Platelet Utilization in Cardiac Surgery

[sandy]

Can anyone direct me to some benchmarks?

[dcharland]

Can anyone direct me to some benchmarks?

Did you get any benchmarks? I'm looking for the same thing, we are trying to come up with cardiac surgery transfusion criteria.

[Lcsmrz]

My experience with cardiac surgery platelet usage is that no pattern exists. A vast majority of procedures are uncomplicated, then you get one that uses 4 PLTs, 10 FFP, 20 Cryo, and an armful of RBCs within an hour or two.

Because of the potential for a post-op problem, you have to stock PLTs for all cardiac surgeries. But if you don't have an Oncology Unit, you end up throwing over half of them out! I'd try to arrange to give short-dated products to a nearby trauma center or oncology unit on consignment to see if you can recover some of the cost.

[John C. Staley]

There is one other variable with the cardiac surgery. The surgeons. The cardiac surgeons at my facility use very few blood products and that even varies between the four of them, the younger 2 use more than the other 2. We have a sister hospital about 70 miles away and their usage is 2 to 3 times what ours is. If you can find some bench marks I would like to see them but I'll be surprised if you do.

[rcurrie]

If you want to create a firestorm, just tell any group of surgeons that you are trying to create some transfusion benchmarks for their service. They will quickly tell you that the patient's condition is the benchmark- not some (seemingly) arbitrarily determined scale. That said, look at ordering v. usage practices to see where your transfusion services are being overutilized. The crossmatch to transfusion ratio can be useful in detecting someone who overorders products. You then need to find out why they are overordering. It may be that they don't realize that they are ordering a 6-unit crossmatch and routinely only use two units. Then again, they might well know this, but have had trouble in the past getting a unit of blood beyond what was requested to be crossmatched. That will cause any surgeon to consistently overorder. Rather than pointing to a problem with the surgeon, you may find that you have a problem providing products in a timely manner. My point is that the problem may not lie with the surgeon- it may lie with your transfusion service.

Years ago, when I was lab director over a medium size hospital lab, I had a physician tell me that he expected his interactions with the lab to be seamless. I asked what he meant. He said that when he ordered a test, his expectation would be that the test would be performed in a timely manner and the results placed in the chart, and that when he ordered blood products, they would be available for transfusion in a timely manner. If he had to make any followup calls to obtain results that were not in the chart when he expected them to be, or to inquire about blood products not ready in a timely manner, then the lab was not meeting his expectations. Rather than blowing him off, I took this to heart and I strive to provide every physician with those expectations. I would ask you to look within and see if your interactions with physicians are seamless, or do certain physicians always have to call for results or blood products that should have been on the chart or ready. In other words, clean up your own house before asking someone to clean theirs.

BC

[sarahk]

If physicians are defensive about the practice of benchmarking, it is probably because they are aware of their tendency to over-order. The one-time inability of the blood bank to find a suitable unit for a patient with five antibodies and get it ready in fifteen minutes is not a reason to consistently over-order. If physicians expect seamless interaction with the lab, we should expect the same (i.e. realistic expectations, appropriate orders, an awareness of what an antibody is, not thinking we should have "known" their patient would need blood when they didn't order any.)

Not only is there tremendous variability among surgeons, but even more variability among patients. The same surgeon will use no blood products one day and more than 50 the next. Open heart patients are more high risk than ever, many have multiple stents, and almost all are on medications like Plavix that wreak havoc with their coagulation. Not that benchmarking can't be useful--if some institutions can use relatively little blood for similar patients undergoing similar procedures, why can't everyone? We should be looking at the practices of surgeons who use excessive amounts of blood products. But good luck finding benchmarks--I haven't found any. Please share if you do!

[rcurrie]

No, I think physicians are defensive about benchmarking because they know that benchmarking per se is a load of bull for the reasons you stated, Sarah. That's why you won't find any benchmarks for cardiac surgery, or many other high blood usage surgery. Physicians are only overordering blood if they order it and don't use it on a consistent basis. That is what I recommend that we look at.

I used to be amazed at the relative ignorance of physicians regarding transfusion medicine until I found out how much transfusion medicine they got in medical school: little or none. For instance, I have been teaching transfusion medicine to Texas A&M University medical students since 2001. Until then, they got absolutely no lectures in transfusion medicine. I deal with residents from all over the world. I always ask what they learned about transfusion medicine in medical school. The consensus is zero, zip, and nada. Once you realize this, you can add a little transfusion medicine education when dealing with those physicians you suspect as transfusion medicine challenged.

We can't expect physicians to read our minds. We have to let them know (again, in a timely manner) what the problems are and what they can expect ("Mrs. Jones has anti-e, and it is going to take us at least a day to find compatible blood for her because donors who lack the e-antigen are less than 1% in our donor area. I will keep you up to date on our progress.") Seamless interaction does not mean "no communications". Rather, it often means extra communications. But those communications are not seamless if the physician has to drag them out of us. We have a patient with 5 antibodies and an order for 2 units? Don't make that physician call to find out what the delay is. We call the physician first. That is the type of seamless interaction I imply. After all, they are our customers. I haven't had an unhappy customer in a very long time. We given them what they need when they want it, or let them know right away if there is going to be a delay or if there is any other problem. If they understand there is going to be a delay, and the reason for the delay is reasonable (not something like you forgot to order reagents), then seamlessness is still there. (BTW: I have a patient in house with 5 allos and a warm auto, and a sickle cell patient with anti-Fy3 and anti-c who needs 2 units. It is never easy, but we keep the physicians well-informed as to our progress, and they don't bug us or get upset.)

The purpose of this forum is to share solutions. That is why I offer the above. It works for me. I have 600+ happy physicians.

BC

[sarahk]

Aww, I don't think benchmarking is completely useless! It's just difficult, and as with anything in medicine, an inexact science subject to outliers. At the very least, it would be interesting to see the average usage for open hearts (I may only say that because we tend to use a lot at our facility. Every aspect of medical practice is evaluated and quantified--why leave transfusion medicine out of the fun? It just seems like there needs to be something to compare to--C/T ratios don't tell me much when the surgeon dumps in everything he orders (it's not that unusual for us to give more than 100 products in a day)--is that excessive or ok because he gave everything he ordered?

I absolutely agree with your philosophy when it comes to communication with physicians (it seems like the root cause of almost every complaint and error is lack of effective communication), but would like it to be a two way street. It's hard to communicate delays if they won't return your phone calls! You are a brave man for teaching med students and completely correct about their lack of transfusion medicine training. It's our responsibility to be the experts in this field and communicate that knowledge to physicians.

Wow, you can keep those antibody patients in Texas! Thanks for sharing an obviously effective method of keeping docs happy (always appreciated!)

[Karen Olsen]

Our profusionist has been using the TEG instrument during OHS for about 7 years now. We have noticed a drastic reduction in product usage since they started using TEG. One particular week in the middle of this 7 year period they were back to using tons(in our opinion) of blood products. We later found out that the TEG instrument was down that week due to a computer issue. "VERY INTERESTING!" What TEG does for you is allows you to know whether the patient is bleeding due to a Coag issue or a bleeder in the heart, so they can fix the exact problem rather than throwing all kinds of blood products at the patient and hoping for the best. We do use a fair number of platelets when we have an emergent OHS and the patient was on Plavix, sometimes as many as 9 or 10. I don't want to give the impression that since TEG we do not ever have an OHS go "bad". We do still have those patients that for whatever reason go through quite a few products.

I would also be interested in seeing some average useage data. We collected a lot of data when we were doing the initial study for the TEG instrument, but it just proved that usage went down drastically with TEG, there was no comparison to other facilities.

[rcurrie]

I love the thromboelastograph. Unfortunately, our current cardiac surgeons don't use it, and won't consider using it. I am waiting for them to retire so some progressive surgeons can take their place. We have two TEGs sitting in Biomed under a plastic cover. What a waste.

BC

[rcurrie]

Sarah, we do get involved- we just don't talk about benchmarking or mention MSBOS as something we are interested in ;-) I do look at usage, and I forward any cases with high usage to the blood bank residents to investigate, and then we discuss in committee. Plavix has been the biggest thorn in our side. We do a lot of "redo" CABGs here, and those are naturally more bloody than the first. I can remember years ago if you needed a second CABG, it wasn't available. Now it is quite common, at least in my institution. Kind of makes me wonder where they are getting the grafts. All that said, we have patients who go home after a CABG procedure having received not a drop of blood during or after surgery. One of our surgeons just orders a type and screen for routine first time bypass operations. That used to worry me, but not any more.

BC

[Karen Olsen]

That is just about the saddest story I've heard in a long time! Good luck in getting some new blood in to turn things around. Our Profusionist was instrumental in pushing the TEG through and essentially forcing them to use it when they were leary. He is the one that trained on it an does all the testing and interpretations. Without him ours would probably be in BioMed under plastic also!

Good Luck

[rcurrie]

I actually brought this up in our regular 1:00 PM daily team meeting yesterday as a goal for 2007. We actually used our TEGs for a short period of time, but the surgeon instrumental in bringing them to our institution retired. So, we haven't completely given up. If you are willing to share your data with me, I could use it to help persuade our surgeons to begin using them again. Any help from anyone would be appreciated.

Thanks,

BC

[caj1018]

I think having a benchmark for platelet usage would have helped the problem I had about 2 weeks ago. We are not a trauma hospital though we are a teaching facility. For some reason unknown to me, we received a ruptured AAA via helicoptor on a weekend that I was working. The patient was whisked to surgery and they wanted 8 uncrossmatched O Negs to start with. Once the surgery started they requested 6 platelet pheresis units. Knowing this is a massive transfusion patient I had thawed 2 AB FFP and issued them along with RBCs when they came to pickup blood. They had a hissy fit and refused the FFP and wanted those 6 platelet pheresis products NOW. We only stock 1 plt pheresis. I ordered 5 more from the blood supplier and issued them 1 at a time with other blood products. The patient received 14 RBCs including the 8 uncrossmatched O negs and all 6 Plt pheresis units during surgery as well as 20 units of cryo. Once in the ICU and the coag was WAY out of whack the docs ordered and FINALLY gave the first 2 FFP and eventually 4 more. No coag testing was done before or during surgery. At our facility, during CABG they perform ACTs to determine platelet need! At our teaching facility the doctors get a total of TWO hours of transfusion lecture. I think the problem I was encountering is that the doctors do not know what and how platelets are used - that we have not had random platelets available for years. They would not listen to me during the situation. Part of the problem was that the nurse I was working with ALSO would not listen to me and insisted that YES the patient does need all 6pheresis. Fortunately, our patient is doing well and recovering in LTAC. My solution for now is to create a Massive Transfusion Policy that we can have the medical directors approve. Then I or other Bloodbankers can refer the docs to this policy - ie usually we give 1 or 2 platelet products for every x number of red cells....we should be performing coag testing every x minutes during a massive transfusion so we can determine when cryo and ffp are needed.......

Do you have any suggestions or comments that I can use? I hope to complete this policy by January 30th to present to our transfusion committee.

[rcurrie]

We created something we call the Blue Book. It has an abbreviation of the Circular of Information in it, including the component therapy portion of the CIO. It has other information such as the phone numbers of the blood bank, the medical director, beepers, etc., and a calendar that can be filled in. We give this Blue Book out to all physicians. We have 600+ staff physicians and about 200 residents. If you stop 10 people in the hallway, 8 will have the Blue Book in their labcoat pocket. I have heard one physician ask another if they had their Blue Book with them so they could look something up. You might want to try something like that. If time is of the essence, simply hand out copies of the pocket version of the circular of information.

Good luck!

BC

[caj1018]

I liked your idea of using a "blue book" so much that I passed the idea on to our Lab Director and Transfusion Committee. They absolutely loved the idea. We have such a problem with physican education. Our transfusion committee is poorly attended by physicians and we are a teaching facility. The associated med school provides a whole TWO hours on transfusion medicine - which consists of transfusion reactions and atypical crossmatch problems. We routinely transfuse blood at 9 and 10 Hgb and just last week a cardiologist ordered transfusion to greater than 13 Hgb because his patient was having knee surgery the following morning. Our docs also continue to transfuse 2 units when 1 (or possibly 0) are needed. Our Pathologist/Medical Director is happy with the status quo and supports all decisions made by our physicians including transfusing to 13. The good news is that he also supports the idea of creating a "blue book" though we will probably change the name to "Orange Book" since we are associated with the OSU Cowboys (Go pokes!).

I have one major request! Do you have a copy of your book that we can emulate? Something you can send via email? Thank you again for your wonderful idea.

[Mabel Adams]

http://www.psbc.org/bcrm/index.htm

Try this website for the Puget Sound Blood Center's online Blood Component Reference Manual. Maybe it will also give you ideas for your "Orange book". It looks like their site might have other useful info too.

[rcurrie]

If you will give me a mailing address, I will try to obtain one and send it to you. You can send your address to my work email:

rcurrie@swmail.sw.org

BC