In this "Chat with the Chair" podcast, William Morice, II, M.D., Ph.D., Chair of the Department of Laboratory Medicine and Pathology (DLMP) at Mayo Clinic in Rochester, Minnesota, and President of Mayo Medical Laboratories, sits down with Daryl Kor, M.D., Medical Director of Patient Blood Management and Consultant in the Department of Anesthesiology at Mayo Clinic in Rochester. The two discuss CareSelect Blood, a patient blood-management solution that improves patient blood health, guides health care providers on the proper utilization of blood products, and reduces the overall cost of care. Connect with Dr. Morice on Twitter @moricemdphd to let him know what you would like to hear next.
William Morice, II, M.D., Ph.D.: Hi, Everybody. This is Dr. Morice, your Department Chair for Laboratory Medicine and Pathology here at Mayo Clinic, as well as the President of Mayo Medical Labs, coming at you with another “Chat with the Chair” podcast. It is my distinct pleasure today to be joined by my colleague from Mayo's Department of Anesthesia, Daryl Kor. Dr. Kor, welcome.
Daryl Kor, M.D.: Thank you very much, Bill. I appreciate it.
WM: It’s great to have you here today because the work that you do is so important for our patients. Number one, it really represents the whole team-based model of care that we have at Mayo Clinic with me here talking to you, an anesthesiologist, not a laboratorian. And yet, we work together on really important patient problems. Number two, to talk about something that I think is a really important extension of Mayo Clinic care that you have been a big part of, and I’d just like to talk to you about that today a little bit.
DK: That sounds great. Thank you for the opportunity to be here with you today.
BM: My pleasure, absolutely. We’re here to talk about patient blood management. Could you just kind of describe what that is and why it’s important?
DK: So, first, thank you again very much for the opportunity to spend a little time with you, and I couldn’t agree more that really, to be effective in patient blood management, it requires a multidisciplinary effort. So, it’s a great opportunity for us to sit down as anesthesiologists and lab medicine professionals to have a discussion about patient blood management. Really, historically, patient blood management focused on three pillars, which were largely relating to: 1. Optimizing patients’ hemoglobin status before a surgical procedure, 2. Minimizing the blood loss that can sometimes occur during a surgical procedure or throughout the course of a surgical encounter, and 3. Optimizing physiologic reserve to anemia so that the patients can tolerate whatever degree of anemia they might experience. It’s transitioned a fair amount from those early days, in my view, really toward the concept of total blood health, which is not just focused on anemia management and the management of red blood cell transfusions, for example, but really all aspects of hematologic status for patients who are going through a surgical procedure and increasingly for patients just in general who come in contact with the health care setting. So, it’s not just related to anemia management, but how do we optimize coagulation status? And platelet function and status? We want to ultimately provide the best outcomes that we can for our patients.
BM: Just wondering if you could speak a little bit to the importance of patient blood management. This is a fascinating issue because it’s important for the individual patients, but then knowing the challenges with blood supply in this country and the impacts of transfusion on patients and kind of the impact on the health care system in a larger sense as well—What does this do for individual patients and then for the health care system if we manage patients’ blood products and their hemostasis, etc., in a more effective way?
DK: Yeah, it’s really a nice opportunity to see wins on multiple fronts, that is, in the space of patient blood management. As an example, patients who come in anemic for a procedure, it’s been very well-documented that those patients, all other things being equal, do worse than similar patients who are not anemic at the time of a surgical procedure. Historically, we thought, "Well, if that’s the case, let’s just transfuse red blood cells to bring that hemoglobin up." But what we found was that was just a second hit. Rather than bringing that patient up to the expected outcomes you might see in a non-anemic patient, a patient who is anemic and then managed with transfusion actually did worse than the patient who was anemic and non-transfused. So, by optimizing patients’ hematologic status before surgery, not only do we provide them the optimal outcomes in their surgical encounter, but we also prevent them from being exposed to additional interventions like transfusion therapies, which in the right context, are certainly lifesaving, but in the wrong context, they can potentially increase risk for that patient and are certainly associated with significant cost to the health care environment. So, what we’re trying to do is to provide the best outcomes we can for patients by optimizing their hematologic status and, in doing so, hopefully preserving this scarce resource and improving the economics of the care that we’re delivering by avoiding these unnecessary transfusion episodes.
BM: There is so much that goes into it that I think many in medicine don’t really even appreciate. I remember when I was an intern. We just ordered platelets if someone’s platelet count was below 25,000. You didn’t put that much thought into what’s really the patient’s hemodynamic status or how that relates to their physiology and their disease state, and how can we best support them? As I hear you speak, it makes me proud to have the opportunity to work here at Mayo Clinic, but again, having a team-based approach that really looks at the patient from multiple dimensions from the perspective of an anesthesiologist supporting someone’s physiology through an invasive procedure and from the perspective of a laboratorian who is asked to manage the asset, the blood, and the blood products for our patients. It screams for a team-based approach with the patient at the center of that team, which is what we’re all about here. I just wonder if you could talk a little bit about what Mayo Clinic in particular has done in terms of focusing on this issue of blood management and optimizing the hemodynamic status for our patients.
DK: Well, I certainly couldn’t agree more with the sentiments that you just expressed. I think the greatest win for Mayo Clinic in this space of patient blood management is that we really brought all relevant stakeholders to the table to discuss how we do the best things that we can for patients for their surgical encounter or their medical encounter if it happens to be a medical episode of care. So, we’ve got Transfusion Medicine at the table. We’ve got Anesthesiology at the table. We’ve got Laboratory Medicine. We’ve got Emergency Medicine. We’ve got surgeons—really, everybody who has a component of their practice that relates to the potential need for a blood-component therapy has been involved in the patient blood-management program, which I think is really what has defined its success.
We’ve also identified some other key characteristics that we feel are very important in the success of patient blood management, and two of those perhaps that we could highlight are the need to provide decision support at the right time in a clinician’s workflow. So, it’s one thing to try to educate a practice about what are the best practices in terms of transfusion therapies, but in a clinician’s busy day, sometimes those educational efforts can be lost when they’re in the middle of a busy ICU and have to move from patient to patient. By making sure that that education is continually reinforced at the time that they’re planning to order a blood-component therapy within their clinical workflow, that has, in our experience, been an extremely important component of the patient blood-management program. Then, maybe one other that I would mention, in addition to the collaborative efforts and the decision support that we just mentioned, is the need to have data to define what your transfusion practice looks like. Where are your blood components going? Are they appropriate indications for transfusion. Are there other things we can be doing to support this practice's blood health, whether it be with anemia management or coagulation status management? And so, really, having data available that can describe our practice and help us to know where our potential deficiencies might be and where we should focus our efforts further has been another key component to the success of our patient blood-management program.
BM: I first became familiar with the depth of our expertise in this area in Laboratory Medicine. We’re a pretty highly regulated part of the medical practice—Transfusion Medicine in particular because they also have AABB, the American Association of Blood Banks, which inspects them as well as the FDA. This is such a new and emerging topic whose importance is just starting to really be appreciated, that the AABB has just started a preliminary program in terms of inspecting programs around their blood management. They came to Mayo, and it was early in my time as department chair, and they just lauded us for our efforts and exactly the collaborative approach that you described. You and I have both been here at Mayo Clinic a long time. We kind of stand at a very interesting threshold in terms of medicine and medical care, as we think about the ways that we can provide care for all of our citizens in a responsible way, number one, and also Mayo Clinic’s role in that. So, when I came here, there was the Mayo Clinic newsletter or "health letter" that went out on some brown paper, and that’s kind of how we shared things. That’s just how Mayo Clinic does things, and we have our journal Mayo Clinic Proceedings. I was at a hospital in China with 10,000 beds, and the one English-speaking journal they had was Mayo Clinic Proceedings.
BM: But these decisions like blood management are made under duress, and we know the compendium of information that we expect our providers to really have access to has really outstripped their ability to understand and keep up with the medical education. So, that’s why it was really exciting for us when we think about ways that we can allow patients to benefit from the knowledge of Mayo Clinic, patients who may never visit here, and that has led us down the path to look at decision support and decision-support tools. Through that, we formed a collaboration with a company called National Decision Support Company (owned by Change Healthcare). I know you’ve been involved with that, and we now have a patient blood-management program rolling out with them. Could you speak to that a little bit?
DK: Yes, again, building really on what we had experienced with our past successes where we had built our own decision support with our own local-vended products and our own blood, sweat, and tears, again, it is quite clear that decision support has been and continues to be very important. As the volume of information that we’re bombarded with, particularly in our acute-care environments like an operating room or an ICU environment, continues to increase, the synthesis of that information and the delivery of that information to clinicians within their workflow is only going to grow in importance, at least that’s been my view.
The other thing that we’ve learned with decision support is that while it can be incredibly helpful and it can greatly facilitate clinical workflows, if it’s not done well, it can actually impede those workflows and create more errors and problems than it actually solves. So that’s why I think increasingly, we need to make sure that when we’re developing decision-support aids, we’re doing it in a way that’s well-thought-out, that’s robust, and ideally, that can be generalized as fully as possible across the practice. That’s really, I think, one of the things that got me excited about the potential opportunity to collaborate with a company like NDSC because they have substantial experience in the space of how to deliver decision support to providers in the right way that doesn’t impede workflows but ultimately enhances them. Our experience to this point with National Decision Support Company, at least in the blood-management space, has been very encouraging. This is a group that knows how to do this right, and that ultimately in the collaboration between hopefully bringing our knowledge to the technology that a company like NDSC has, we can provide substantial benefits not just for the patients that we have here at Mayo Clinic but ideally to patients really across the much broader landscape of health care.
BM: Yes, I couldn’t agree more. I mean, I’ve gotten to work with NDSC, and clearly, they understand the dynamic of the provider experience, and they’re trying to be a help and not a hindrance. I think oftentimes those decision-support systems feel exactly like that, or they feel sometimes onerous outside of the health care system of someone just trying to control costs, and this isn’t about controlling costs. I think the thing that’s so exciting about this effort is it really is a win-win. I mean, if you do things right for the patients, you improve their outcomes, you decrease their exposures to blood products that aren’t needed, then it’s a win for the health care system because it actually helps drive down costs, you know, because we’re using resources more judiciously. So, it’s a great opportunity for us to share our knowledge in a way that can actually make an impact on health care because it’s something that’s not just in the lab, but it really represents the team-based Mayo Clinic culture.
The other item is, as I heard you talk, is that I preach this message in pathology a lot, but I think it’s not specific to pathology. I think as providers, we’re really trained in the patient experience and understanding the context of our individual patients and providing the best care, but I think it’s incumbent on our profession to really start thinking about the data that we create and how you can think of the aggregated data to create insights into how we’re providing our care. I think that’s the other thing that a lot of institutions need to learn how to do. So, I think that’s the other exciting piece of this that, again, helping them understand how to actually use the data that they’re generating from transfusion patients to understand then how to best optimize their care.
DK: Yes, I couldn’t agree more. That’s certainly, as I mentioned earlier, been our experience. One of the key aspects of success has been really using data and metrics to define your transfusion practice, congratulate those areas that are doing well with their transfusion practice, and target your educational efforts on those areas that may be underperforming with what they could be doing with their transfusion therapies. And really, not just transfusions. One of the things I like about the National Decision Support Company and this collaborative effort is that it’s not about the blood product. It’s about the patient. The blood product is a component of that discussion, but it might be that the right answer is some other intervention that isn’t a blood product, and there’s also some decision support that’s being developed for those types of interventions as well. So, I do want to make sure that when we talk about patient blood management that we are talking mostly about the patient and a little bit less about the blood. That’s just one component of what we’re trying to do for these individuals.
BM: Well, that sounds like a great place to wrap up this conversation. Well said. I really appreciate you taking the time, Dr. Kor. It is really fun to speak to you about projects like this. Opening the doors of the laboratory to the non-laboratorian to come and chat with the chair is awesome, so I really appreciate you taking the time to visit with me. It’s been fun working with you on this project.
DK: Yes, thank you so much for the opportunity to sit down and chat with you again, and I look forward to continuing the collaboration.