Service: Evidence Based, Multidisciplinary Approach Drives Results
73% Reduction in Blood Transfusions, 22% Decrease in Length of Stay, 186% Improvement in Discharge to Home
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.