Taipei Medical University Hospital (TMUH) in Taiwan was founded in 1976 and provides patient-centered, comprehensive medical services with more than 800 beds, 39 specialty/subspecialty medical departments, and 2,000 medical personnel. Since 2009, TMUH has been accredited four times by the Joint Commission International, which recognizes the high-quality services and world-class patient care the hospital provides. By joining the ACS National Surgical Quality Improvement Program (NSQIP®), TMUH can promote cross-team collaboration, improve surgical quality, and achieve patient safety and cost savings through different aspects of analysis.
Through NSQIP online data, our team found that overall surgical performance at TMUH was better than international peers, but our transfusion rates in November 2019 (7.98%) and February 2020 (9.66%) were higher than peer hospitals (7.2%). Further analysis found that some surgical categories had higher transfusion rates than international peers. The blood transfusion rate of our hospital in 2019 was 9%, higher than the 8.7% rate in 2018.
The NSQIP blood transfusion rate in our hospital dropped from 6.66% (October 2019 to February 2020) to 5.38% (March 2020 to September 2020), and the blood transfusion rate in the hospital showed a downward trend, decreasing from 9.16% to 7.98% during the same time frames (see Figure 1).
Blood transfusion is a common medical practice during treatment but often comes with adverse side effects. Reducing unnecessary transfusions can reduce the risk of fever, rashes, allergic reactions—such as urticaria and hemolytic transfusion reactions—and transfusion-related acute anaphylactic shock. Reducing unnecessary transfusions also can improve patient safety and reduce the waste of medical resources.1,2
To reduce the rates of blood transfusion at TMUH, our team conducted two phases of intervention:
- In Phase I, our team built a NSQIP blood transfusion business intelligence (BI) dashboard to provide a collection of blood transfusion cases for clinical case discussion and hospital-wide awareness.
- In Phase II, the BI dashboard was used to drill down to departmental characteristic analysis for improvement through cross-departmental collaboration.
Upon further analysis of the BI dashboard, intraoperative blood transfusion in our hospital accounted for 88.6% of all blood transfusions, of which single-unit (1U) blood transfusion accounted for 12.9% and orthopaedic surgery accounted for 92%. According to the Pareto principle—which states that for many outcomes, roughly 80% of consequences come from 20% of causes—the Blood Transfusion Committee (BTC) recommended priority intervention in 1U intraoperative blood transfusion of orthopaedics and other key departments as the means to accurately reduce unnecessary blood transfusion (see Figure 2).
The BTC recommended adding intraoperative blood loss and timing of the blood transfusion (intraoperative/postoperative) in the BI dashboard, which is convenient for drill-down analysis. In addition, cross-professional case-by-case discussions determined that the most likely reasons for 1U blood transfusion were high-risk factors such as advanced age, low preoperative hemoglobin (Hb), low body mass index (BMI), coronary heart disease, inadvertent perioperative hypothermia, unstable vital signs, and bleeding during an operation.
Reasons for unnecessary blood transfusion were revealed through observations and interviews with surgeons, including:
- Preventative blood transfusion: There have been cases of stroke in elderly patients and delayed bleeding after tourniquet removal.
- Early ordering of blood products: Surgeons worry that blood delivery is too slow, so they ordered blood earlier. The amount of blood scrapped in 2020 was 0.64%, higher than the 0.54% rate in 2019.
Goal Specification
We developed a set of SMART Goals for our quality improvement program:
- Specific: In order to avoid unnecessary blood transfusion in orthopaedic surgery, we aim to reduce 1U blood transfusion by 80% in orthopaedic surgery. Our goal is to reduce the overall 1U blood transfusions rate to 0.78%.
- Measurable: We will evaluate our progress using the NSQIP registry and hospital administrative data.
- Achievable: The primary issue is decision-making for blood transfusion during surgeries. We will work with the individual departments to improve this process.
- Relevant: Decreasing unnecessary preventative blood transfusions and minimizing early ordering of blood products will reduce waste and allow more blood products to be available for other patients, which is especially important because the COVID-19 pandemic has resulted in limited blood supply. There also is a risk of infections associated with blood transfusions.
- Timeline: Phase II intervention began in September 2020, and the project is ongoing. The BTC monitors data monthly.
Strategic Planning
The quality improvement team consists of eight people: the director of orthopaedic surgery, director of anesthesiology, BTC chair, blood bank division head, director and assistant director of medical quality department, NSQIP surgeon champion, and the NSQIP surgical clinical reviewer.
Key stakeholders include all orthopaedic surgeons, anesthesiologists and assistants, operating room (OR) nursing staff, blood bank staff, transfer staff, and administrative staff.
The BTC monitors indicators to ensure hospital quality. The committee discovered the rates of blood transfusion for total knee replacement (TKA) and total hip replacement (THA) were higher than NSQIP peer hospitals (see Figure 2).
The team met with the orthopaedic, anesthesia, blood bank, and surgical departments to further review the data. We discovered that most of the orthopaedic patients in our hospital were elderly and had coronary heart disease. Additionally, the higher blood transfusion rate was specific to some orthopaedic surgeons who previously had poor surgical outcomes due to delays in receiving intraoperative blood transfusion and patients experiencing postoperative strokes. Consequently, the orthopaedic surgeons began implementing preventative 1U prophylactic blood transfusions for patients undergoing TKA and THA procedures to prevent cardiovascular complications such as stroke. We hope that in the future we can reduce unnecessary intraoperative blood transfusion and bleeding.
Based on this review and previous experience, we updated our blood transfusion process and received approval from the BTC:3–8
- The suitability of blood transfusion is determined by the actual situation of the patient during the operation. The surgeon and anesthesia team have strengthened communication on the patient’s age, preoperative Hb, BMI, medical history (e.g., coronary heart disease), intraoperative body temperature, vital signs, operation time, blood loss, and other information during the operation.
- To ensure timely delivery of intraoperative blood to the patient, the blood bank staff randomly checks the time to deliver blood for surgical patients, including the time when the blood bank staff receives the blood collection request in the OR, preparation time of the blood bank, and blood delivery time.
- The blood product is provided to the OR within 5 to 30 minutes.
There were no funding sources or additional costs for this project.
Process Evaluation
The phase I intervention led to a downward trend in overall blood transfusions in the hospital. The phase II intervention has now started and spans several areas. The initial steps were:
Department of Orthopaedics:3-8
- Review the literature for methods to reduce bleeding and high-risk factors requiring blood transfusion for medical team judgment; this review confirmed that there is no literature proving that prophylactic blood transfusion can effectively prevent stroke.
- Agree to use hemostatic drugs (Transamin) during and after surgery, do not use tourniquets during the operation, and communicate results in the morning department meeting
- Start individual communications with specific physicians
Department of Anesthesiology:
- Discuss the strategy for reducing unnecessary blood transfusion and communicate the BTC decision during Department of Anesthesiology nursing meetings; also work with the chief surgeon to determine the necessity of blood transfusion according to the patient’s current vital signs, body temperature, and blood loss during the operation
BTC:
- Analyze 1U blood transfusion cases on a quarterly basis through preoperative and intraoperative case data to confirm if there are still unnecessary blood transfusions
- Conduct onsite inspections to confirm the process for OR requests for blood from the blood bank, prepare blood from the blood bank, and deliver blood to the OR in a timely manner
Quality Management Department:
- Continuously review medical records to collect blood transfusion events for surgery according to NSQIP specifications
- Use the BI dashboard to monitor the cross-year trend chart, NSQIP peer comparison chart, and case list (including case number, chief surgeon, intraoperative blood loss, blood transfusion timing, and surgical procedure)
- Make sure the data are presented and that the clinical team can quickly monitor the blood transfusion situation
Outcome Evaluation
We accepted cases according to NSQIP guidelines. Patients must meet certain criteria in order to transfuse blood products (specifically red blood cell and whole blood products) or reinfuse autologous red blood cells or cell-saver products during the procedure.
Exclusion criteria included outpatient procedures, patients under 18 years of age, patients who have been assigned with an American Society of Anesthesiologists score of 6, patients with an injury caused by trauma or abuse, and/or patients who received hyperthermic intraperitoneal chemotherapy. In addition, according to the needs of cross-team experts, we collected blood transfusion timing (intraoperative and postoperative) and blood loss to facilitate judgment. The team also used a combination of chart review, automated BI dashboards, drill-down analyses, and continuous monitoring of blood transfusion across team members.
As mentioned previously, after phase I intervention in March 2020, the average NSQIP blood transfusion rate in our hospital dropped from 6.66% to 5.38%.
After phase II intervention in September 2020, the intraoperative blood transfusion rate of orthopaedics decreased slightly from 14.94% to 11.41% (p = 0.139), and intraoperative 1U blood transfusion rate of orthopaedics decreased significantly from 3.9% to 0.2957% (p <0.05) (see Figure 3). We were pleased to see a drastic reduction in intraoperative 1U blood transfusion rate. The orthopaedics postoperative length of stay decreased from 6.1 days to 5.7 days (p = 0.49).
Limitations
- This project is focused on our hospital and includes a small sample size. It would be useful to conduct a multicenter or larger trial on this issue.
- We changed our culture and behaviors, but we are unsure if this type of experience has occurred in other hospitals.
Cost Evaluation
According to the study, the average blood transfusion cost per patient is $219.1 The results showed that 126 patients’ blood transfusions were reduced per year. It is estimated that 1 year can reduce the cost of blood transfusions for orthopaedic surgery by $27,594.
Knowledge Acquisition
- Communication of the data is essential. The BI dashboard is a useful tool. We will continue to use this system to monitor patients, identify problems, educate, and share data between colleagues and surgeons.
- The project involved the cooperation of four departments: orthopaedic, anesthesiology, BTC, and quality management. We worked together to review the data, determine the transparency, and develop solutions.
- This project has encouraged our hospital and surgeons to increase our focus on patients. We will monitor the patients and their medical conditions even more closely. We can do more for patient safety and patient care.
Next Steps
Although we shared our results within the hospital, we felt it was important to communicate our results to others for awareness and also to encourage more surgeons and hospitals to outline their experiences.
We plan to continue investigating these data to determine if there are additional procedures or issues to monitor. For example, the problem may not be surgical; it could be related to the specific patient case. We also will review the suitability of blood transfusion through intraoperative blood loss, blood transfusion time, and procedure. On a case-by-case basis, the blood bank and BTC will continue to conduct discussions based on the NSQIP case list.
