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Instructions for Calculating the Rate of

Retained Blood Syndrome (RBS) Intervention Rates at Your

Institution

PURPOSE:

The purpose of this document is to provide guidance on how to calculate and present Retained Blood Syndrome (RBS) intervention rates and costs in an adult cardiothoracic surgery population from a clinical database. SCOPE:

A. ESTIMATING THE RATE OF RBS INTERVENTIONS AT YOUR INSTITUTION

B. CALCULATING THE INCREMENTAL COST OF AN RBS PATIENT

C. CALCULATING THE ESTIMAED COST SAVINGS WHEN RBS IS REDUCED

D. ENTERING OUTCOMES IN RBS COST CALCULATOR

E. EXHIBITING IMPACT OF RBS ON POSTOPERATIVE OUTCOME

For assistance with completing this form, please contact your local representative at http://www.clearflow.com/find-my-rep/ or contact:

ClearFlow, Inc. www.clearflow.com info@clearflow.com

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DEFINITION OF RETAINED BLOOD SYNDROME (RBS)

Retained Blood Syndrome is a composite of postoperative complications related to incomplete evacuation of blood that are detrimental to outcomes and costs after cardio-thoracic surgery (Figure 1). Chest tube clogging is a leading cause of incomplete blood evacuation after cardiac surgery that leads to Retained Blood Syndrome. RBS may require early or late intervention to remediate.

Retained Blood Syndrome can occur at any stage of recovery:

• Acute- pericardial tamponade or hemothorax

• Sub-acute- bloody pleural or pericardial effusions

• Chronic- fibrothorax, constrictive pericarditis        

Figure 1: Postoperative complications related to incomplete evacuation of blood

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INTERVENTIONS FOR RETAINED BLOOD SYNDROME

The composite of measurable clinical interventions required to manage Retained Blood Syndrome during the acute and sub acute phases consist of one or more of the following conditions:

-Re-exploration for bleeding, tamponade or washout of retained blood

-Any procedure to treat pericardial effusion; i.e., pericardial window, pericardiocentesis, placement of pericardial drain

-Any procedure to treat pleural effusion; i.e., thoracentesis under any image-guided modality

-Any procedure to treat hemothroax; i.e., chest tube, thoracoscopy, thoracotomy, etc.

-Any procedure to treat pneumothorax  

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A. ESTIMATING THE RATE OF RBS INTERVENTIONS AT YOUR INSTITUTION1

STEP 1- NUMBER OF ADULT CARDIOTHORACIC SURGERY PATIENTS

To calculate the number of patients who had cardiothoracic surgery during a 1-year period:

Select the search period in your database for the desired 1-year period, i.e. 1/1/2014 to 12/31/2014. Calculate the number of patients who had cardiothoracic surgery from your database using the following inclusion and exclusion criteria.

I. Inclusion criteria- patients who had a cardiothoracic surgery of interest including, CABG, valve replacement, valve repair, CABG and valve combination, concomitant surgical procedure outside the heart (i.e., tumor removal). Procedures on the ascending aorta and/or aortic arch. Open procedures for atrial and ventricular repair, etc. (For a full list see the ICD-9-CM codes provided in Appendix A).

II. Exclusion criteria- patients younger than 18 years age and patients undergoing TAVR procedures or any other percutaneous procedures. Use the resulting number as your Step 1 number.

STEP 2- NUMBER OF PATIENTS WHO HAD RBS INTERVENTIONS

To calculate the number of patients who required measurable clinical interventions to manage their RBS during the acute and sub-acute phases use one of the following methods:

I. Search for ICD-9-CM and CPT codes of interest (See Appendices B and C for detailed list of ICD-9-CM and CPT codes, respectively). These codes of interest cover surgical intervention for drainage of retained blood from cardiothoracic surgery;

II. Search for relevant fields of interest entered by your institution to the STS adult cardiac surgery database (See Appendix D). Use the resulting number as your Step 2 number.

                                                                                                               1 Any patient information used to calculate RBS shall meet and abide by HIPAA and patient privacy requirement

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Note 1: Searching for relevant ICD-9-CM and CPT codes will provide a more accurate estimation of the rate of RBS. Note 2: A patient that has one or more codes for RBS is counted as a patient having RBS.

STEP 3- CALCULATE THE RATE OF RBS (% RBS)

To calculate the % RBS: take the number of patients who had RBS interventions (Step 2) divide it by the number of adult cardiothoracic surgery patients (Step 1) and multiply the result with 100. This number is your institution’s rate of RBS. In formula form: % RBS = (Step 2 / Step 1) x 100 Use the resulting number of patients as your Step 3 number.

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B. CALCULATING THE INCREMENTAL COST OF AN RBS PATIENT

STEP 4- AVERAGE COST OF A CARDIOTHORACIC PATIENT

Obtain the average cost of a cardiothoracic surgery patient if readily available. If only charge information is available apply the institutional cost-to-charge ratio to derive the average cost of cardiothoracic surgery procedure at your institution.

Use this number as your Step 4 number.

STEP 5- AVERAGE COST OF A PATIENT WITH RBS INTERVENTIONS

Repeat the calculation in Step 4 for the cohort of patients with RBS. Use the resulting number as your Step 5 number.

STEP 6- AVERAGE COST OF A NON RBS PATIENT

Repeat the calculation in Step 4 for the cohort of patients without RBS. Use the resulting number as your Step 6 number.

STEP 7- AVERAGE INCREMENTAL COST OF AN RBS PATIENT

To derive the average incremental cost of a patient with RBS: subtract the average cost of a non RBS patient (Step 5) from the average cost of a RBS patient (Step 6). In formula form:

Average Incremental Cost of an RBS Patient = Step 5 – Step 6

Use the resulting number as your Step 7 number.

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C. CALCULATING THE ESTIMATED COST SAVINGS WHEN RBS REDUCED

STEP 8- YEARLY COST OF RBS COMPLICATIONS

To calculate the yearly cost of RBS complications to your institution: take the number of adult cardiothoracic surgery patients (Step 1) multiplied by the % RBS rate (Step 3) multiplied by the average incremental cost of an RBS patient (Step 7). In formula form: Yearly Cost of RBS Complications = (Step 1) x (Step 3) x (Step 7)

Use the resulting number as your Step 8 number.

STEP 9- ESTIMATED COST SAVINGS WHEN RBS REDUCED

To calculate the estimated cost savings your institution will experience when ClearFlow is used in all adult cardiothoracic surgery patients: Take the yearly cost of RBS complications (Step 8) multiply by 42% 2 and subtract the multiplication of the number of adult cardiothoracic patients (Step 1), the number of PleuraFlow Systems per procedure, and the price per PleuraFlow System.

In formula form:

Estimated Cost Savings = [Step 8 x 42% 2] – [(Step 1) x (# of PleuraFlow Systems per procedure) x (price per PleuraFlow System)]

The resulting number is your institution’s average yearly cost savings.

                                                                                                               2  Clinical trial results of 42% reduction in RBS interventions from Paracelsus Medical University Klinikum Nürnberg Germany. Presented at CVTCC Meeting October, 2014

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D. ENTERING OUTCOMES IN RBS COST CALCULATOR

The information obtained through Steps 1 through 8 can be presented in a table format (See a Cost Calculator in Appendix E).

Appendix F includes a recent abstract on RBS that was presented at the International Anesthesia Research Society (IARS meeting) on 3/21/2015. You may want to consider a similar format for publication purposes.

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E. EXHIBITING IMPACT OF RBS ON POSTOPERATIVE OUTCOMES

Tables 1-4 provide the format for data collection and presentation of the clinical outcomes showing the impact of RBS. The variables are calculated for: all cardiothoracic surgeries, cardiothoracic surgeries with RBS, and cardiothoracic surgeries with no RBS.

 

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APPENDIX A: HOSPITAL ICD-9-CM CODES TO IDENTIFY CARDIO-

THORACIC SURGERY

ICD-9-CM Procedure Code

35.10 Open heart valvuloplasty without replacement, unspecified valve

35.11 Open heart valvuloplasty of aortic valve without replacement 35.12 Open heart valvuloplasty of mitral valve without replacement

35.13 Open heart valvuloplasty of pulmonary valve without replacement 35.14 Open heart valvuloplasty of tricuspid valve without replacement

35.20 Open and other replacement of unspecified heart valve 35.21 Open and other replacement of aortic valve with tissue graft

35.22 Open and other replacement of aortic valve 35.23 Open and other replacement of mitral valve with tissue graft 35.24 Open and other replacement of mitral valve

35.25 Open and other replacement of pulmonary valve with tissue graft 35.26 Open and other replacement of pulmonary valve

35.27 Open and other replacement of tricuspid valve with tissue graft 35.28 Open and other replacement of tricuspid valve 35.31 Operations on papillary muscle

35.32 Operations on chordae tendineae 35.33 Annuloplasty

35.34 Infundibulectom 35.35 Operations on trabeculae carneae cordis

35.39 Operations on other structures adjacent to valves of heart 35.41 Enlargement of existing atrial septal defect 35.42 Creation of septal defect in heart

35.50 Repair of unspecified septal defect of heart with prosthesis 35.51 Repair of atrial septal defect with prosthesis, open technique

35.52 Repair of atrial septal defect with prosthesis, closed technique. Insertion of atrial septal umbrella [King-Mills]

35.53 Repair of ventricular septal defect with prosthesis, open technique 35.54 Repair of endocardial cushion defect with prosthesis

35.55 Repair of ventricular septal defect with prosthesis, closed technique 35.60 Repair of unspecified septal defect of heart with tissue graft 35.61 Repair of atrial septal defect with tissue graft

35.62 Repair of ventricular septal defect with tissue graft 35.63 Repair of endocardial cushion defect with tissue graft

35.70 Other and unspecified repair of unspecified septal defect of heart 35.71 Other and unspecified repair of atrial septal defect 35.72 Other and unspecified repair of ventricular septal defect

35.73 Other and unspecified repair of endocardial cushion defect 35.91 Interatrial transposition of venous return

35.92 Creation of conduit between right ventricle and pulmonary artery

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35.93 Creation of conduit between left ventricle and aorta 35.94 Creation of conduit between atrium and pulmonary artery

35.95 Revision of corrective procedure on heart 35.98 Other operations on septa of heart

35.99 Other operations on valves of heart 36.03 Open chest coronary artery angioplasty

36.09 Other removal of coronary artery obstruction; coronary angioplasty NOS 36.10 Aortocoronary bypass for heart revascularization, not otherwise specified 36.11 (Aorto)coronary bypass of one coronary artery

36.12 (Aorto)coronary bypass of two coronary arteries 36.13 (Aorto)coronary bypass of three coronary arteries

36.14 (Aorto)coronary bypass of four or more coronary arteries 36.15 Single internal mammary-coronary artery bypass 36.16 Double internal mammary-coronary artery bypass

36.17 Abdominal-coronary artery bypass 36.19 Other bypass anastomosis for heart revascularization 36.20 Heart revascularization by arterial implant 36.31 Open chest transmyocardial revascularization

36.32 Other transmyocardial revascularization 36.33 Endoscopic transmyocardial revascularizationThoracoscopic transmyocardial .

revascularization 36.39 Other heart revascularization. Abrasion of epicardium. Cardio-omentopexy.

Intrapericardial poudrage Myocardial graft: mediastinal fat Omentum pectoral muscles

36.91 Repair of aneurysm of coronary vessel

36.99 Other operations on vessels of heart.Exploration of coronary artery. Incision of coronary artery. Ligation of coronary artery. Repair of arteriovenous fistula

37.10 Incision of heart, not otherwise specified 37.11 Cardiotomy

37.12 Pericardiotomy 37.24 Biopsy of pericardium 37.31 Pericardiectomy

37.32 Excision of aneurysm of heart 37.33 Excision or destruction of other lesion or tissue of heart, open approach

37.35 Partial ventriculectomy 37.36 Excision, destruction, or exclusion of left atrial appendage (LAA) 37.37 Excision or destruction of other lesion or tissue of heart, thoracoscopic approach

37.41 Implantation of prosthetic cardiac support device around the heart 37.49 Other repair of heart and pericardium

37.51 Heart transplantation 37.52 Implantation of total internal biventricular heart replacement system

37.53 Replacement or repair of thoracic unit of (total) replacement heart system 37.54 Replacement or repair of other implantable component of (total) replacement heart

system 37.55 Removal of internal biventricular heart replacement system

37.60 Implantation or insertion of biventricular external heart assist system

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37.61 Implant of pulsation balloon

37.62 Insertion of temporary non-implantable extracorporeal circulatory assist device

37.63 Repair of heart assist system

37.64 Removal of external heart assist system(s) or device(s)

37.65 Implant of single ventricular (extracorporeal) external heart assist system

37.66 Insertion of implantable heart assist system

37.67 Implantation of cardiomyostimulation system 37.68 Insertion of percutaneous external heart assist device

38.04 Incision of Aorta

38.05 Incision of vessel; other thoracic vessels

38.15 Endarterectomy; other thoracic vessels

38.34 Resection of vessels with anastomosis aorta

38.65 Other excision of vessel; other thoracic vessels

36.31 Open chest transmyocardial revascualrization

38.45 Resection of vessel with replacement: other thoracic vessels

39.0 Systemic to pulmonary artery shunt

39.52 Other repair of aneurysm

39.54 Re-entry operation (aorta)

39.57 Repair of blood vessel with synthetic patch graft

39.61 Extracorporeal circulation auxiliary to open heart surgery

39.62 Hypothermia (systemic) incidental to open heart surgery

39.63 Cardioplegia

39.65 Extracorporeal membrane oxygenation [ECMO]

39.66 Percutaneous cardiopulmonary bypass

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APPENDIX B: HOSPITAL ICD-9-CM CODES TO IDENTIFY RBS INTERVENTION

ICD-9-CM procedure codes 34.01 Incision of chest wall

34.02 Exploratory thoractomy 34.03 Reopening of recent thoracotomy site 34.04 Insertion of intercostal catheter for drainage

34.05 Creation of pleuroperitoneal shunt 34.06 Thoracoscopic drainage of pleural cavity

34.09 Other incision of pleura 34.1 Incision of mediastinum 34.20 Thoracoscopic pleural biopsy

34.21 Transpleural thoracoscopy 34.59 Other excision of pleura. Excision of pleural lesion

34.51 Decortication of lung 34.52 Thoracoscopic decortication

34.6 Scarification of pleura of lung 34.71 Suture of laceration of chest wall 34.91 Thoracentesis 37.0 Pericardiocentesis 37.12 Pericardiotomy 37.91 Open chest cardiac massage 39.98 Control of hemorrhage NOS

 

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APPENDIX C: CURRENT PROCEDURE TERMINOLOGY (CPT) CODES TO IDENTIFY RBS INTERVENTION  

CPT Codes 32035 Thoracostomy, with rib resection for empyema

32036 Thoracostomy; with open flap drainage for empyema 32100 Thoracotomy; with exploration 32110 Thoracotomy; with control of traumatic hemorrhage and/or repair of lung

tear 32120 Thoracotomy; for postoperative complications 32150 Thoracotomy; with removal of intrapleural foreign body or fibrin deposit 32160 Thoracotomy; with cardiac massage 32215 Pleural Scarification for repeat pneumothorax 32220 Decortication, pulmonary (separate procedure); total

32225 Decortication, pulmonary (separate procedure); partial 32320 Decortication and parietal pleurectomy

32540 Extrapleural enucleation of empyema (empyemectomy) 32550 Insertion of indwelling tunneled pleural catheter with cuff 32551 Tube thoracostomy, includes connection to drainage system (eg, water seal),

when performed, open (separate procedure 32554 Thoracentesis, needle or catheter, aspiration of the pleural space; without

imaging guidance 32555 Thoracentesis, needle or catheter, aspiration of the pleural space; with

imaging guidance 32556 Pleural drainage, percutaneous, with insertion of indwelling catheter; without

imaging guidance 32557 Pleural drainage, percutaneous, with insertion of indwelling catheter; with

imaging guidance 32560 Instillation, via chest tube/catheter, agent for pleurodesis (eg, talc for

recurrent or persistent pneumothorax) 32561 Instillation(s), via chest tube/catheter, agent for fibrinolysis (eg, fibrinolytic

agent for break up of multiloculated effusion); initial day 32562 Instillation(s), via chest tube/catheter, agent for fibrinolysis (eg, fibrinolytic

agent for break up of multiloculated effusion); subsequent day 32601 Thoracoscopy, diagnostic (separate procedure); lungs, pericardial sac,

mediastinal or pleural space, without biopsy 32604 Thoracoscopy, diagnostic (separate procedure); pericardial sac, with biopsy 32650 Thoracoscopy, surgical; with pleurodesis (eg, mechanical or chemical)

32651 Thoracoscopy, surgical; with partial pulmonary decortication 32652 Thoracoscopy, surgical; with total pulmonary decortication, including

intrapleural pneumonolysis 32653 Thoracoscopy, surgical; with removal of intrapleural foreign body or fibrin

deposit 32658 Thoracoscopy, surgical; with removal of clot or foreign body from pericardial

sac 32659 Thoracoscopy, surgical; with creation of pericardial window or partial

resection of pericardial sac for drainage 33010 Pericardiocentesis; initial 33011 Pericardiocentesis; subsequent 33015 Tube Pericardiostomy

33020 Pericardiotomy removal of clot/foreign body primary 33025 Creation of pericardial window or partial resection for drainage

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35820 Exploration for postoperative hemorrhage, thrombosis or infection; chest 39000 Mediastinotomy with exploration, drainage, removal of foreign body, or

biopsy; cervical approach 39010 Mediastinotomy with exploration, drainage, removal of foreign body, or

biopsy; transthoracic approach, including either transthoracic or median sternotomy

76930 Ultrasonic guidance for pericardiocentesis, imaging surgery & interpretation

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APPENDIX D: STS DATABASE FIELD TO IDENTIFY RBS (SEQUENCE CODES)  

STS database fields

4755 Post op re-op bleed 4860 Postop pleural effusion requiring drainage 4915 Post op other tamponade non surgical intervention 4865 Post op pneumothorax requiring intervention

 

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APPENDIX E: COST OF RETAINED BLOOD SYNDROME INTERVENTIONS CALCULATOR*

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 APPENDIX F: SAMPLE ABSTRACT WITH SUMMARY OF RBS DATA