2011 Presentation Abstracts - SABM - Patient Blood Management

Blood Transfus 2011; 9 Suppl 5
Blood Transfus 9, Supplement no. 5, September 2011
ISSN 1723-2007
BLOOD TRANSFUSION
since 1956
Official journal of
Società Italiana di Medicina Trasfusionale e Immunoematologia - SIMTI
Associazione Italiana dei Centri Emofilia - AICE
Hellenic Society of Blood Transfusion - HSBT
Sociedad Española de Transfusión Sanguínea y Terapia Celular - SETS
Associação Portuguesa de Imuno-Hemoterapia - APIH
www.bloodtransfusion.it
2011 Annual Meeting
Society for the Advancement of Blood Management -
SABM
Philadelphia, 22-24 September 2011
ABSTRACTS
GUEST EDITORS: Nabil Hassan and Roslyn Yomtovian
Edizioni SIMTI
SIMTI

BLOOD TRANSFUSION
Journal founded in 1956 by SIMTI
Official journal of
Società Italiana di Medicina Trasfusionale e Immunoematologia - SIMTI
Associazione Italiana dei Centri Emofilia - AICE
Hellenic Society of Blood Transfusion - HSBT
Sociedad Española de Transfusión Sanguínea y Terapia Celular - SETS
Associação Portuguesa de Imuno-Hemoterapia - APIH
Editor-in-Chief
Claudio Velati
claudio.velati@simti.it
Associate Editors
Massimo Franchini
Giancarlo Maria Liumbruno
Daniele Prati
Roberto Reverberi
Luisa Romanò
Giuseppe Tagariello
Alberto Zanella
Affiliated Society Editors
Maria Helena Gonçalves, APIH
Alice Maniatis, HSBT
Pier Mannuccio Mannucci, AICE
Isidro Prat Arrojo, SETS
Executive Director
Stefano Antoncecchi
Founder
Lorenzo Lapponi
Past Editors-in-Chief
Lorenzo Lapponi, 1956-1964
Carlo Alberto Lang, 1965-1966
Roberto Venturelli, 1967-1968
Rosalino Sacchi, 1969-1978
Giorgio Reali, 1979-2006
Editorial Office
Camilla Granzella
SIMTI Servizi Srl
Via Desiderio, 21, 20131 Milano
Tel.: +39 02 23951119 - Fax: +39 02 23951621
E-mail: camilla.granzella@bloodtransfusion.it
Printing
Grafica Briantea Srl
Via per Vimercate, 25/27
20040 Usmate (MI)
The journal is indexed in PubMed-MEDLINE,
Google Scholar, Embase and Scopus and PubMed Central
Impact factor (2010): 2.519
International Editorial Board
Jean-Pierre Allain, United Kingdom
Giuseppe Aprili, Italy
Michele Baccarani, Italy
John Barbara, United Kingdom
Franco Biffoni, Italy
Pietro Bonomo, Italy
Dialina Brilhante, Portugal
Maria Domenica Cappellini, Italy
Jean-Pierre Cartron, France
Alberto Catalano, Italy
Roberto Conte, Italy
Francine Décary, Canada
Giovanni de Gaetano, Italy
Willy Flegel, United States of America
Salvatore Formisano, Italy
Gabriella Girelli, Italy
Giuliano Grazzini, Italy
Antonio Iacone, Italy
Pasquale Iacopino, Italy
Giancarlo Icardi, Italy
Syria Laperche, France
Luis Larrea, Spain
Franco Locatelli, Italy
Aurelio Maggio, Italy
Mike Makris, United Kingdom
Anna Lucia Massaro, Italy
Eduardo Muñiz-Diaz, Spain
Mario Muon, Portugal
Alessandro Nanni Costa, Italy
Salvador Oyonarte, Spain
Arturo Pereira, Spain
Paolo Rebulla, Italy
Philippe Rouger, France
Paul FW Strengers, The Netherlands
Cees L van der Poel, The Netherlands
Alessandro Zanetti, Italy
Tribunale di Milano
Authorisation n° 380, 16 th June 2003
This number is published in 400 copies
Printed in September 2011
ISSN 1723-2007
Edizioni SIMTI
© SIMTI Servizi Srl
www.bloodtransfusion.it
Associated with USPI
Unione Stampa Periodica Italiana

ABSTRACTS
CONTENTS
SCIENTIFIC: ANEMIA MANAGEMENT
2011-01 Preoperative determinants of transfusion and their effects on transfusion rates s1
Freedman J., Vernich L., Howell A., Luke K.
and the Transfusion Coordinators of the ONTraC program, Ontario, Canada
SCIENTIFIC: BLOOD UTILIZATION
2011-02 Increasing transfusion efficacy of stored blood
by using quality-based alternatives to first-in-first-out inventory planning s1
Beeker A., Metzger P., Moldawer D., Tarasev M., Alfano K.
2011-03 Effectiveness of an electronic provider alert system in reduction of deviant PRBC use s2
Waters J., Dyga R.M., Wisniewski M.K., Yazer M.H.
2011-04 Patterns of transfusion in obstetrical patients: information from the IMPACT TM online database s2
Thurer R.L., Precopio T., Parce P., Popovsky M.A.
2011-05 Appropriateness of red cell transfusion for patients with gastro-intestinal bleeding s3
Thurer R.L., Precopio T., Parce P., Popovsky M.A.
2011-06 Variability in surgeon blood use performing primary total hip replacement for arthritis s3
Waters J., Dyga R.M., Wisniewski M.K., Yazer M.H.
SCIENTIFIC: ECONOMICS
2011-07 Variation in transfusion rates and cost implications in total knee replacement surgeries s4
Ye X., Shah M., Farrelly E., Rupnow M., Hammond J.
SCIENTIFIC: SURGICAL TECHNOLOGY AND TECHNIQUES
2011-08 Cardiac surgery in Jehovah's Witness patients: 10 year experience s4
Jassar A.S., Ford P.A., Haber H.L., Isidro A., Swain J.D., Bavaria J.E., Bridges C.R.
SCIENTIFIC: OTHER
2011-09 Laying the foundation for a patient blood management registry s5
Shander A., Farmer S.; Gombotz H., Gross I., Hofmann A., Javidroozi M., Juhl A., Leahy M., Ozawa S., Sweeney J.
2011-10 Factors associated with overall and non-elective hospital readmissions following elective total hip replacement s5
Forlenza J.B., Boswell E., Zhang Y., Shen S., Doshi D., Kokkotos F.K., Slabaugh S.L.
2011-11 Factors associated with overall and non-elective hospital readmissions following elective total knee replacement s6
Forlenza J.B., Boswell E., Zhang Y., Shen S., Doshi D., Kokkotos F.K., Slabaugh S.L.
2011-12 Autologous stem cell transplants in Jehovah's Witness: series of 100 Patients s6
Brown N.M., Keck G., Ford P.
2011-13 Reduction of pre-surgical autologous blood donation collection using a collaborative process
between the Blood Center and Hospitals s7
Fredrich N.
2011-14 Tool development for simulation training in patient blood management s7
Banks C., Sokolowski J.A., Manepalli S., Hakim P., Shander A., Ozawa S., Juhl A.
SCIENTIFIC: OTHER TECHNOLOGY AND TECHNIQUES
2011-15 A clinical evaluation of Terumo's prescriptive Oxygenation TM Series Capiox ® FX15
and FX25 Hollow Fiber oxygenators with Integrated arterial filter in the adult population s8
Swanson B., Petterson C., Newberrry J., Korth D., Kmiecik S
SCIENTIFIC: TRANSFUSION
2011-16 The influence of comorbidity on red cell transfusions for patients with upper gastro-intestinal bleeding s8
Parce P., Thurer R.L., Precopio T., Popovsky M.A.
2011-17 RBC transfusion worsens outcome in pediatric patients with ARDS and ALI:
a retrospective case controlled analysis s9
Sanfilippo D., Rajasekaran S., Shoemaker A., Curtis S., Zuiderveen S., Wincek J., Ndika A., Hassan N.
Blood Transfus 2011; 9 Suppl 5
© SIMTI Servizi Srl

PROCESS IMPROVEMENT: ANEMIA MANAGEMENT
2011-18 Productivity assessment in managing pre-operative anemia
after implementation of a Hospital Information System based anemia management tool s9
Nelson T., Gross I.
2011-19 Current use of erythropoiesis-stimulating agents at Helen DeVos Children's Hospital s10
Lunger J., Kovey K., Hassan N.
2011-20 Improving patient outcomes through optimal blood management - Defining the problem: iatrogenic blood loss s11
Kooser J., Duncan P., Thorpe E.
2011-21 Ferumoxytol infusion in pediatric patients with gastrointestinal disorders: 1 st case report s11
Cahill J., Hassan N., Rajasekaran S., Kovey K.
PROCESS IMPROVEMENT: BLOOD MANAGEMENT EDUCATION
2011-22 Internal creation and implementation of a blood management program s12
Nguyen H.
2011-23 Perioperative intravenous Iron Hydroxide Sucrose (Venofer) optimization to enhance erythropoiesis s13
Gagne S., Davis N., Rammler W., Bentley D., Barlow D., Murray G.
2011-24 The autologous transfusion database:
Englewood Hospital and Medical Center's response to the silent call for standardization of data collection s13
Juhl A., Aregbeyen O., Naqvi S., Demir S., Khan A., Shander A.
PROCESS IMPROVEMENT: OTHER TECHNOLOGY AND TECHNIQUES
2011-25 Blood Transfusion-Free complex cardiac reoperation in a Jehovah's Witness child-by use
of a minimized cardiopulmonary bypass circuit, and various blood conservation techniques. A Case Report s13
Lee J.
2011-26 Lean tools and coaching drive 79% reduction in pretransfusion testing TATs and 77% reduction in RBC wastage s14
Dikeman J., Leonard K., South S.
PROCESS IMPROVEMENT: SURGICAL TECHNOLOGY AND TECHNIQUES
2011-27 Appraisal of bloodless surgery for Jehovah's Witness with malignancy in single institute s15
Kawamoto S., Inada K., Nagao S., Hosaka S., Ohkubo S., Ochiai R., Takahashi H., Sakamoto R., Umemoto S., Murakami T.
2011-28 Comparison of robotic versus open urologic surgery in Jehovah's Witness patients: a single center experience s15
Golan R., Llukani E., Eun D.
2011-29 Bloodless surgery for Jehovah's Witness patients:
our initial experience in major robotic urologic procedures and a review of the existing literature s17
Llukani E., Golan R., Eun D.
PROCESS IMPROVEMENT: TRANSFUSION
2011-30 Reducing blood ordered to blood transfused average ratios in the operating room s19
Neville T., Kotin A., Hoskins W., McCollum C., Russell E.
2011-31 Elective total hip and knee surgery transfusion process improvement s19
Loos K., Snyder M., Fellner A., DeRose K., Robinson J.
Citation of the manuscripts published in this volume should be as follows:
Author. Title. Journal year; Volume, Suppl. 5 September: abstract number
E.g.:
Freedman J., Vernich L., Howell A. et al. Preoperative determinants of transfusion and their effects on transfusion rates. Blood Transfusion 2011; 9
Suppl 5 September: 2011-01
Blood Transfus 2011; 9 Suppl 5
© SIMTI Servizi Srl

2011 ANNUAL MEETING SABM
ABSTRACTS
SCIENTIFIC: ANEMIA MANAGEMENT SCIENTIFIC: BLOOD UTILIZATION
2011-01 PREOPERATIVE DETERMINANTS OF
TRANSFUSION AND THEIR EFFECTS ON TRANSFUSION
RATES
Freedman J., Vernich L., Howell A., Luke K. and the Transfusion
Coordinators of the ONTraC program, Ontario, Canada
Preoperative anemia is a major determinant of intra- and postoperative
transfusion. Our program of Transfusion Coordinators
(TC) in 25 hospitals in Ontario aims to evaluate patients early
preoperatively to facilitate appropriate management of anemia.
Data will be presented on orthopedic patients (knee arthroplasty
N=4235; hip N=2805; revision hip N=348; spine surgery
N=178), and on cardiac surgery patients (CABG N=1010;
CABG+valve N=144; valves N=197; AAA N=63) seen in 2010.
In CABG patients seen by the TC, 23.2% were transfused; in
those not seen 32.4% were transfused. Transfusion rates were
affected by gender and elderly status, initial, preoperative and
nadir hemoglobin (Hb) levels, lead times prior to surgery,
and by preoperative treatment of anemia. In CABG patients
with initial Hb 130 g/L 16.5% were transfused, and for those with
initial Hb >140 g/L, transfusion rate was 10.2%. Women were
twice as likely to be transfused than men (50.6% versus 22.9%).
Mean initial Hb levels were 128.2+14.9 and 141.6+13.1 g/L in
women and men respectively: in transfused men, mean initial
Hb was 129.3 and in women 121.3 g/L, in contrast to initial Hb
in nontransfused patients of 143.6 versus 133.2 g/L for men and
women respectively). Cardiac surgery patients generally had
shorter lead times e.g. 42% of CABG patients, in contrast to
70% of orthopedic patients, had lead time >14 days. Transfusion
rates were inversely proportional to lead time.
In CABG, transfusion rates were 40.7% when lead time
was 14
days. As lead time increased, there was an increase in use of
preoperative blood conservation measures. 4.4% of CABG
patients, 13% of CABG+valve, 15% of valves, and 7% of
minimally invasive cardiac surgery patients received ESAs;
2.2% of CABG patients, 6.3% of CABG+valve, 7.6% of valves,
and 7% of minimally invasive cardiac surgery patients received
IV iron. 7% of knee, hip and revision hip arthroplasty and 17%
of spine surgery patients received ESAs; 3.2% of knee, 2.4% of
hip, 3.2 % revision hip arthroplasties, and 0.6% spine surgery
patients received IV iron. Use of these therapies increased mean
Hb levels e.g. in CABG patients mean dose of ESA was 100,000
IU and mean Hb increase was 14.9 g/L; mean Hb increase with
IV iron was 10.6 g/L.
Patients treated preoperatively with ESAs and/or with
intravenous iron had lower transfusion rates than those not
treated. Length of stay and infection rates were signifi cantly
lower in nontransfused patients and incidence of thrombotic
events was not higher in patients who received ESAs.
Transfusion rates have decreased progressively since the
program's inception in 2002 (60.1% in CABG in 2002 vs 23.6%
in 2010) and transfused patients receive fewer units (0.60 units
in 2010 versus 2.01 units in 2002 per transfused patient).
While other factors, including intra-and post-operative patient
blood management measures, and education and "culture
change", also play important roles, we conclude that appropriate
anemia management can signifi cantly reduce transfusion rate
and improve quality of care.
Blood Transfus 2011; 9 Suppl 5
2011-02 INCREASING TRANSFUSION EFFICACY
OF STORED BLOOD BY USING QUALITY-BASED
ALTERNATIVES TO FIRST-IN-FIRST-OUT
INVENTORY PLANNING
Beeker A. (1) , Metzger P. (1) , Moldawer D. (1) , Tarasev M. (1) ,
Alfano K. (1,2)
(1) College of Engineering, University of Michigan, Ann Arbor,
MI; (2) Blaze Medical Devices, Ann Arbor, MI , United States of
America
Introduction The effect of red blood cell (RBC) storage on
transfusion effi cacy is a topic of considerable debate. While
signifi cant data exist linking "older" blood to "worse" outcomes,
other studies question any such correlation. Within today's
maximum FDA-allowed 42-day shelf life for RBC, hospital
blood banks routinely use First-In-First-Out (FIFO) inventory
management protocols. The predominant use of FIFO means
a heavy reliance on time as the only indicator of prospective
transfusion effi cacy. Focusing on storage time as the sole metric
for viability loss ignores the variability in properties of RBC
even of the same age. Inherent as well as conditional differences
between units can markedly affect both the scope and rates of
RBC quality loss. Emerging in-vitro tests aim to correlate unitspecifi
c data with transfusion effi cacy and clinical outcomes.
This study presents a basic model for Blood Bank inventory
management based on in-vitro RBC quality testing to supplant
FIFO. It demonstrates the potential impact on transfusion effi cacy
for a sample Blood Bank inventory, from reorganizing inventory
in a Blood Bank based on measured RBC properties of individual
units - and their respective projected degradation rates.
Methods The model, built as a linear program in AMPL,
determined the times of transfusion for each unit of RBC in
inventory, to maximize cumulative anticipated effi cacy (CAE)
of all inventory at transfusion. Inputs included blood type,
collection date, and the date(s) and results of quality test(s)
performed upon each unit. Each test provides actual effi cacy
(ACT) of a given unit as of that day, and a rate of degradation
(R AE ) used to calculate the anticipated effi cacy (AE) on any
subsequent date. Constraints included a minimum required
level of AE for every unit transfused and full satisfaction of
daily blood demand. Model output was simulated using sample
inventory data provided by Dr. Davenport and Ms. Downs from
the University of Michigan Hospital Blood Bank.
Results Preliminary simulations of inventory management
process resulted in 10-15% improvement in overall effi cacy
over traditional FIFO. Modifying the date of quality testing and/
or the number of times it is performed during storage can further
improve the model. Effi cacy improvements also signifi cantly
depended on the variability in RBC initial quality (IAE) at t=0
and upon the variability among rates of decline of AE. Increase
in overall inventory effi cacy (CAE) notably did not result in any
shorter average storage time.
Conclusions The replacement of FIFO with an inventory
management system based on RBC unit quality testing allows
for signifi cant improvement of overall transfusion effi cacy, while
fully satisfying the demand. Implementation of such testing for
inventory optimization is expected to improve clinical outcomes
while reducing blood usage and associated costs.
Disclosures This work was supported by Blaze Medical
Devices, Ann Arbor, MI.
s1

2011-03 EFFECTIVENESS OF AN ELECTRONIC
PROVIDER ALERT SYSTEM IN REDUCTION OF
DEVIANT PRBC USE
Waters J., Dyga R.M., Wisniewski M.K., Yazer M.H.
University of Pittsburgh, PA, United States of America
Introduction Within our blood management program, evidence
based transfusion guidelines have been developed by our
transfusion committee. The medical staff in our health system
have been extensively educated in these transfusion guidelines.
Despite multiple different types of educational efforts, many
patients are still receiving PRBCs outside of the institutional
guidelines. Here we report on the effectiveness of an electronic
alert system which was established to further reduce nonindicated
RBC transfusions.
Methods The Cerner computerized physician order entry
system was used to alert the clinician when they were ordering
PRBCs outside of recommended indications. The alert was
designed to appear on the clinician's computer when PRBCs
were being ordered and the most recent hemoglobin value was >
8.5 gm/dL. The language of the alert was as follows: "The most
recent available hemoglobin value for this patient is X gm/dL.
A transfusion is not consistent with the institutional guidelines
for administration of red blood cells. Unless your patient
2011-04 PATTERNS OF TRANSFUSION IN
OBSTETRICAL PATIENTS: INFORMATION FROM
THE IMPACT TM ONLINE DATABASE
Thurer R.L., Precopio T., Parce P., Popovsky M.A.
Haemonetics, Braintree, MA, United States of America
Introduction Pregnant women are routinely given iron and
vitamins to mitigate the anemia of pregnancy. Cell salvage
is advocated when Cesarean delivery with high blood loss is
anticipated. However, to understand the potential opportunities
for improved blood management in obstetrical patients analysis
of transfusion data from a large number of patients is needed.
Materials and Methods Impact TM Online (Haemonetics,
Braintree, MA) is a newly developed data mining tool which
extracts transfusion practice data from hospital information
systems. The IMPACT TM Online database allowed us to identify
74,065 patients who delivered vaginally and 52,253 who had
Caesarian sections at 29 hospitals throughout the United States.
We analyzed this information with the goal of evaluating the
s2
2011 ANNUAL MEETING SABM
ABSTRACTS
is experiencing an acute ischemic event, or acute on-going
blood loss, the transfusion will be considered a deviation from
evidence-based transfusion recommendations". The clinician
was given the opportunity to override the alert and proceed with
ordering the blood product. Data was collected over the fi rst 3
months of implementation of the alert and is presented here.
Results Over the 3 month interval, the alert fi red 2900 times.
The alert resulted in the clinician not proceeding with transfusion
in 12.5% of the cases or 363 cases. The majority of the ordering
clinicians were from our internal medicine and family practice
programs. Data from the OR was not part of the reporting because
blood orders are not made through our computerized physician
order entry system. In the fi gure below, each hospital within the
UPMC health system is reported with the entire bar representing
the total number of times that the alert fi red with the yellow
representing the number of times that the transfusion was aborted.
Discussion While the electronic alert made an impact, it was
minimal at best. If these numbers are annualized and each
event avoided a single transfusion, then the effect amounts to
$270,000 of annual savings for the health system. The alert
did allow for our blood management team to better identify
where transfusions were taking place that were outside of
our institutional guidelines. This should help better target
educational efforts.
appropriateness of transfusion and identifying opportunities for
improvement in blood management.
Results For patients delivering vaginally, 0.55% received
RBC, 0.05% received platelets and 0.05% received FFP. For
patients having Cesarean section 2.49% received RBC, 0.40%
received platelets and 0.34% received FFP. The incidence
of transfusion as related to the lowest measured hemoglobin
(Nadir Hgb) is presented in Table I. Table II shows the
number of units transfused and the associated fi nal Hgb (last
measurement obtained during hospital stay) of each group of
patients. 47% of transfused patients delivering vaginally and
54% of transfused patients having Cesarean section had a fi nal
hemoglobin ≥9.0 g/dL.
Conclusions Based on the nadir hemoglobin data, transfusions
to these obstetrical patients were used sparingly. However, when
transfusions were given, the fi nal hemoglobin data suggests
that approximately 50% were "over transfused". Two unit
transfusions were most common although the data suggests that
one unit would have been suffi cient for most of these patients.
Blood Transfus 2011; 9 Suppl 5

2011 ANNUAL MEETING SABM
ABSTRACTS
Table I
Nadir Hgb
(g/dL)
Vaginal %
Transfused
Blood Transfus 2011; 9 Suppl 5
C-Section %
Transfused

s4
SCIENTIFIC: ECONOMICS
2011-07 VARIATION IN TRANSFUSION RATES
AND COST IMPLICATIONS IN TOTAL KNEE
REPLACEMENT SURGERIES
Ye X. (1) , Shah M. (2) , Farrelly E. (2) , Rupnow M. (1) , Hammond J. (1)
(1) Ethicon Inc., Somerville, NJ; (2) Xcenda, Palm Harbor, FL,
United States of America
Introduction The purpose of this study was to examine the
transfusion rates in total knee replacement (TKR) surgeries
across hospitals in the US and its cost implications.
Methods A retrospective analysis was conducted using Premier
administrative data. TKR was identifi ed by the ICD-9-CM
procedure code of 81.54. All hospitals in the Premier database
that had TKR in 2009 were extracted. Blood transfusion was
identifi ed using a list of ICD-9-CM diagnosis and procedure
codes and billing charge codes. The transfusion rate for each
individual hospital was calculated as the percentage of TKRs
with blood transfusion over the total number of TKRs that
were performed in that hospital in 2009. The average costs
of TKR were calculated for each hospital. A generalized
linear model with log-link/gamma distribution was used for
analyzing the average TKR costs across hospitals, adjusting
for hospital characteristics (i.e., region, teaching status, bed
size, rural/urban).
Results Out of 440 hospitals in the Premier database in 2009,
404 hospitals that had TKR surgeries were identifi ed from
the Premier database, with a total of 95,117 TKRs performed
during the year of 2009. The transfusion rate ranged from 0%
to 100% across hospitals. Specifi cally, 36 (9%) hospitals had a
zero transfusion rate, 169 (42%) hospitals had a transfusion rate
of 1-20%, 166 (41%) hospitals had a transfusion rate of 21-50%
and 33 (8%) hospitals had a transfusion rate higher than 50%.
The mean hospital costs (weighted by the number of surgeries)
ranged from $13,275 for hospitals with 0% transfusion rate
to $17,179 for hospitals with a transfusion rate over 50%. In
comparison to hospitals with 0% transfusion rate, on average
the costs of TKR were 18% (95% CI: 6%-32%, p

2011 ANNUAL MEETING SABM
ABSTRACTS
vascular disease (20.9%), and renal failure (11%). Operations
included CABG (n=45), valve procedures (n=30), combined
valve/CABG (n=11), type A aortic dissection (n=1), aortic
root replacement (n=1), cardiac tumors (n=2), and PFO
closure (n=1). Mean postoperative length of stay was 9.8±7.9
days. Overall mortality was 5.5% (n=5). Mortality for isolated
CABG and isolated AVR was 2.2% (O/E=1.05[0, 3.02]) and
5.6% (O/E=1.46[0, 3.76]) respectively. Other complications
included reoperation (all=8.8%, cardiac=2.2%), sepsis (2.2%),
sternal wound infection (1.1%), TIA (1.1%), renal failure
requiring dialysis (1.1%), and prolonged ventilation (18.7%).
Major complication rate was not signifi cantly different between
the elective and urgent group.
Conclusion Bloodless cardiac surgery in JW patients can be
performed with excellent outcomes in both the elective and
the urgent situations using a multi-disciplinary approach.
Mortality rates for isolated CABG and isolated AVR are
within the expected 95% confi dence intervals of STS predicted
mortality.
Blood Transfus 2011; 9 Suppl 5
SCIENTIFIC: OTHER
2011-09 LAYING THE FOUNDATION FOR A PATIENT
BLOOD MANAGEMENT REGISTRY
Shander A., Farmer S., Gombotz H., Gross I., Hofmann A.,
Javidroozi M., Juhl A., Leahy M., Ozawa S., Sweeney J.
Introduction The increased adoption of Patient Blood
Management (PBM) as part of routine clinical practice calls for
a systematic standardized data collection strategy to quantify
the effectiveness of PBM in improving patient outcome. This
proposed data registry would allow exploration of the relationship
between patient characteristics and anemia/transfusion-related
events, benchmarking PBM activities, and providing a database
for related clinical studies of patients managed in "real" clinical
settings. We have developed the proposed characteristics of a
PBM registry to serve these critical needs.
Methods A multi-national, multi-disciplinary team of clinicians,
scientists, and advocates with a shared interest and experience
in PBM and transfusion medicine convened a three-day meeting
in Vermont, United States, in Spring 2010, during which they
reviewed a number of existing relevant studies/programs, and
discussed various aspects of a PBM registry. Following the
meeting, the group voted and scored the proposed key elements
of a PBM registry.
Results The key aspects considered for PBM registry were:
1) defi ning the population of interest; 2) stratifi cation approaches;
3) standardizing data collection to allow comparisons; 4) defi ning
the endpoints and 5) standardized reporting format across
participating institutions.
The target population may include patients who are at risk of
bleeding, receiving transfusion, or who may be candidates for
PBM strategies, and selection may be based on patient- and
procedure-related factors. All critically ill patients, cardiac
surgery patients, acute coronary syndrome or myocardial
infarction patients, major orthopedic surgery patients, admitted
hematology and oncology patients, admitted trauma patients, and
non-surgically managed bleeding patients should be included.
Patient stratifi cation should be performed based on factors
likely to affect the outcomes, namely, demographics, measures
of severity of illness, and patient/condition-specifi c measures
of acuity.
Validated standardized data collection forms and defi nitions for
the data fi elds are necessary, and their feasibility must be preestablished.
Existing data collection systems in centers must be
used whenever available, and possibly integrated with the PBM
registry. Suggested general data fi elds include: demographics,
anemia laboratory tests, current diagnosis, comorbidities,
risk scores, relevant medications, autologous and allogeneic
transfusions, and procedure data. Additionally, appropriate
"denominators" (e.g. patient numbers and measures of acuity)
to allow comparison of data from different centers/time periods
need to be established. Centralized data management and
verifi cation is the other key issue.
Challenges in collecting reliable data on clinically-relevant
endpoints may lead to use of more accessible "surrogate"
endpoints. Suggested endpoints of interest in a PBM registry
included: mortality, morbidity, length of stay , quality of life,
resource consumption, and discharge disposition.
PBM registries require effective reporting to disseminate
data back to the clinicians, administrators, and the healthcare
community, in simple, standardized, meaningful and
easily-comparable formats.
Conclusion As previously reported, implementation of
PBM strategies may yield unexpected observations, and use
of standardized data collection methods, stratifi cation, and
proper denominators within a registry can be invaluable in
understanding these fi ndings. PBM registries are vital to
continued success and adoption of PBM to ensure the key
goal - improvement of patient outcome - is achieved.
2011-10 FACTORS ASSOCIATED WITH OVERALL
AND NON-ELECTIVE HOSPITAL READMISSIONS
FOLLOWING ELECTIVE TOTAL HIP REPLACEMENT
Forlenza J.B. (1) , Boswell E. (2) , Zhang Y. (2) , Shen S. (2) , Doshi D. (1) ,
Kokkotos F.K. (2) , Slabaugh S.L. (1)
(1) Janssen Services, LLC, Horsham, PA; (2) Trinity Partners,
LLC, Waltham, MA, United States of America
Introduction Over 225,000 total hip replacement (THR)
surgeries occurred in the US in 2004, and this number may double
by the year 2015. Readmissions after THR may impact patients,
providers, and payers. This analysis evaluated discharge, patient,
and hospital level factors associated with readmissions after THR.
Methods Elective THR discharges for adults during 2005-2009
were identifi ed using the Premier database. Total hip replacement
discharges were excluded if multiple surgeries or death occurred
during admission or if a patient had a hospital admission in the
dataset 3 months pre-THR. All hospital readmissions in the
month of or after THR discharge were identifi ed. Two logistic
regression models were used to evaluate associations between
characteristics from the THR claim and readmissions (Model 1:
all readmissions; Model 2: non-elective readmissions, defi ned
as emergency/urgent/trauma center admissions).
Results A total of 172,942 THR discharges were included
(55.8% females; mean age=65 years; 54.9% were in nonteaching
hospitals; mean length of stay [LOS] for THR admission
was 3.64 days; 55.2% had no red blood cell/whole blood or
other transfusion claims; and 37.5% had a discharge status of
transferred/referred). There were 10,859 total discharges with
readmissions, and 4,759 readmissions were non-elective. In
both models, factors that were not found to be signifi cantly
associated with readmissions included gender, infection status,
and severity of illness (all p-values >0.05). Factors that were
s5

signifi cantly associated with readmissions (p0.05) while infection
status was only found to be signifi cant in the model for all
readmissions (p=0.046). Factors signifi cantly associated with
readmissions (p

2011 ANNUAL MEETING SABM
ABSTRACTS
Discussion Using our blood management techniques, HDC
with ASCT can be safely performed without the use of blood
products. Our mortality rate is 4% which is similar to the
national mortality rate of 1-3.5% for lymphoma and multiple
myeloma 1,2,3 . We report a 25% risk of cardiac complications
which were manageable with telemetry monitoring,
antiarrhythmics and volume resuscitation. Whether the cardiac
complications are due to the prolonged and profound anemia
related to withholding blood products or the HDC and ASCT
procedure itself requires further investigation. Many of the
blood management strategies utilized in bloodless ASCT may
be appropriate in all patients undergoing HDC and ASCT to
avoid the risks of blood transfusions.
1. Gertz MA, Ansell SM, Dingli D, et al. Autologous stem
cell transplant in 716 patients with multiple myeloma:
low treatment-related mortality, feasibility of outpatient
transplant, and effect of a multidisciplinary quality initiative.
Mayo Clin Proc. 2008; 83: 1131-8.
2. Viviani S, Di Nicola M, Bonfante V. Long-term results of
high-dose chemotherapy with autologous bone marrow or
peripheral stem cell transplant as fi rst salvage treatment for
relapsed or refractory Hodgkin lymphoma: a single institution
experience. Leuk Lymphoma. 2010: 51; 1251-9.
3. Ulrickson M, Aldridge J, Kim HT. Busulfan and
cyclophosphamide (Bu/Cy) as a preparative regimien for
autologous stem cell transplantation in patients with non-
Hodgkin lymphoma: a single-institution experience. Biol
Blood Marrow Transplant. 2009; 15: 1447-54.
2011-13 REDUCTION OF PRE-SURGICAL AUTOLOGOUS
BLOOD DONATION COLLECTION USING A
COLLABORATIVE PROCESS BETWEEN THE BLOOD
CENTER AND HOSPITALS
Fredrich N.
BloodCenter of Wisconsin, Milwaukee, WI, United States of
America
Introduction Nationally, presurgical autologous donation
(PAD) collections decreased by 27% from 2004 to 2006, while
wastage remained high at 44%. During this period, our blood
center had a gradual decline in PAD of 7% with wastage rates
similar to those seen nationally. Due to high wastage, lack of
reimbursement and potential for preoperative anemia, strategies
to reduce PAD have been advocated. In 2008, we began an
initiative to reduce PAD by 20%. We describe our approach
for reducing autologous collections with our hospital customers
and thereby reducing costs and PAD wastage within our
community.
Materials and Methods Blood center records from 2008 were
retrospectively reviewed to provide baseline data on number
of PAD units collected, number wasted, surgical procedure
utilizing PAD, days between donation and surgery, surgeon,
and hospital. Distribution of this baseline data was targeted at
the local top 30 ordering surgeons, with particular emphasis
on orthopedics and neurosurgery. Individual surgeon reports
included number of patients, number of units collected and
percent wastage by procedure grouping. For each surgical
procedure group, community data was compiled to be used
as comparison in the individual surgeon reports. A PAD fact
sheet, including risks, benefi ts and suggested patient selection
criteria was created and included with the reports. Reports were
distributed to individual surgeons and affi liated hospitals in late
Blood Transfus 2011; 9 Suppl 5
2009. Ongoing PAD data was provided to partner hospitals as
requested. During this time, several hospitals also introduced
internal methods to reduce usage of PAD.
Results Number of PAD units collected and percent wastage is
shown in the table.
2008
(baseline)
2009 2010
Total # Units Collected 2,824 2,333 1,172
Percent Reduction from 2008
All Hip Procedures:
17% 58%
# Units Collected 647 542 174
% Wastage
All Knee Procedures:
55% 48% 52%
# Units Collected 630 613 260
% Wastage
Neurosurgery Procedures:
49% 46% 37%
# Units Collected 1,165 954 613
% Wastage 49% 53% 60%
Compared to baseline, PAD collections for hip and knee
procedures in 2010 declined by 73% and 59%, respectively.
Reduction in PAD wastage for the same procedures was 5.4%
and 24.5%, respectively. For neurosurgery procedures in 2010
there was a 47% reduction in PAD units collected but percent
wastage increased. Using just the direct cost of an autologous
unit ($354) and the difference in units collected in 2010
compared to 2009, cost savings was $130,272 for hip, $124,962
for knee, and $120,714 for neurosurgery procedures.
Conclusion Though a small decline in autologous collection
was noted prior to distribution of our reports, afterwards this
reduction tripled, surpassing our goal. Percent wastage also
declined for hips and knees though not at the rate of collection,
likely refl ecting the impact of fewer unit collections or need
for further education for selected surgeons and/or hospitals By
partnering with our hospital customers and providing surgeons
with their individual practice of PAD, we believe increased
awareness contributed to a more dramatic reduction in PAD and
thereby cost savings to the hospitals.
2011-14 TOOL DEVELOPMENT FOR SIMULATION
TRAINING IN PATIENT BLOOD MANAGEMENT
Banks C., Sokolowski J.A., Manepalli S., Hakim P., Shander A.,
Ozawa S., Juhl A.
Introduction This research details the methodology and
development of a web-based simulation training tool that
incorporates blood management practices for peri-operative
patient care. The tool satisfi es an unmet need for simulation
training modalities in the fi eld and provides the means for
comprehensive and effective training.
Methods Medical simulation is able to execute training in a
multiplicity of modes, house large digital libraries for a breadth
of experiences, and accommodate a repetition of exercises to
reinforce learning. This simulation training tool is grounded in
engineering and mathematical modeling and the simulations are
drawn from actual patient case studies that lend credibility to
s7

the exercises as these are the basis for training scenarios of
proven blood management practices. The target audience is
trained and skilled physicians who are unfamiliar with blood
management techniques and/or are without a practical means
to train to them.
Results The tool is developed for web-based access with
continuous simulation capability and hands-on exercises. It is
the result of a multi-disciplinary effort drawn from medical,
engineering, and computer science expertise.
Conclusions This training tool will facilitate a patient blood
management learning exercise for closing the learning gap
through simulation (re-)training of new information and new
techniques for peri-operative patient care.
2011-15 A CLINICAL EVALUATION OF TERUMO'S
PRESCRIPTIVE OXYGENATION TM SERIES CAPIOX ®
FX15 AND FX25 HOLLOW FIBER OXYGENATORS
WITH INTEGRATED ARTERIAL FILTER IN THE
ADULT POPULATION
Swanson B., Petterson C., Newberrry J., Korth D., Kmiecik S.
University of Kansas, Hospital Center for Advanced Heart
Care, Kansas City, KS, United States of America
Advancements in perfusion safety over the last decade have
been empirical in making cardiopulmonary bypass (CPB)
progressively safer than ever. However, with the increasing
amount of evidence supporting the detrimental effects of blood
products, the need for change in practice is most urgent. The new
2011 level (1A) recommendations from the Society of Thoracic
Surgeons (STS) suggests the best standard of care with regards to
blood conservation, is to identify high risk patients and prepare
accordingly. Previous studies have determined that a reduction
in surface area-priming volume of the CPB circuit reduces the
frequency of low HCT values and subsequently reduces the
incidence of allogeneic blood transfusions. One measure of
recent interest is Terumo ® Prescriptive Oxygenation TM , a series
of hollow fi ber oxygenators with integrated arterial fi lters,
which offer lower prime volumes to specifi c sized patients
with low body weight, pre-operative anemia, advanced age, or
other said factors vulnerable to low hemoglobin levels. This
was a clinical, non-randomized retrospective evaluation of
the Terumo ® Capiox ® FX15 and FX25 series oxygenators for
effi cacy in priming, blood conservation, gas exchange, oxygen
delivery, as well as patient selection bias for either FX unit.
In 300 cases requiring CPB with accordance to institutional
perfusion protocol, the FX series was remarkably effi cient
in priming due to absence of CO 2 fl ushing and de-airing of
an arterial line fi lter. Additionally, the FX15 and FX25 were
able to reduce prime volumes by 400cc and 300cc and able to
increase on pump hematocrits by 25% and 18% respectively.
The effect of the integral arterial fi lter on ventilation and gas
exchange was minimal, as optimal PCO 2 levels were achieved
at sweep ratios between of .8-1 as well as comparable PO 2 levels
at 100% FIO 2 . Both FX series were effective in oxygen delivery
within their corresponding fl ow ranges. Markedly, the FX15
performed optimally above and at the limit of its manufacturer's
recommended fl ow rates, rendering it the preferred oxygenator
of choice even in larger patients that we would have previously
used a FX25 on. Decidedly, body surface area (BSA) was the
s8
SCIENTIFIC:
OTHER TECHNOLOGY AND TECHNIQUES
2011 ANNUAL MEETING SABM
ABSTRACTS
most constraining factor when it came to patient selection, ahead
of age, complexity of surgery and sex. However, in borderline
patients, BSA 2.0(±.2) m2, a reverse relationship between BSA
and age was observed, based on metabolic demands, advanced
aged patients trended towards the FX15 while the FX25 was
preferred for younger patients. Overall the Terumo ® Capiox ®
FX15 and FX25 series oxygenators are extremely safe and
effective adjuncts to previous systems, and are able to drastically
reduce prime volume and surface area, especially important in
patients under 60 kg and or at high risk for blood transfusions.
1. Ferraris V.A. et al. 2011 Update to The Society of
Thoracic Surgeons and the Society of Cardiovascular
Anesthesiologists Blood Conservation Clinical Practice
Guidelines. Ann Thorac Surg 2011; 91: 944-82.
2. Shann K.G. et al. Focus on neurologic injury, glycemic
control, hemodilution, and the infl ammatory An evidencebased
review of the practice of cardiopulmonary bypass in
adults. J Thorac Cardiovasc Surg 2006; 132: 283-90.
SCIENTIFIC: TRANSFUSION
2011-16 THE INFLUENCE OF COMORBIDITY ON
RED CELL TRANSFUSIONS FOR PATIENTS WITH
UPPER GASTRO-INTESTINAL BLEEDING
Parce P., Thurer R.L., Precopio T., Popovsky M.A.
Haemonetics, Braintree, MA, United States of America
Introduction While the majority of patients with upper gastrointestinal
bleeding (UGIB) are ≥65 years of age and likely to
have comorbid conditions, little is known about frequency
or reasons for transfusion. Since transfusions are commonly
given to patients with UGIB, understanding the infl uence of
comorbidities on transfusion practice may identify opportunities
for improvements in blood management. This study examined
the impact of comorbid conditions on transfusion.
Methods Impact TM Online (Haemonetics, Braintree, MA) is a
newly developed data mining tool which extracts transfusion
practice data from hospital information systems. We analyzed
3+ years of patient- specifi c transfusion data from 29 US
hospitals in the IMPACT Online database and identifi ed
13,407 patients with UGIB who had diagnostic and/or
therapeutic endoscopy. The Charlson Comorbidity Index (CCI)
was used to stratify patients based on medical comorbidity. The
CCI score is the sum of 18 conditions weighted according to
the degree to which they predict mortality. We looked at age,
percent transfused, units transfused, and fi nal hemoglobin of
transfused patients in separate cohorts of CCI from 1-7 and >8
to determine if there was a correlation between the CCI and
transfusion rate. Final hemoglobin, defi ned as the last recorded
hemoglobin prior to discharge, was included in the analysis as
an indicator of transfusion practice.
Charlson Scoring
1 point each - acute MI, previous MI, CHF, connective tissues
disease, COPD, dementia, diabetes, cerebrovascular disease, mild
liver disease, ulcer, peripheral vascular disease
2 points each - chronic renal failure, diabetes with sequelae, cancer,
hemiplegia
3 points each - liver disease
4 points each -AIDS, metastatic cancer
Low score (≤3) Moderate (4-5) High (6-7) Very High (≥8)
Blood Transfus 2011; 9 Suppl 5

2011 ANNUAL MEETING SABM
ABSTRACTS
Results 65.6% of patients with UGIB (n=8,786) received red
cell transfusion. As seen in the table, there was an increase
in the incidence of transfusion and the mean number of units
transfused with increasing CCI score. As expected, patients with
comorbidities were older. There was no signifi cant difference in
the fi nal hemoglobin of transfused patients.
CCI n Age n Tx % Tx Units Final Hgb
Tx
0 1,857 57.5 888 47.8% 3.31 10.2
1 3,164 61.9 1,994 63.0% 3.47 10.1
2 2,443 68.4 1,675 68.6% 3.64 10.2
3 1,816 71.3 1,303 71.8% 3.83 10.3
4 1,799 63.7 1,284 71.4% 4.36 10.0
5 1,025 61.9 724 70.6% 4.21 10.0
6 620 64.5 421 67.9% 4.43 10.0
7 361 66.8 269 74.5% 4.29 10.0
≥8 312 64.6 227 72.8% 4.93 10.4
Conclusions These data demonstrate that greater co-morbid
conditions are associated with transfusion in UGIB patients.
Although the presence of comorbidities increases the likelihood
of transfusion, the fi nal hemoglobin data (values 10.0-10.4 g)
suggests that the transfusion "trigger" is similar for all patient
groups. This raises the question whether the "hemoglobin
target" is too high, at least in less ill patients. Additional studies
are needed to determine the effect of transfusion on short and
long-term outcomes.
2011-17 RBC TRANSFUSION WORSENS OUTCOME
IN PEDIATRIC PATIENTS WITH ARDS AND ALI: A
RETROSPECTIVE CASE CONTROLLED ANALYSIS
Sanfi lippo D., Rajasekaran S., Shoemaker A., Curtis S.,
Zuiderveen S., Wincek J., Ndika A., Hassan N.
DeVos Children's Hospital, Grand Rapids, MI, United States
of America
Introduction Acute respiratory distress syndrome (ARDS) and
Acute Lung Injury (ALI) can occur after systemic insults such
as sepsis and trauma or after direct lung injury like aspiration.
The management of the ARDS patient involves preserving
oxygen delivery to tissue as lung compliance deteriorates and
ventilation/perfusion (V/Q) mismatch worsens. Red Blood
Cell (RBC) Transfusions are often considered in clinical
care of the ALI or ARDS patient given their potential value
in volume expansion and oxygen delivery. There are even
consensus statements that recommend transfusion to maintain a
hemoglobin threshold in anemic patients with ARDS. However,
RBC transfusion is not without risk and recent data suggests
association between transfusion and poor outcome in critically
ill children.
Materials and Methods We hypothesized that patients with
ARDS or ALI who receive RBC transfusion in the fi rst 48 hours
of mechanical ventilation were likely to suffer a complicated
course with prolonged mechanical ventilation, morbidity and
mortality. During a 24 month period (Jan 1 st 2008- Jan 1 st 2010),
the clinical course of 34 transfused ARDS and ALI patients
were compared to 45 control patients. Cerner and Virtual PICU
Blood Transfus 2011; 9 Suppl 5
databases were abstracted to collect laboratory and clinical data
for analysis once IRB approval was granted.
Results The mean hemoglobin in the study group was
8.2±0.23 g/dL just prior to transfusion. The pre-transfusion
hemoglobin at a comparable time point was 10.23±0.23 g/dL in
the control group. The transfused group had a PF ratio change
from 135.43±7.5 to a post-transfusion value of 116.5±8.8
whereas the control group improved from 148.0±8.0 to
190.4±17.8. The transfused group spent a total of 15.6±1.68
ventilator days compared to control with a total of 9.51±0.58
days (P=0.000). ICU mortality in the transfused ARDS and
ALI group was 4/34 compared to 1/45 (P=0.090) in the non
transfused group. The transfused group 6/34 (17.6 %) tended
to require CRRT (Continuous Renal Replacement Therapy)
later, beyond the initial 48 hours compared to control 2/45
(4.4%) (P=0.057).Secondary MODS was more common in the
transfused group 8/34 (23.5 %) vs. 3/45 (6%) (P=0.048).
Conclusion This study though limited by its size and
retrospective design, does highlight some important factors.
First, in the midst of trying to ensure adequate oxygenation in
early ARDS, blood transfusions could delay and complicate that
process. Second, there is some indication that transfusions may
increase the rates of CRRT and secondary MODS thus delaying
the recovery of these patients.
PROCESS IMPROVEMENT:
ANEMIA MANAGEMENT
2011-18 PRODUCTIVITY ASSESSMENT IN
MANAGING PRE-OPERATIVE ANEMIA AFTER
IMPLEMENTATION OF A HOSPITAL INFORMATION
SYSTEM BASED ANEMIA MANAGEMENT TOOL
Nelson T., Gross I.
Eastern Main Medical Center, Bangor, ME, United States of
America
Introduction Patient Blood Management Programs (PBMP)
identify, evaluate and manage anemic pre-operative patients. As
part of a development project with Cerner Corporation (Kansas
City, MO), Eastern Maine Medical Center (EMMC) designed
and implemented a computer-based anemia management
solution, designated by Cerner as the Pre-operative Anemia
Management Lighthouse Solution and referred to as the
" Anemia M-Page". A time study was conducted to measure
its impact on anemia management patient volume and the
productivity of the program coordinator in the identifi cation,
enrollment, evaluation and treatment of patients undergoing
elective surgery.
Methods Our pre-operative anemia management program
began in June 2007. Initially the program focused on total joint
arthroplasty and spine fusions. Patients were enrolled by the
surgeon's offi ce.
Beginning the second year, patients were identifi ed from the
electronic surgical scheduling event. Laboratory results from
the electronic medical record (EMR) were reviewed to identify
anemic patients and determine the etiology of the anemia. If no
labs were available, orders were entered into the EMR. Based on
these results, patients were scheduled for treatment if indicated.
In January, 2011 Anemia M-Page was implemented. This
automated enrollment based on the scheduling event in EMMC's
EMR. The solution allows the PBMP to defi ne which patient
procedures are evaluated. Only procedures with an estimated
s9

lood loss greater than 500 mL are included. The types of
procedures screened increased from 3 to 28. Once scheduled,
patients automatically populate the M-Page. The M-Page
"dashboard" is only accessible to PBMP staff and includes
patient name, demographics and any hemoglobin result within
the past 60 days. If no result is found a red exclamation icon
alerts the coordinator to schedule labs.
Patients are organized on the M-Page based on number of
days to procedure using the following tabs: Emergent/Urgent,
4 weeks. The M-Page has a second
view that opens to patient specifi c details about the patient's
labs, and procedure information and includes a link to the
patient's EMR. This detail view has links to documentation
forms, provides a place to print a lab requisition, document
patient education, medications ordered to treat anemia, and
to document outside lab results, automatically populating the
patient list dashboard view. This allows the PBMP team to
organize and make available the most current information.
If the coordinator is not available the Program Medical
Director can view the information and assess patient status at
any time.
Results Time studies were completed during two time
periods; in February 2010 before the M-Page "go-live"
and after "go-live" in June, 2011. Post- implementation the
number of patients enrolled increased from 40 to 96 patients
per month. A time study showed EMMC's PBMP coordinator
was able to increase work productivity by 100%.
Conclusion Development and implementation of a computerized
electronic pre-operative anemia management solution resulted
in a productivity increase of 100% for the pre-operative anemia
management program. This electronic tool has the ability to
increase the number of PBMP patients enrolled without adding
additional staff, ensures no eligible patients are missed and
creates a more effi cient work fl ow.
2011-19 CURRENT USE OF ERYTHROPOIESIS-
STIMULATING AGENTS AT HELEN DEVOS
CHILDREN'S HOSPITAL
Lunger J., Kovey K., Hassan N.
Helen DeVos Children's Hospital, Grand Rapids, MI, United
States of America
Background Critically ill hospitalized patients frequently
develop anemia and subsequently may receive blood
transfusions. Anemia may result from bone marrow suppression
as occurs with chemotherapy, bone marrow inactivation such as
with chronic kidney disease, and blood losses from phlebotomy,
gastrointestinal losses, or procedural losses. Use of hematinics
and erythropoiesis-stimulating agents (ESAs) has increased
at Helen DeVos Children's Hospital (HDVCH) following the
launching of the Blood Management Service.
Aim Due to the cost of ESAs and recent FDA Black Box
Warnings for use, the Pharmacy & Therapeutics Committee
commissioned the investigator to conduct a Medication Use
Evaluation to describe the frequency of use and cost of epoetin
and darbepoetin at HDVCH.
Methods A list of all pediatric inpatients at HDVCH who
received darbepoetin or epoetin between January 2010 and
September 2010 was collected using the Pharmacy Drug
Inquiry application of the Cerner data system. Patient
demographics and hemoglobin values were also collected
using Cerner.
s10
2011 ANNUAL MEETING SABM
ABSTRACTS
Results Epoetin or darbepoetin was administered to 84 of 99
patients (85%) for blood management purposes, with an actual
blood management consult on record for 62 patients (73%).
The remainder of patients (15 of 99) who received ESAs for
renal disease were excluded from analysis. The average patient
age was 5.9±6.5 years (median 2.0 years). 57 patients (68%)
were in the intensive care unit during admission. 72 patients
(86%) received epoetin and 12 patients (14%) received
darbepoetin, with variable dosing frequency. The intravenous
route was used for 52 patients (72%) receiving epoetin.
An average of 4.2±3.9 doses were administered per patient,
with an average of 4.4±3.8 doses for epoetin and 1.8±1.2
doses for darbepoetin. 25 patients (30%) received 1 dose only.
Average cost per patient was approximately $319±398, with
estimated annual costs at HDVCH of $36,000. The average
hemoglobin (Hg) at initiation was 8.5±1.5 g/dL. Blood
transfusions were given to 15 patients (18%) before ESA
initiation and 12 patients (14%) after ESA initiation, with 56
patients (68%) not transfused (see Table I). For patients who
were not transfused, the average change in Hg during therapy
was 1.2±1.4 g/dL (see Figure 1). In 38 patients (45%), there
was no hemoglobin value recorded after ESA initiation. Nine
patients (11%) had Hg >12 g/dL during therapy.
Therapy was appropriately discontinued for all patients with
Hg >12 g/dL, excluding 2 patients with Hg >12 g/dL at
initiation (Jehovah's Witness patient and patient undergoing
major surgery). There is no clear cost advantage with either
agent. Darbepoetin is more expensive, however less frequent
dosing may offset the additional cost.
Table I - Blood Transfusions During ESA Therapy
Hemoglobin at
ESA Initiation
(g/dL) (N=83)
N Percent
Transfused
before ESA
Initiation
Percent
Transfused
after ESA
Initiation
Percent Not
Transfused

2011 ANNUAL MEETING SABM
ABSTRACTS
Conclusions A small number of patients are receiving ESAs
for blood management at a cost of approximately $319±398 per
patient. More effect on hemoglobin was noticed in patients with
lower hemoglobin at ESA initiation, with lower transfusion
rates compared to previously published data. No adverse events
were reported.
Limitations of the Report There was no stratifi cation with
regard to patient diagnosis, patient acuity, ongoing blood losses,
or length of therapy.
2011-20 IMPROVING PATIENT OUTCOMES THROUGH
OPTIMAL BLOOD MANAGEMENT - DEFINING THE
PROBLEM: IATROGENIC BLOOD LOSS
Kooser J., Duncan P., Thorpe E.
University of Kansas Hospital, Kansas City, KS, United States
of America
Purpose The purpose of this evidence-based practice project
was to quantify the volume of patient blood lost due to blood
draws. This information will serve as the background for
developing a procedure/guideline for blood reinfusion to reduce
iatrogenic blood loss.
Methods This project documented lab related blood loss in
two groups of patients where laboratory specimens were drawn
from indwelling lines. Patients from the Surgical Intensive Care
Unit (SICU) the Burn Center, and two acute care units were
included. There were two separate groups for this study. Group
one, the draw and discard group, and group two, the draw
and reinfuse group. Within these groups, there were different
types of access devices, such as arterial lines, PICC lines and
Central lines. The amount of waste and amount needed for each
specimen collection was recorded in both groups. A reinfusion
tool was implemented for group two: a 10 mL syringe for the
closed pressure system or arterial line, and a 3-way stop-cock
for the PICC and central lines. The amount of waste and amount
drawn for each specimen collection was recorded. The amount
of blood wasted pre reinfusion and post reinfusion were then
compared.
Results A total of 240 blood draws were collected. We
collected 120 blood draws from each group, 60 from arterial
lines and 60 from PICC and central lines. Patients from group
one experienced anywhere from 1 to 5 blood draws per day. The
volume of blood wasted ranged from 3 to 14 mls/draw, with
an average waste of 43 mL/day per patient from arterial lines
and 13.85 mL/day from PICC and central lines. Patients from
group two experienced 1 to 4 blood draws per day. The amount
of waste was 0 mls/day from arterial lines and 0 mls/day from
PICC and central lines.
Discussion Because iatrogenic blood loss has been an ongoing
concern to the study at this hospital, it was important to
quantify the scope of the problem. Our fi ndings support that the
incidental blood loss due to discarded blood is noteworthy. This
study lends support to the next phase of this evidence based
project that of implementing new policies and/or products that
reduce or eliminate blood wasted due to laboratory tests.
Conclusion This study supports that in many patients, blood loss from
laboratory draws and discards is clinically signifi cant. Interventions
to reduce or eliminate such blood loss must be developed.
Blood Transfus 2011; 9 Suppl 5
2011-21 FERUMOXYTOL INFUSION IN PEDIATRIC
PATIENTS WITH GASTROINTESTINAL DISORDERS:
1 ST CASE REPORT
Cahill J., Hassan N., Rajasekaran S., Kovey K.
The Pediatric Blood Management Program from Helen DeVos
Children's Hospital, Grand Rapids, MI, United States of
America
Introduction Children with gastrointestinal disorders
frequently suffer from iron defi ciency anemia due to
malnutrition, malabsorption and/or blood losses from the
gut. When enteral iron therapy is ineffective, parenteral iron
therapy becomes the alternative. Ferumoxytol is a new iron
preparation which has recently been FDA approved for use
in adult patients with chronic kidney disease; however no
guidelines exist for the use in pediatrics. This is the fi rst
report of ferumoxytol administration in pediatric patients,
monitoring its safety and effi cacy in the outpatient setting.
Ferumoxytol has been shown to have fewer incidences of
severe allergic reactions and because of the slow iron release,
a larger dose can be given on a single occasion.
Patients and Methods Due to these advantages over other
preparations on the market, it was administered to pediatric
patients with gastrointestinal disorders in the outpatient
setting. Six patients, ranging in age from 6 months to 16
years old, with various gastrointestinal disorders and iron
defi ciency anemia were treated with ferumoxytol. These six
patients had failed enteral iron therapy, and subsequently
were given ferumoxytol dosed in the range of 8-12 mg/kg.
It was administered intravenously over 15-60 minutes, and
monitoring occurred for one hour post infusion. Patients who
had no adverse events were discharged.
Results All patients did well with the infusion, except for
one who developed pruritus; however no interventions
were required (Table I). Iron studies obtained 5-7 days
later showed improvement except for patient #1, who had
signifi cant chronic blood loss (Figure 1).
Conclusion The administration of ferumoxytol to six
pediatric patients at a dose of 8-12 mg/kg, at a rate of 15 or
more minutes was effective and well tolerated except for a
single case of pruritus.
Figure 1
s11

Table I - Dosing of Ferumoxytol
s12
# Age (y) Wt
(kg)
Dx Cause of Anemia Total Dose
(mg)
1 9 29 Short Gut GI blood loss
Malabsorption
2 0.5 4.7 Short Gut Malabsorption PN
dependent
3 13 50 IBD GI blood loss
Malabsorption
4 17 43 Chronic bowel
dysfunction
Malabsorption
TPN dependent
Dose
(mg/kg)
2011 ANNUAL MEETING SABM
# Doses Infusion
Length
(min)
ABSTRACTS
Side
Effects
255 9 3 60 None
350 12 2 60
350 12 1 15
50 11 1 60 min None
510 10.5 1 60 min None
510 10.5 1 15 min None
510 11.8 1 60 min pruritis
5 17 88 IBD GI blood loss
Malabsorption
510 5.8 2 15 min None
6 2 12.8 Mitochondrial
Disorder
PN dependence 120 9.3 1 60 min None
PROCESS IMPROVEMENT:
BLOOD MANAGEMENT EDUCATION
2011-22 INTERNAL CREATION AND IMPLEMENTATION
OF A BLOOD MANAGEMENT PROGRAM
Nguyen H.
Northwest Texas Healthcare System, Amarillo, TX # , United
States of America
Introduction Blood management is recognized as an
important facet of improving patient quality of care and
minimizing health care costs through the encouragement of
effi cient and appropriate use of blood products. Commercial
blood management solutions have been available to medical
facilities for several years. In 2010, Northwest Texas
Healthcare System # , began internally to create and implement
a blood management program.
Method Northwest Texas Healthcare System (NWTHS)
initiated the process by hiring a Transfusion Safety Offi cer
(TSO) to create, implement, and maintain the blood
management program. The TSO performed a 3-month
(June 2010-August 2010) retrospective audit in order to
establish a baseline for transfusion practices at NWTHS.
A committee of physician "Champions" was formed to
approve the implementation strategy devised by the TSO.
The committee appointed members of the medical staff to
a multi-disciplinary Transfusion Standards Committee to
create and support guidelines for transfusion, taking into
account current medical literature to ensure the guidelines
were evidence-based. In general, the guidelines suggest a red cell
transfusion order is appropriate for patients with a pre-transfusion
hemoglobin

2011 ANNUAL MEETING SABM
ABSTRACTS
2011-23 PERIOPERATIVE INTRAVENOUS IRON
HYDROXIDE SUCROSE (VENOFER) OPTIMIZATION
TO ENHANCE ERYTHROPOIESIS
Gagne S., Davis N., Rammler W., Bentley D., Barlow D., Murray G.
Niagara Health System, St Catherines, Ontario, Canada
Andrews et al., identifi ed that total joint arthroplasty patients,
without obvious anemia or iron defi ciency, who started on an
oral iron supplementation plan preoperatively, were protected
from a larger fall in hemoglobin immediately postoperatively,
suggesting that a widespread underlying depletion of iron
stores was present despite normal hemoglobin in many patients.
Finch defi ned a "relative iron defi ciency state", also known as
"functional iron defi ciency", as circumstances in which increased
erythron iron requirements exceed the available supply of iron.
The discovery of the iron regulatory hormone hepcidin further
allows for a better understanding of the therapeutic uses of
oral and intravenous iron. The interplay of short timeline for
assessment and treatment of anemia; presence of functional iron
defi ciency (with or without anemia); emphasis on shorter length
of stay and transfusion avoidance in the perioperative setting,
encourage the addition of intravenous iron to the armamentarium
of surgical treatment. IV iron has been shown to be safe, in fact
standard of care for renal and oncology patients. A literature
review has shown some intravenous iron preparations to be
a safe, effi cacious treatment modality for iron defi ciency in
surgical patients. We describe here an algorithm for the use of
perioperative intravenous iron hydroxide sucrose (Venofer ® )
to correct functional iron defi ciency and protect against ironrestricted
erythropoiesis which we plan to implement in the
Ontario Transfusion Coordinators (ONTraC) program. The
goal is to reduce transfusion rates and enhance "recovery
times postoperatively". Utilizing ONTraC data base, evidence
will subsequently be gathered on the impact of intravenous
iron in decreasing transfusion rates, dosage of erythropoiesis
stimulating agents and length of stay.
2011-24 THE AUTOLOGOUS TRANSFUSION
DATABASE: ENGLEWOOD HOSPITAL AND MEDICAL
CENTER'S RESPONSE TO THE SILENT CALL FOR
STANDARDIZATION OF DATA COLLECTION
Juhl A. (1) , Aregbeyen O. (1) , Naqvi S. (1) , Demir S. (1) , Khan A. (1) ,
Shander A. (1,2)
(1) Englewood Hospital and Medical Center, Englewood, NJ;
(2) Mount Sinai School of Medicine, New York, NY, Unites
States of America
Introduction In 1996, at the onset of the Bloodless Medicine
and Surgery Program at Englewood Hospital and Medical Center
(EHMC), the research department developed an Institutional
Review Board (IRB) approved database to collect patient data
involving the use of autologous transfusion techniques (Cell
Salvage, OrthoPAT ® and Acute Normovolemic Hemodilution
[ANH]). While this data collection helped to meet state
regulatory guidelines and maintain AABB certifi cation of Peri-
Operative Services, it did not meet the need for clinical research.
In 2010, a multi-national, multi-disciplinary team of experts in
Patient Blood Management (PBM) and representatives from the
industry and medical societies convened in Vermont, United
States to address the need for nationwide PBM data registries.
At the same time, it was noted that in Western Australia, where
PBM modalities are implemented as a state-wide standard, data
Blood Transfus 2011; 9 Suppl 5
is consistently monitored for practice improvement and risk
management. Responding to this call, we rebuilt our existing
autologous transfusion database into a large, comprehensive
data collection tool with an expanded capacity for conducting
clinical research while providing more accurate data for Peri-
Operative Services certifi cation.
Methods The original database served as the basis for
developing a new list of fi elds. After revising the IRB protocol
to refl ect the modifi cations and consulting with experts in
PBM and medical research, we created a blueprint for the
new customized database. A database systems expert was
consulted and hired to help design, format and eventually build
the database. Microsoft ® Access software was chosen for its
world-wide availability and ease of use. Within six months, a
prototype was ready. After one month of extensive testing, our
system was fully operational. Given the extensive list of data
fi elds to be populated, various sources were considered. These
included electronically captured and stored patient data as well
as manual input from other sources such as anesthesiology
reports, diagnostic reports and chart review. Hospital-wide
training and education was necessary to ensure standardization
of data entry. Data fl ow processes and system manuals were
created. Teams were also put in place for quality control audits.
Results Currently, data is being compiled and recorded for over
8,000 EHMC surgical patients who have received autologous
transfusion modalities. Data on demographics, diagnoses,
surgical information, blood conservation techniques, transfusion
data, lab fi ndings, morbidities and outcomes are included for
analysis. A variety of reports can be generated for monitoring
and trending blood utilization in patients receiving ANH, Cell
Salvage and/or OrthoPAT ® .
Conclusion National PBM data registries remain a necessary
future goal. Until then, it is critical that hospitals with PBM
programs begin to collate their patient data. These statistics
can also serve as a basis for additional teaching tools to educate
medical staff on the benefi t of PBM modalities. EHMC strives
to meet the expanded PBM data management standards which
will also continue to have a positive impact on the patient
population for whom blood is not an option. We expect this
data to validate that PBM techniques have become a safe and
effective standard of care for not just the "bloodless" patients,
but for all patients undergoing surgery, especially those at risk
for high blood loss and possible transfusion.
PROCESS IMPROVEMENT:
OTHER TECHNOLOGY AND TECHNIQUES
2011-25 BLOOD TRANSFUSION-FREE COMPLEX
CARDIAC REOPERATION IN A JEHOVAH'S WITNESS
CHILD-BY USE OF A MINIMIZED CARDIOPULMONARY
BYPASS CIRCUIT, AND VARIOUS BLOOD
CONSERVATION TECHNIQUES. A CASE REPORT
Lee J.
Sejong General Hospital, South Korea
Cardiac surgery involving cardiopulmonary bypass (CPB) in
patients who are Jehovah's Witnesses, particularly in young
children, presents a challenge to the surgical team. In open heart
surgery in neonates and small children, CPB circuit surface and
the priming volume are relatively large in relation to patient
size and blood volume. Therefore, the use of allogeneic blood
is inevitable to maintain the optimal hematocrit level during
s13

ypass. Strategies to avoid the use of homologous blood product
during cardiac surgery must incorporate miniaturization of CPB
circuit and other bypass techniques in order to avoid problems
with excessive hemodilution. We report a 15.1 kg male child
who underwent successful surgical correction in redo surgery of
complex congenital heart disease. Our strategies included the pre-
s14
2011 ANNUAL MEETING SABM
ABSTRACTS
operative administration of erythropoietin and iron to increase
red blood cell mass; cell salvage; modifi ed ultrafi ltration; and
vacuum-assisted venous drainage to minimize the circuit size
and prime volume.
Key Words Blood transfusion, cardiac surgery, cardiopulmonarybypass,
Jehovah's Witness, pediat ric.
Table I - Comparison of Conventional and Modifi ed Child CPB Systems
Console Conventional Circuit
(Terumo SarnsTM Modifi ed Circuit
9000,
(Performer
Soma technology,USA)
TM CPB
Medtronics, USA)
Oxygenator Didaco D 902 (105 mL) Terumo Capiox RX05(43 mL)
Arterial fi lter Didaco D 736 (40 mL) Dideco D 736 (40 mL)
Arterial tubing size(ID) 1/4 inch 1/4 inch (volume fi lled)
Venous tubing size(ID) 3/8 inch 1/4 inch (volume empty
Position of reservoir Below heart level Same as heart level
Suction & LA, LV Vent tubibg size(ID) 1/4 inch 3/16 inch (volume empty)
Venous drainage method Gravity Vaccum-assist
Maximum fl ow rate 2 L/min(limited by arterial fi lter) 1.5 L/min(limited by oxygenator)
Prime volume, total ≥450 mL ≤200 mL
CPB: cardiopulmonary bypass; ID: internal diameter
LA: left atrium; LV: left ventricle
Figure 1A - The heart-lung machine that is used for minimized
priming volume method. Note the vertical alignment of
pump heads.
2011-26 LEAN TOOLS AND COACHING DRIVE 79%
REDUCTION IN PRETRANSFUSION TESTING TATS
AND 77% REDUCTION IN RBC WASTAGE
Dikeman J., Leonard K., South S.
Ortho Clinical Diagnostics, Scottsdale, AZ, United States of
America
Introduction The goal of lean is to eliminate waste, create
increased process fl ow and provide more value to the end
customer. In transfusion services, the goal of lean fi ts with
patent-centric processes and high-quality outputs. Lean tools
and coaching helped meet the business needs of our highvolume
transfusion service by creating increased process
reliability and capacity, improved resource utilization,
Figure 1B - The heart-lung machine that is used for conventional
cardiopulmonary method. Note the horizontal and
ground based alignment of pump heads.
decreased RBC waste and error potential, and improved
specimen and operator fl ow.
Method Our transfusion service supports a large metropolitan
area facility of 1,300 beds, delivering multi-dimensional care
and related services and dispenses 53,000 blood products
annually. Lean tools were used to assess work processes related
to specimen and order receipt and pretransfusion testing,
redesign work processes and implement improvements to meet
business goals without reconstruction. The main tools were
value added fl ow analysis and defect potential. Work practice
assessment included the people, processes, and physical space.
Rather than using strictly didactic learning and mandating
process changes, we chose focused coaching sessions for the
personnel learning new processes and the middle managers
Blood Transfus 2011; 9 Suppl 5

2011 ANNUAL MEETING SABM
ABSTRACTS
who would be monitoring processes and encouraging adoption
of new ways of thinking. Key personnel were engaged to help
design and implement standardized work areas for specimen
receipt and processing, automated and manual testing, and
specimen storage. One-on-one training and coaching sessions
were done with each technologist, to make sure they were
comfortable with the redesigned work processes and analyzers.
Daily huddles were introduced to enhance communication and
foster teamwork, and assignments were rotated among technical
leaders to monitor and support fl ow.
Results Analyses showed multiple delay points from
specimen receipt to verifi ed results. Baseline condition
included lack of standardization in manual and automated
work processes and work areas along with batch processing
throughout. Multiple improvements were identifi ed. Our
team implemented a specimen processing area and testing
processes and automation that created fl ow and decreased
error potential. Work stations and supply presentation
were standardized and task assignments redesigned. An
improvement summary is shown in the table I and included
a 79% reduction in routine T&S TATs and 94% reduction
in error potential. Rh phenotyping, donor unit confi rmatory
testing, and cord bloods were moved to automation which
reduced the total labor needed for testing by 68%. Other
results included >95% reduction in pretransfusion testing
clerical errors and customer complaints, 20% savings in
physical space, 77% reduction in RBC waste, and >$39,000
reduction in special unit charges due to personnel suggesting
and implementing Rh phenotyping on an analyzer. Because
personnel were involved with every level of the changes,
they felt that their ideas and concerns were being heard and
respected.
Conclusion The application of lean tools provided an effective
way to uncover and implement signifi cant process changes.
Redesigned testing processes allowed for less labor needed to
support testing, which was re-allocated to blood management.
The coaching approach moved our employees from a less
engaged group to a fully engaged team, focused on serving our
patients more effectively and optimizing resources.
Table I - Lean Application Results Summary
Category Baseline 3-Mo.
Post Lean
% Reduction
Routine T&S 5:40:24 1:15:00 79%
Aver. Batch
Size
35-40 9 74%
Process Steps 17 4 76%
Wait Points 8 4 50%
Error Potential 132 7 95%
Testing Labor
Savings
- - 68%
Space Savings - - 20%
Clerical Errors 8-14/mo 95%
Customer
Complaints
18/mo 95%
Savings from - - >$39,000
Special Donor
Unit Orders
annually
Expired RBCs 30/mo

invasive urologic surgeries. We present a single center
comparison of robotic assisted vs. open urologic approaches
among JW patients.
Patients and Methods We retrospectively compared records
of all JW patients who underwent major open versus robotic
urologic operations from 10/2006 through 05/2011. Major
operations were defi ned as any procedure requiring general
anesthesia and an abdominal incision. As such, we excluded
endoscopic and percutaneous renal operations. The robotic
surgery arm included a single surgeon's experience, while
the open surgery arm represents the experience of three open
surgeons. Estimated blood loss (EBL), hospital length of stay
(LOS), body mass index (BMI), operative times (OT) and 90day
complications by Clavien classifi cation 1 were collected
by chart review. Data was analyzed using univariate analyses.
Results Of 172 total JW patients who underwent surgery during
this 5-year period, 46 patients underwent a major urologic
operation per our defi nition. 27 patients had robotic-assisted
and 19 had open procedures (See fi gure 1). The robotic arm
included 19 radical prostatectomies, 4 partial nephrectomies,
2 radical cystectomies with ileal loop diversion (1 was
post-TAH/brachytherapy/pelvic irradiation), 1 pyeloplasty,
and 1 retroperitoneal lymph node dissection. The open arm
included 9 radical nephrectomies, 5 partial nephrectomies,
3 radical prostatectomies, 1 partial cystectomy, and 1
nephroureterectomy, which was started laparoscopically and
converted to open.
Radical
Prostatectomy
Radical
Nephrectomy
Partial
Nephrectomy
s16
Partial
Cystectomy
Nephroureterectomy
N=
3
9
5
2011 ANNUAL MEETING SABM
ABSTRACTS
The BMI and operative time between the two groups was not
signifi cantly different (See fi gure 2). Both LOS and EBL for
the open and robotic groups were found to be signifi cantly
different (p

2011 ANNUAL MEETING SABM
ABSTRACTS
Blood Transfus 2011; 9 Suppl 5
Open Robotic
Sample size 19 27
Mean LOS (days) * 5.9 1.8
Range of LOS 3 to 14 1 to 8
Mean BMI 31.1 30.6
Range of BMI 19.1 to 50 19.7 to 61
Mean EBL (cc) * 384.2 143.3
Range of EBL 75 to 1300 25 to 500
Mean OT (minutes) 174.8 216.2
Range of OT 85 to 380 110 to 600
Figure 2 - Combined Peri-operative Outcomes; *: p

Table #1 - Lower Urinary Tract Procedures
s18
Reference #1
(Fregonesi)
Reference #2
(Nieder)
Reference #3
(Dr Eun)
2011 ANNUAL MEETING SABM
Reference #4
(Dr Eun)
ABSTRACTS
Reference #5
(Dr Eun)
Sample size 25 3 19 1 1
Operation
Mean LOS-days
(range)
Mean BMI
(range)
Mean EBL-cc
(range)
Mean OT-min
(range)
Open Radical
Prostatectomy
3.5
(3-7)
Open Radical
Prostatectomy
N/A
N/A N/A
430
(310-550)
733
(300-1500)
N/A N/A
Robotic Radical
Prostatectomy
1.1
(1-3)
29.3
(24-36)
127
(50-400)
194
(135-289)
Cystoprostatectomy
Robotic
Anterior
Exenteration
7 8
29.9 19.7
400 150
505 600
Cell-Salvaged blood intraop. No Yes No No No
Preoperative recombinant erythropoietin Yes No Yes in 1/19 No No
Reference #1: Fregonesi A., Ciari C., Melotti L. at al. Strategies For Transfusion-free Radical Retropubic Prostatectomy In Jehovah's Witnesses.
Actas Urol. Esp. 2010 May; 34(5): 440-3.
Reference #2: Nieder A.M., Simon M.A., Kim S.S. et al. Intraoperative Cell Salvage During Radical Prostatectomy: A safe Technique for Jehovah'
Witnesses. International Braz J Urol. Sep-Oct 2004; 30(5): 377-9.
Reference #3: Dr. Eun: Robotic Radical Prostatectomy.
Reference #4: Dr. Eun: Robotic Cystoprostatectomy With Ileal Loop Urinary Diversion.
Reference #5: Dr. Eun: Robotic-Assisted Anterior Exenteration With Ileal Loop Urinary Diversion.
Table #2 - Upper Urinary Tract Procedures
Reference #6 Reference #7 Reference #8 Reference #9 Reference #10 Reference #11
(Moskowitz) (Chin) (Yohannes) (Dr Eun) (Dr Eun) (Dr Eun)
Study size (n=) 1
Nephrectomy,
1 1 1 1 4
Operation
vena cava
and atrial
thrombectomy
Lap BL partial
adrenalectomy
Lap partial
nephrectomy
Robotic
RPLND
Robotic
pyeloplasty
Robotic partial
nephrectomy
Age
(range)
47 32 76 28 29
Mean: 58
(39-79)
LOS-days
(range)
7 N/A 4 1 8
Mean: 2.75
(1-7)
BMI
(range)
N/A N/A 29.3 29.9 19.7
Mean: 42
(30-61)
EBL-cc
(range)
N/A N/A 500 100 25
Mean: 168
(50-500)
OT-min
(range)
N/A N/A N/A 263 204
Mean: 141
(110-176)
Cell-Salvaged blood
intraoperatively
Yes N/A N/A No No No
Preoperative recombinant
erythropoietin
N/A N/A N/A No No Yes in 1/4
Reference #6: Moskowitz D.M., Perelman S.I., Cousineau K.M. et al. Multidisciplinary Management of Jehovah's Witnesses Patient For Removal
Of A Renal Cell Carcinoma Extending Into The Right Atrium. Can J Anesth 2002; 49(4): 402-408.
Reference #7: Chin E.H., Baril D.T., Weber K.J., Divino CM. Laparoscopic Cortical-Sparing Adrenalectomy for Bilateral Pheochromocytoma.
Surg Endosc 2008 Sep; 22(9): 2075.
Reference #8: Yohannes P., Rao M., Burjonrappa S. et al. Laparoscopic Nephron-Sparing Surgery in a Jehovah's Witnesess Patient. Journal Of
Endourology 2004 Feb; 18(1): 59-62.
Reference #9: Dr. Eun: Robotic Right Modifi ed Template RPLND For Stage 1 Right Testicular Non-seminomatous germ cell tumor.
Reference #10: Dr. Eun: Robotic Right Pyeloplasty For Right UPJ Obstruction.
Reference #11: Dr. Eun: Robotic Partial Nephrectomy For RCC.
Blood Transfus 2011; 9 Suppl 5

2011 ANNUAL MEETING SABM
ABSTRACTS
PROCESS IMPROVEMENT:
TRANSFUSION
2011-30 REDUCING BLOOD ORDERED TO
BLOOD TRANSFUSED AVERAGE RATIOS IN THE
OPERATING ROOM
Neville T., Kotin A., Hoskins W., McCollum C., Russell E.
Memorial Sloan-Kettering Cancer Center, New York, United
States of America
Introduction The total cost of blood acquisition, preparation,
and administration in the operative suites at Memorial Sloan-
Kettering Cancer Center is not insignifi cant. The night before
surgery, the blood bank prepares blood for transfusion during
the surgical procedure. This blood is prepared based on the
surgeon's request. It was discovered that for high blood use
surgical services, up to ten units of blood were being prepared
for every one unit of blood actually being transfused. This
results in lost productivity for blood bank staff (who prepare
blood for transfusion), increased blood acquisition costs, and
increased risk that unused blood will need to be discarded.
Methods Following a lengthy data collection and review,
we identifi ed blood ordering practices which consistently
appeared excessive. In phase 1, we summarized the data and
presented it to surgical service chiefs asking if there was a
Blood Transfus 2011; 9 Suppl 5
clinical indication for this practice. In most cases, surgeons
were not aware of their individual blood ordering/transfusion
rate. In phase 2, we identifi ed offi ce staff who were ordering
excessive units of blood preoperatively using MSBOS
(Maximum Surgical Blood Ordering Schedule).
If our group was to impact blood ordering practice, we had
to have clear data indicating excessive blood ordering. Due
to FDA imposed restrictions on our clinical blood banking
system, data collection from two separate and distinct systems
(the clinical blood banking system and the OR information
system) was necessary. Painstakingly, data elements were
extracted from each system and combined into a single
document.
Results Through staff education and MSBOS system edits,
from December 2008 to January 2010 we reduced the blood
ordered to blood transfused average ratio from 5:1 to 2:1
resulting in 660 fewer units of blood being unnecessarily
prepared from Q2009 - Q2010.
Conclusions Using a combination of staff education and
clinical information system changes, we were able to
reduce the blood ordered to blood transfused average ratio
with no adverse outcomes or complaints from surgery or
anesthesiology staff. Our data also seems to indicate a lower
actual transfusion rate following our efforts and may provide
the framework for further projects on reducing overall blood
transfusion rates.
Dec-08 Qtr 2009* Qtr 2010** Ordered to Used Ratio
Service OR TX OR TX OR TX 2008 2009 2010
Hepatobiliary 48 4 219 22 139 35 12:1 10:1 4:1
Thoracic 108 11 490 55 107 54 10:1 9:1 2:1
Neuro 111 12 410 50 302 54 9:1 8:1 6:1
Ortho 69 15 251 171 205 101 5:1 2:1 2:1
Gyn 58 16 229 103 91 57 4:1 2:1 2:1
Urology 38 19 176 89 207 63 2:1 2:1 3:1
CRS 10 14 70 40 22 19 1:1 2:1 1:1
GMT 11 4 90 39 101 42 3:1 2:1 2:1
Peds 28 12 84 84 46 61 2:1 1:1 0.7:1
Head & Neck 14 0 49 14 11 4 14:1 4:1 3:1
Total 495 107 2068 667 1231 490 5:1 3:1 2:1
* Period from 11/2008 - 1/2009
** Period from 11/2009 - 1/2010
2011-31 ELECTIVE TOTAL HIP AND KNEE SURGERY
TRANSFUSION PROCESS IMPROVEMENT
Loos K., Snyder M., Fellner A., DeRose K., Robinson J.
Good Samaritan Hospital, Cincinnati, OH, United States of
America
Introduction Blood transfusions should be used to correct an
oxygen-carrying defi ciency in the blood, or to correct chronic
blood conditions, such as sickle cell or aplastic anemia. Often,
this is not the case. At the Good Samaritan Hospital in Cincinnati
(GSH) red blood cells were being used to treat chronic anemia,
which could have been treated with less invasive medications.
Blood management programs promote the optimal use of
multimodal therapies, including medicines and surgical
techniques to prevent and treat anemia, thereby using blood
products only when absolutely necessary. In October 2009
GSH started a program with the goals of (1) appropriately using
blood products, and (2) improving patient outcomes.
Method Hospital wide transfusion data was collected specifi c
to service lines, physicians, and Medicare Services Diagnosis
Related Groups (MS-DRGs). Orthopedic surgeries constituted
three of the 15 MS-DRGs highest in the use of packed red
blood cells. Analysis of Peer Resource Consumption Analysis-
Population Based (PRCA) data revealed that among orthopedic
surgeons there was a wide range of practice variation, with
physician-specifi c transfusion rates varying from 5 to 80%.
s19

Overall transfusion rates in total joint (i.e., knee and hip)
surgeries were 22 to 58%. This comparison data was blinded as
to specifi c surgeon and was presented at the orthopedic section
meeting, following which the orthopedics department decided to
change practice behaviors. A small focus group was formed to
look at options to decrease the use of packed red blood cells and
develop an evidence based approach to best practice guidelines
for elective orthopedic surgeries. The project began in June of
2010. This task force developed a multimodal approach that
included: (1) decreased drain use, (2) reinfusion systems use,
(3) perioperative bipolar use, (4) revised transfusion triggers
(7 gm HgB/21 HCT), and (5) preoperative Tranexamic acid
(15mg/kg IV, 15 minutes before incision). Transfusion data
was delivered at the monthly section meetings. Physicians were
engaged and buy-in was strong. Education of surgeons and
anesthesia began, and order sets were revamped incorporating
new medical therapies.
s20
2011 ANNUAL MEETING SABM
ABSTRACTS
Results After one year, overall transfusions of red blood cells
have decreased by over 50% to a rate of 4 to 7% in elective
total joint procedures. In addition the donation and use of
autologous blood has decreased, and average units of blood
transfused per event has also decreased. These practices have
led to a decreased length of stay of one (1) day on average,
and no adverse patient outcomes have been observed. In
addition the hospital has saved on average $5,700 per month
purchasing blood products, achieved Orthopedic Center of
Excellence status and some of the practice guidelines are
now being evaluated and used by cardiothoracic surgery after
witnessing the success of the orthopedic program.
Conclusion Blood management at GSH has made considerable
inroads in the orthopedic arena; they are no longer on the list
of top 15 MS-DRGs using blood. Other services that now top
the list are to become the next focus for blood management
at GSH.
Blood Transfus 2011; 9 Suppl 5