February 8, 2023
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:
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:
We developed a set of SMART Goals for our quality improvement program:
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
There were no funding sources or additional costs for this project.
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:
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).
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.
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.
Chih-Yau Chang is the division head of the Department of Quality and ACS NSQIP Surgical Clinical Reviewer at Taipei Medical University Hospital in New Taipei, Taiwan. Dr. Jia-Lin Wu is the corresponding author.