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SABM 2019 Newsletter Publication Schedule
March | July | November
Carolyn Burns, MD Editor
Tiffany Hall, RN Associate Editor
Sherri Ozawa, RN Kevin Wright
Contributors for This Issue
Allison Jones, PhD, RN
Becky Rock, RN
James Brown, MHA, CCP, LP
Seth Perelman, MD, FASA
Keck PBM Steering Committee
Larry Burns, FACHE
Tamara Glover, MSc, CPHQ (on behalf of WA State Hospital Association)
350 Engle Street Englewood, NJ 07631 USA Phone: (928) 551-6400 Fax: (877) 944-2272 EMAIL:[email protected]
An Interview with SABM President - Pierre Tibi, MD
By Larry Burns, FACHE and SABM Advisory Director
Burns: My name is Larry Burns and I’m one of SABM’s new Advisory Directors. I’m here today to interview SABM President, Dr. Pierre Tibi. I’ve had the pleasure of knowing Dr. Tibi for the past 10 years. He introduced me to the concept of Patient Blood Management (PBM). As an administrator, you don’t often have something presented to you that improves patient safety, clinical outcomes, quality of care, and also saves money. Yet, that’s exactly what a PBM program does. It’s now been 5 years since we began the PBM Program at Yavapai Regional Medical Center in Prescott, Arizona. Dr. Tibi, what prompted your interest in PBM?
Tibi: Thank you, Larry. Basically, after my residency, when I started in private practice in Phoenix, my cases were few and far between. I was approached by a patient seeking “no blood” surgical care. He needed open heart surgery, he had consulted with several heart surgeons who had declined to operate on him simply because he refused to have blood transfusions. I agreed to perform his operation. It was not all that altruistic because I basically needed the work. I needed to figure out what I could do to increase the safety on a patient that refuses blood where normally 60-70% of patients who underwent heart surgery at the time were getting blood or blood products.
I thought about how to change the risk of requiring a unit of blood for patients undergoing cardiac surgery, some of these techniques we still use today. The most fundamental is just being a careful surgeon and very meticulous about any blood lost during surgery. Nevertheless, I operated on the patient and the patient did well. From that time forward, more patients were coming to me asking me to provide what they called “bloodless” heart surgery. Right about that time a fair amount of evidence was coming out that blood transfusions, contrary to popular belief, could be harmful to patients if it's not absolutely needed. This evidence prompted myself and the director of a hospital program in Phoenix, Richard Melseth, in 2003, to look at our results on hundreds of patients who had blood transfusions and those who did not. Our results mirrored the research - patients who were not receiving blood we're actually doing better than the patients who were receiving blood. It prompted us to ask the question, “why don't we apply this approach to everyone?” Our bloodless approach then expanded to applying PBM principles and techniques to all patients. Over the years that ensued, more and more research showed that avoidance of transfusion – especially when it's not absolutely necessary – correlates with decreased morbidity, decreased mortality and cost savings.
Burns: At Yavapai Regional Medical Center we were able to benefit from your early exploration, Dr. Tibi. We’re at over 2,000 open hearts right now. You might not expect open heart to be where you start a PBM Program. However, your leadership helped us implement PBM principles from open heart to orthopedic to general surgery. Can you talk about what your colleagues thought of PBM when it was introduced to them?
Tibi: By the time I arrived at YRMC, I was well on my way in my interest in PBM and using these skills routinely. Funny fact, I understand that the blood bank in Prescott was very concerned that we were going to start open heart surgery at YRMC because that would significantly increase the amount of blood stored and used. I was told that they had bought an extra refrigerator. We got here and after the first year I think we used 47 units of blood for the entire year which was on the order of 1% to 3% of the blood utilization for the hospital. Everyone was surprised that you could do heart surgery with minimal use of blood transfusion. The hospital administration then talked with me about applying PBM principles to many other areas or all areas of medicine. Blood transfusions were to be used in a much more stringent fashion, only where truly indicated.
We set up a PBM Program with Dale Black, also a SABM member, as the Director. We spoke with the different specialties about PBM and how the paradigm in regards to transfusions for treating patients had shifted. We backed that up with tremendous amounts of clinical data in research and we basically had to sell it. We sold it through education, we sold it through creating awareness not only to physicians but also the nurses and others that work in the hospital, as well as the community. This work continues to this day; every year we have a PBM event for the public where hundreds of patients attend. We stream it live where physicians and nurses can talk about their PBM experience. Patients who have directly benefited from the PBM Program speak. It takes a lot of work.
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The bottom line is that the concept is simple, but putting PBM into action is very hard because it involves so many people involved with the care of a patient both in and outside of the hospital. PBM is patient-centered, PBM is cross-disciplinary, PBM is evidence-based.
Burns: Early on we were very successful from a surgical perspective. One of the keysto getting things beyond the OR was the formation of the PBM Committee. It was a committee of clinical staff focused on data collection. If the SABM Executive Guide (released in 2015) had been available at the time it would have made things a lot easier.
Tibi: I agree. The PBM Director, Dale, and that team, over the last 5 years have collected an extremely large amount of data including every unit that’s been utilized: blood, platelets and FFP. At a recent meeting of American College of Healthcare Executives (ACHE) we presented data that shows how we have saved millions of dollars and improved patient care by instituting PBM.
Burns: Looking back on the decision, it was difficult to step into a new arena, but it was one of the best things the hospital had done in a long time; that decision impacted patient safety, improved quality, and led to cost savings on top of that. Was there any pushback?
Tibi: It wasn’t pushback, it was simply a failure to understand the potential positive impact. It wasn’t that we needed to transfuse patients. The PBM concept is easy, but carrying it out is difficult. Behavioral change is not easy.
Burns: Steady progression came about by providing evidence – article after article, journal after journal – that supported the practice. It was hard to ignore. The PBM committee continued to provide the data, outcomes and research. More and more people started paying attention and the numbers kept telling good stories.
Back then we never talked about the cost savings. The focus was on good care, outcomes and being evidence-based practitioners. In the end, however, we saved a ton of money and that makes administrators happy.
Tibi: There are very few other things that do that.
Burns: Moving on, can you tell me about your first year as president of SABM?
Tibi: It’s going very well. SABM had one of its most successful Annual Meetings, if not THE most successful, in New York last year. SABM now has a section in the peer-reviewed Anesthesia and Analgesia (A&A) journal. We have multiple growing associations with very large groups such as Society of Thoracic Surgeons (STS). SABM clinical guidelines will be published this coming year by STS, the Society of Cardiovascular Anesthesiologists (SCA), and hopefully A&A. We have a strong membership with committed members who take the time, with zero compensation, to develop SABM and the realm of PBM. We’ve had timely help with the executive directorship of Ardent and Richard Melseth.
I believe that SABM is doing well. My first year was relatively easy due to all the help in getting the message out and the message being accepted by other societies. This includes Europe with the Network for the Advancement of Patient Blood Management, Haemostatsis and Thrombosis (NATA) and other countries such as Asia, including China and Korea.
While PBM is a movement, SABM’s strategy is to advance PBM as a world-wide standard of care. This is accomplished by supporting research, education, quality and safety metrics—and achieving this through strategic partnerships. I believe SABM is at the forefront and tracking well with this strategy. So yes, my first year as president has gone very smoothly.
Burns: My first experience of the SABM Annual Meeting was last September. It was evident that PBM is an international movement! It was exciting to hear societies in other countries addressing similar problems and issues and presenting alternatives that were new to us. Bringing people together from all over the world is significant. What was your biggest surprise?
Tibi: My biggest surprise was the support and warm collegial approach that members of SABM all around the world share. I was surprised to see so many people who are involved in PBM, and when at the Annual Meeting the feeling is like brethren or crusaders for a common cause. That kind of feeling was really good. As SABM President, I was lucky enough to be in a place where those statements were being made to SABM and I accepted on behalf of SABM.
Burns: I would echo that comment. At that Annual Meeting I spoke with program directors, coordinators, nurses, surgeons, etc. Everyone had a passion for SABM’s mission and the excitement was clearly evident. My hope going forward is to have more administrators involved in these programs – it’s great medicine, it’s good for the community and for the hospital. What’s your vision for SABM?
Tibi: We’re on the verge of exciting things in the progression of PBM both nationally and internationally. My hope is to continue with SABM’s vision to educate the country and the world about PBM. We are making progress by connecting with other countries and their interests in PBM, with larger societies such as STS, the American Hospital Association (AHA), ACHE and others.
I’m hoping that our message will impact government leadership and regulatory authorities to bring PBM as, not state-of-the-art, but standard practice throughout the country.
Burns: PBM is always a good practice. In addition to better outcomes, it also demonstrates respect for a scarce resource. There are always blood shortages. If you use blood and blood products appropriately, you are being a good steward of a scarce resource. We are not being wasteful or over-utilizing a scarce resource.
Consider submitting your future manuscripts in PBM for peer review and publication in this new section. The success of this endeavor will depend on the provision of material to make it lively and attractive to our colleagues and other professionals in the field.
