Sunnybrook’s Schulich Heart Centre has developed a successful multidisciplinary strategy for greatly reducing the need for blood transfusions in primary elective coronary artery bypass grafting, commonly known as heart bypass surgery that is planned in advance.
“We took it upon ourselves to create a new environment where transfusions would be something that would be a rarity versus something common,” says Dr. Gideon Cohen, cardiac surgeon, Schulich Heart Centre. “By improving communication among the team and developing strict guidelines as to when patients should be transfused, we have seen an incredible improvement in lowering our transfusion rates for heart bypass surgery.”
The centre, together with Sunnybrook’s Blood Conservation Clinic, has closely followed the provincial transfusion benchmarks for elective heart bypass surgery. In recently released rates from the Ontario Nurse Transfusion Coordinators (ONTraC) Program, the Schulich Heart Centre has improved greatly, showing the lowest provincial transfusion rate for this group, with data drawn from 60 consecutive patients in 2011. Sunnybrook has been a participant in the highly successful ONTraC blood conservation program funded by the Ontario Ministry of Health and Long Term Care since its inception in 2002 and currently has one full-time and one part-time blood conservation nurse dedicated to this initiative.
Patients are assessed before surgery by the Blood Conservation Clinic to determine their hemoglobin level, after which an individualized plan is developed for patients with low hemoglobins. Optimization strategies include having patients increase dietary iron, take iron supplementation weeks before surgery or receive medications to treat anemia.
“Blood is a precious and limited resource,” explains Dr. Yulia Lin, Transfusion Medicine Specialist at Sunnybrook. “We know that there are risks, both infectious and non-infectious, with transfusions. Enhancing pre-operative blood conservation strategies for patients before their heart bypass surgery really decreases the need for transfusions.”
The multidisciplinary team, which includes anaesthesiologists, nurse practitioners, surgeons, perfusionists and staff in the Cardiovascular Intensive Care Unit (CVICU) and D3 Inpatient Unit, also began to look at techniques within the operating room and catheterization labs.
“We are meticulous in the operating room to ensure that there is considerably less bleeding. We spend extra time with each case to ensure that patients are hemostatic,” explains Dr. Gideon Cohen, adding that Sunnybrook’s “take back” rate in which patients are returned to the operating room for re-exploration related to bleeding is the lowest in the city.
Sunnybrook’s perfusionists, who operate the heart-lung machine during heart bypass surgery, are an integral part of the team. Perfusionists have a good system of retrieving all the blood within the pump circuit and concentrating the blood for return to the patient, with the goal of decreasing the need for a blood transfusion, improving patient safety and enhancing the outcomes of cardiac surgery.
“This was truly a culture shift where everyone came together to work towards decreasing the amount of bleeding and the need for transfusions, which is ultimately the best thing for our patients,” says Dr. Cohen.