork is required to enable Zero in on Zero
Surgeons Staff Administration Patients 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 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

19 Blood Transfusions

20 REMEMBER THAT THE TWO LEADING CAUSES OF BLEEDING SUFFICIENT TO REQUIRE TRANSFUSION ARE 1) PRE-OP ANEMIA AND 2) POTENT ANTICOAGULANTS Salida JA, et al. Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: predictive factors. JBJS :216 Bong 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 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

22 Total Blood Transfusions
Zero BPP designed and trialed


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 leadership Supportive multidisciplinary team Zero in on Zero initiative with strong body of evidence to support best practice initiatives High usage of blood products Wide variation in blood management practices

26 ORTHOPAEDICS Example of physician blinding for elective total hip arthroplasties

27 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

28 Pre-Surgical Anemia Protocol

29 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 Edu. 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 anemia Overwhelmed when notified of anemic status Feared surgery cancelation Did 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 process Clinical exam space Departments wanted new business but sometimes resisted implementation Multi dept involvement Verbal 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.

34 Patient Consent IRB Approved

35 REGISTRY BENEFITS! Early warning Influence MD behavior
Decrease AE cost, M&M, revTJA volume They 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 rate 3 falls, 2 DVT, I dislocation, 1 PJI

40 How was this accomplished?
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

41 ZERO in on zero TAKE HOME MESSAGES THE PATH Center of Excellence Zero in on Zero safety and quality initiative Initiative deployment Physician credentialing agreement Registry 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.

42 Failure is not fatal: it is The courage to continue
“Success is not final, Failure is not fatal: it is The courage to continue That counts.” Sir Winston Churchill

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