Feature
Targeting Anemia, Improving Outcomes By Ratna Swaminathan
A paradigm shift is occurring within Duke. Anesthesiologists here are redefining their role in perioperative medicine by proactively identifying risks, modifying them and improving outcomes after surgery. In the post-healthcare reform environment that is focused on the cost-effective improvement in patient outcomes, Duke anesthesiologists are enhancing care delivery in a financially responsible manner. This time, they’re taking on anemia. It’s a global health problem that afflicts populations indiscriminately, both in the developed and developing nations. Anemia is a well-known risk factor for patients undergoing surgery. In fact, a 2002 Veterans Affairs study estimates that up to one-third of surgical patients have anemia. “Complications of anemia in surgical patients primarily relate to the risks of blood transfusion, for which they are at higher risk than non-anemic patients. These risks include lung injury, renal failure, hemolysis, and transfusion reaction, as well as mortality,” according to former Assistant Professor, Jason Guercio, MD, MBA. On September 24, 2014, the Duke Pre-operative Anemia Clinic (PAC) opened its doors to patients with chronic anemia who are at an increased risk for blood transfusion and adverse outcomes when undergoing surgery. The PAC is a multidisciplinary anemia management program set up and operated by the Duke Department of Anesthesiology’s Perioperative Enhancement Team (POET). Nurturing the project since its conception, Assistant Professor, Thomas J. Hopkins, MD, reflects on the vision of the PAC. “The concept is to do everything that you can to improve patient outcomes and reduce costs, essentially to provide cost-effective care for patients in a way that 22
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enhances their outcomes perioperatively.” “The PAC is unique,” adds Duke Anesthesiology Executive Vice Chairman, Solomon Aronson, MD. It is an effort to identify anemia before surgery and treat it so that it no longer poses a risk to the patient – an innovative upstream solution to a serious downstream problem. The clinic helps identify patients at high risk based on their preoperative screening and enables better blood management care during surgery. It also allows the team to better understand patients from a population health standpoint. Dr. Aronson adds, “What we implemented is a low risk, low cost point of care test (POCT) – a screening device for patients who are designated or likely to be designated as surgical candidates.” According to Dr. Guercio, a POCT called Hemocue is used to identify anemic patients in the Duke Orthopedic Clinic. Currently, patients undergoing elective total joint surgery of the hip and knee, as well as those in the perinatal clinic, are being tested. Assistant Professor of Obstetrics and Gynecology, Andra James, MD, MPH, recommends treating moderate to severe anemia in pregnant patients before surgery. Citing large studies, she adds that anemia increases both the risk for postpartum hemorrhage and transfusion, while adversely affecting both length of stay in the hospital and maternal outcomes. “Some women fail oral therapy, and intravenous iron is an essential alternative to transfusion. We are very grateful
that the PAC has expanded services to women who are approaching delivery.” Pregnant patients at high risk for cesarean section are routinely screened for anemia during their 28 week mark at the prenatal clinic. Out of the 1,000–1,250 patients seen here every month, approximately 25 percent are new pregnant patients and are screened for anemia. If they are found to be anemic, they are referred to the Center for Blood Conservation (CBC), where their tests are interpreted. Aime Grimsely, nurse practitioner and program manager for the CBC, evaluates and speaks with patients utilizing the clinic workspace of the Pre-Anesthesia Testing Clinic (PAT). If appropriate, she schedules them for treatment in the Infusion Center to correct their anemia prior to surgery. “The PAC is an outgrowth of the CBC,” informs Nicole R. Guinn, MD, Medical Director of the CBC. The original purpose of the CBC was to manage and treat pa-
Natisha Wiley, a patient with a history of three C-sections, had her fourth C-section on March 12, 2015. She was referred to the Pre-op Anemia Clinic with hemoglobin of 8.4. After treatment her hemoglobin was 11.1. Natisha delivered her newborn baby, Ayden Noel, without blood transfusion.
DUKE ANESTHESIOLOGY
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9/21/15 11:00 AM