Analyzing the Impact of Implementing a Systems-Based Hematologist into the Healthcare Delivery System at an Academic Medical Center
Authors: Greenberg Charles S , Vaughn Caroline Dupre , Boylan Alice , Squires Jerry E , DeGrace Sharon , Lazarchick John , Reuben Adrian , Finley Alan C. , Mazur Joseph 
Published: October 2019

Abstract
There remains a clinical shortage of benign hematologists to manage the growing number of patients with non-malignant yet life-threatening and chronic blood diseases. The American Society of Hematology proposed creating System-Based Hematologist (SBH) positions to meet this need. The purpose of this study was to provide quantitative data regarding the impact that a SBH has on health care delivery in both the inpatient and outpatient settings. In 2011, the Department of Medicine successfully negotiated a Medical Directorship position for a SBH for the MUSC Health System. The position functions within the hospital as a part of the Medical Acute Critical Care Service Line, and the clinical service run by the SBH conducts inpatient consults daily. A benign hematology outpatient clinic was also established and is located on the hospital campus. In the years 2013-2014, clinic referrals of new patients grew 20% and the inpatient consult service grew by 38%. The SBH managed all hemophilia admissions from the emergency room and the use of recombinant blood products was reduced by an average of 35% per patient. The SBH evaluated the performance characteristics of the ROTEM instrument, recommended the instrument be purchased by the hospital for clinical use and collaborated to establish algorithms to guide replacement therapy. In CT Surgery, an anesthesiologist was trained in ROTEM and blood management who then served as the champion that implemented the ROTEM-based system for intra- and post- operative CABG care. From 2013 to 2014, we found that the use of FFP in CABG patients decreased from 25.8% to 12.7%. Platelet usage per patient dropped from 0.72 to 0.43. Cryoprecipitate decreased from 0.37 to 0.2 per patient. A ROTEM -based algorithm was also implemented to manage pre-procedure replacement therapy in patients with a coagulopathy from chronic liver disease. This protocol has led to reduction in fresh frozen plasma use from 3 units per patient to 0.4 units per patient, and has eliminated the use of pre-procedure INR correction as a target for promoting hemostasis. The ROTEM-guided algorithm resulted in safe and satisfactory outcomes for all liver disease patients requiring interventional procedures, as well as substantial cost savings. In addition, the SBH established a heparin-induced thrombocytopenia monitoring program. The EMR was specifically modified to provide guidance regarding calculating the 4T score and decision support for heparin-platelet factor 4 antibody testing and use of heparin alternatives. The SBH consults on patients that have positive heparin-platelet factor 4 assays and helps guide safe anticoagulation therapies in those patients that require treatment. Following the implementation of this program, serotonin release assays were reduced by 70% and there was also a substantial reduction in the use of direct thrombin inhibitors of 78%. Clinical outcomes in all patients today have been satisfactory with no major thrombotic complications apart from one patient that could not receive anticoagulation due to recent surgery, who fully recovered despite having DVT/PE. One patient that had a negative heparin platelet factor 4 assay became positive upon repeat testing and suffered arterial thrombosis that has resolved without any residual deficit. The SBH also educates medical students, interns, residents and fellows in the inpatient and outpatient settings. The addition of a nurse practitioner was necessary as the program has developed a rapid access anemia clinic to diagnose and treat pre-and post-op anemia. The MUSC SBH position is transitioning to play a role in a patient blood management program that will serve the entire healthcare network. In conclusion, this study documents a SBH can reduce cost of HITT management, blood product utilization in CABG and pre-procedure management of the coagulopathy in chronic liver disease as well as hemophilia management. The clinical services provided by the SBH in the clinics and outpatient setting can further enhance the education of students, residents and fellows in academic medical centers. The SBH must have the administrative support to initiate and implement programs through productive collaboration with colleagues within the health care system.The ASH program to encourage implementation of SBH positions and training should provide rewarding career opportunities for hematologists interested in non-malignant hematologic disorders.

Disclosures
No relevant conflicts of interest to declare.