EDUCATIONAL WEBINAR: Evidence-Based Strategy in the Prevention of Complications due to Retained Blood

An Educational Webinar with Presenters: Marc Gillinov, MD, Marc Gerdisch, MD, and Alyson Mehringer, RN discussing the basic principles of Chest Tube Management, the results of a 1 year quality improvement study and the operational perspective from the ICU Nursing Staff.



Improving Your Cardiac Program’s Bottom Line: Six Simple Steps to Recoup Lost RBS Costs After Heart Surgery

shutterstock_227454934Bleeding is one of the most common and expensive complications after heart surgery. When a patient hemorrhages not only does it impact patient clinical outcomes, the hospital hemorrhages money in un-recouped costs to manage the ensuing complications. A big driver of these costs is Retained Blood Syndrome (RBS).

Blood is evacuated by drainage systems in the early hours after surgery until the bleeding stops. RBS occurs when the blood evacuation is inadequate at evacuating shed blood.  A common cause of this is chest tube clogging which occurs when thrombus obstructs the inside of the drainage catheters placed around the heart and lungs in the early hours after heart surgery.

The following are six easy steps to help recoup costs and reduce RBS related complications after heart surgery.

  1. Understand which patients are at greatest risk of Retained Blood Syndrome (RBS)

Postoperative bleeding increases the risk for retained post-surgical blood.1 When chest tubes clog in the early postoperative period, evacuation capacity is impaired and blood and clot can be retained in the pleural and pericardial spaces. In a 2013 clinical study, Karimov and colleagues found that patients with greater risk for bleeding also had a significantly higher incidence of chest tube clogging and were significantly associated with postoperative complications like atrial fibrillation, renal failure and stroke.2 Many factors increase the risk for postoperative bleeding, including urgent and emergent procedures, combined procedures, redo operations, and patients on antiplatelet or anticoagulant therapies.3

  1. Know your institutional RBS incidence

Postoperative complications associated with chest tube clogging and RBS impact your bottom line and may impact readmissions. Data managers can readily assess your institutional incidence of RBS after heart surgery at your facility by searching existing database elements for tamponade, hemothorax, pleural effusions, and pericardial effusions. In a national ICD-9 analysis of adult heart surgery patients in 2010, 17% of were found to have additional codes indicating patients required additional interventions due to RBS.4What is the incidence at your institution?

  1. Understand the cost of RBS at your institution

Patients with RBS have longer lengths of stay, doubled mortality rates, and a 55% increase in total cost of care.4 That translates to an extra $28,814 per patient with RBS.4 For most programs, this can result in millions of dollars of lost revenue and significantly strains the financial health of the institution. Understanding this source of healthcare dollar loss can help gain consensus to take remedial actions.

  1. Develop and implement a quality improvement program that institutes proven protocols to maintain chest tube patency and reduce RBS

Many institutions don’t have formal policies with regard to managing chest tube patency.5 Others have very basic guidelines. Often, these guidelines prohibit techniques like chest tube stripping, and require periodic monitoring of chest tube output. The only proven method to improve early postoperative drainage, however, is proactive clearance of chest tubes using PleuraFlow® Active Clearance Technology®.6,7,9,10 Proactively maintaining chest tube patency significantly decreases the volume of blood and clot retained in the thorax,6,7,10 and is clinically efficient and effective.8,9,10 Doing this as part of a continuous quality improvement program allows all the key stakeholders to have input, and to adjust real-time to optimize success in your program.

  1.  Verify active clearance protocol compliance

Protocols are only effective if they are followed. Periodic compliance verification is an excellent way to ensure that the instituted protocols are being followed. If protocols are not being followed, this is an opportunity for further education or to refine the protocols to fit the needs of your institution.

  1.  Measure your success clinically and financially

Reducing the incidence of RBS and chest tube clogging can significantly impact patient outcomes and cost of care.9,10 By measuring the baseline incidence of RBS at your institution, you can measure the clinical and financial success of proactive chest tube management protocols after a period of use. Typically, even small reductions in RBS justify any additional costs associated with the program.

Taking steps to reduce RBS is now easier than ever. ClearFlow’s Continuous Quality Improvement (CQI) Program offers a simple stepwise approach to measure outcomes after implementing ICU protocols to address this common and expensive complex of complications. Call us and we can help you make it happen.

  1. Dixon, B., Santamaria, J.D., Reid, D., Collins, M., Rechnitzer, T., Newcomb, A.E., Nixon, I., Yii, M., Rosalion, A., and Campbell, D.J. 2012. The association of blood transfusion with mortality after cardiac surgery: cause or confounding? Transfusion.
  2. Karimov JH, Gillinov A M, Schenck L, Cook M, Kosty Sweeney D, Boyle EM, Fukamachi K. Incidence of chest tube clogging after cardiac surgery: a single-centre prospective observational study. Eur J Cardiothorac Surj 2013; 1-8.
  3. Christensen, M.C., Dziewior, F., Kempel, A., and von Heymann, C. 2012. Increased chest tube drainage is independently associated with adverse outcome after cardiac surgery. J Cardiothorac Vasc Anesth 26:46-51.
  4. Based on over 313,000 US adult heart surgery patients.  Data extracted using  ICD-9 codes from  the 2010 Nationwide Inpatient Sample (NIS), from the DHHS Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP).
  5. Shalli S, Saeed D, Fukamachi K, Gillinov AM, Cohn WE, Perrault LP et al. Chest tube selection in cardiac and thoracic surgery: a survey of chest tube-related complications and their management. J Card Surg 2009;24: 503–9.
  6. Shiose, A.; Takaseya, T.; Fumoto, H.; Arakawa, Y.; Horai, T.; Boyle, E. M.; Gillinov, A. M.; Fukamachi, K. “Improved drainage with active chest tube clearance.” Interactive CardioVascular and Thoracic Surgery 10 (5): 685–688.
  7. Arakawa, Yoko; Shiose, Akira; Takaseya, Tohru; Fumoto, Hideyuki; Kim, Hyun-Il; Boyle, Edward M.; Gillinov, A. Marc; Fukamachi, Kiyotaka. “Superior Chest Drainage With an Active Tube Clearance System: Evaluation of a Downsized Chest Tube.” The Annals of Thoracic Surgery 91 (2): 580–583.
  8. Perrault, Louis, Michel Pellerin, Michel Carrier, Raymond Cartier, Denis Bouchard, Philippe Demers, Edward M. Boyle. The PleuraFlow Active Chest Tube Clearance System: Initial Clinical Experience in Adult Cardiac Surgery. Innovations. 2012;7:354-358.
  9. Sirch J., Ledwon M., Puski T., et al. Active Clearance of Chest Drainage Catheters Reduces Retained Blood.  2015.  J Thorac Cardiovasc Surg.
  10. Boyle EM, Gillinov AM, Cohn WE, Ley SJ, Fischlein T, Perrault LP.  Retained Blood Syndrome After Cardiac Surgery:  A new look at an old problem.  Innovations in cardiovascular and thoracic surgery. September/October 2015; 10 (5): 296-303.