Ser­vice: Ev­i­dence Based, Mul­ti­dis­ci­plinary Ap­proach Drives Re­sults

73% Re­duc­tion in Blood Trans­fu­sions, 22% De­crease in Length of Stay, 186% Im­prove­ment in Dis­charge to Home

Modern Healthcare - - THE WEEK IN HEALTHCARE -

Back­ground & Ra­tio­nale

Blood trans­fu­sions (expected or un­ex­pected) take place in ap­prox­i­mately two-thirds of pa­tients un­der­go­ing joint arthro­plasty, and are as­so­ci­ated with risks and sub­stan­tial costs of main­tain­ing a safe and ad­e­quate blood sup­ply. 1 Eco­nomic re­search has doc­u­mented pa­tients un­der­go­ing joint surgery who ex­pe­ri­ence com­pli­ca­tions re­lated to bleed­ing and/or trans­fu­sion of blood prod­ucts ex­pe­ri­ence in­creased length of stay (LOS - 4.9 days vs. 3.6 days) and in­creased di­rect costs ($18,972 vs. $14,966). 2 Ev­i­dence-based rec­om­men­da­tions and al­go­rithms have been pub­lished to help op­ti­mize in­tra­op­er­a­tive bleed­ing man­age­ment, fo­cus­ing on he­mo­glo­bin level op­ti­miza­tion, ap­pro­pri­ate use of cell sal­vage, ef­fec­tive use of phar­ma­co­logic in­ter­ven­tions, and re­duc­tion of trans­fu­sion thresh­olds when in­di­cated. 3 In 2010, the Joint Surgery In­sti­tute at Som­er­set Med­i­cal Cen­ter, lo­cated in Somerville, NJ, started work­ing with Mar­shall | Steele and adopted an ev­i­dence based ap­proach to im­ple­ment­ing best prac­tices in blood trans­fu­sion man­age­ment within their fa­cil­ity. The med­i­cal cen­ter part­nered with qual­ity im­prove­ment (QI) pro­fes­sion­als to en­sure best prac­tices were im­ple­mented us­ing a mul­ti­dis­ci­plinary col­lab­o­ra­tive team model to form a Des­ti­na­tion Cen­ter of Su­pe­rior Per­for­mance®.


AS­SESS — In col­lab­o­ra­tion with a QI Pro­fes­sional Team, the med­i­cal cen­ter es­tab­lished a one-year base­line of pa­tient out­comes and met­rics as­so­ci­ated with the joint surgery pro­gram uti­liz­ing a com­pre­hen­sive pro­gram that tracked Hospi­tal Re­ported Out­comes and Pa­tient Re­ported Out­comes.

AR­CHI­TECT — A mul­ti­dis­ci­plinary team was as­sem­bled over the course of six months, in­clud­ing a joint co­or­di­na­tor, nurs­ing di­rec­tors and clin­i­cal man­agers, mem­bers of phys­i­cal and oc­cu­pa­tional ther­apy, ex­ec­u­tive and physi­cian mem­bers of the C-suite, and mar­ket­ing pro­fes­sion­als. This team be­came the per­for­mance im­prove­ment team, who ini­tially met on a weekly ba­sis with the QI pro­fes­sion­als, and de­vel­oped a monthly/quar­terly meet­ing sched­ule to en­sure im­ple­men­ta­tion of on­go­ing QI method­ol­ogy.

AS­SEM­BLE — Af­ter con­duct­ing a thor­ough re­view of their base­line pro­gram met­rics, and an ev­i­dence-based as­sess­ment of best prac­tices, the mul­ti­dis­ci­plinary team worked with their QI part­ners to de­velop a mul­ti­fac­eted in­ter­ven­tion and set ap­pro­pri­ate goals and ob­jec­tives to en­sure best prac­tices were in­cor­po­rated into fa­cil­ity pol­icy. A com­pre­hen­sive ed­u­ca­tional ap­proach was im­ple­mented to en­sure all team mem­bers, in­clud­ing pri­mary care physi­cians and sur­geons, were ed­u­cated on a new blood con­ser­va­tion al­go­rithm and other ev­i­dence-based in­ter­ven­tions im­pact­ing pre- and pe­ri­op­er­a­tive pro­cesses. A de­tailed QI project plan was im­ple­mented us­ing val­i­dated method­ol­ogy to en­sure goals and ob­jec­tives could be achieved.

AS­SURE — A key as­pect to the suc­cess of this ev­i­dence­based process im­prove­ment in­ter­ven­tion was en­sur­ing the mul­ti­dis­ci­plinary team “buy-in” to ev­i­dence-based changes. Us­ing change man­age­ment strate­gies and on­go­ing col­lab­o­ra­tive com­mu­ni­ca­tions, the process im­prove­ment team and QI pro­fes­sion­als were able to en­sure a 100% buy-in by sur­geons, core staff, and all team mem­bers. The mul­ti­dis­ci­plinary team con­tin­ues to mea­sure out­comes, pa­tient ex­pe­ri­ence, and work with the per­for­mance im­prove­ment team to pro­mote long-term suc­cess.


The ev­i­dence-based QI project was suc­cess­ful, and within two years, the Joint Surgery In­sti­tute at Som­er­set Med­i­cal Cen­ter im­ple­mented a dy­namic change re­sult­ing in re­ceipt of the Joint Com­mis­sion’s Gold Seal of Ap­proval for to­tal hip and to­tal knee re­place­ment surgery. There was a 73% re­duc­tion in blood trans­fu­sion from the his­tor­i­cal base­line to the end of first quar­ter 2012 and a 186% in­crease in pa­tients dis­charged to home/health. In ad­di­tion, length of stay was re­duced from a base­line of 3.85 days to 3.15 days.


1. Sharma R, Far­rokhyar F, McKnight LL, Bhan­dari M, Pool­man RW, Adili A. Qual­ity of as­sess­ment of ran­dom­ized con­trolled tri­als in blood con­ser­va­tion af­ter joint arthro­plasty. J Arthro­plasty. 2011;26(6):909-13.

2. Stokes ME, Ye X, Shah M, Mer­caldi K, Reynolds MW, Rup­now MF, Ham­mond J. Im­pact of bleed­ing-re­lated com­pli­ca­tions and/or blood prod­uct trans­fu­sions on hospi­tal costs in in­pa­tient sur­gi­cal pa­tients. BMC Health Serv Res. 2011;11:135.

3. Barr PJ, Bailie KE. Trans­fu­sion thresh­olds in FO­CUS. N Engl J Med. 2012;366(11):1065.

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