Reducing Unnecessary One-Unit Blood Transfusion in Orthopedic Surgeries

General Information

Institution Name: Taipei Medical University Hospital

Primary Author & Title: Chih-Yau Chang, MSN, Division Head, Department of Quality Management and ACS NSQIP Surgical Clinical Reviewer

Co-Authors & Titles: Po-Li Wei, MD, PhD, Division of Colorectal Surgery and Director, Department of Quality Management; Ming-Hui Shen, MPH, Assistant Director, Department of Quality Management; Chuen-Chau Chang, MD, PhD, Director, Department of Anesthesiology; Hsi-Hsien Chen, MD, PhD, Division of Nephrology and Chairman, Blood Transfusion Committee; Jen-Ju Lin, MS, Head, Division of Blood Bank and Executive Secretary, Blood Transfusion Committee; Shu-Tai Shen Hsiao, MSN, Vice Superintendent; Weu Wang, MD, Division of Gastrointestinal Surgery and ACS NSQIP Champion; Chun-Ming Shih, MD, PhD, Division of Cardiology; Jia-Lin Wu, MD, MS, Director, Department of Orthopedics (Corresponding Author)

Name of the Case Study: Reducing Unnecessary One-Unit Blood Transfusion in Orthopedic Surgeries

Problem Detailing

Blood transfusion is a common medical practice during treatment. Reducing unnecessary transfusions can reduce the risk of fever, rashes, allergic reactions such as urticaria, hemolytic transfusion reactions, and even the fatal risk of transfusion-related acute anaphylactic

shock. What’s more, reducing unnecessary transfusions can improve patient safety and reduce the waste of medical resources.^1-2 Research indicates bilateral total knee replacement surgeries have a high blood transfusion rate.³ In the United States, hemoglobin rate is used to determine if a patient needs a blood transfusion.^3-4

Through the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) online data, we found that our overall surgical performance was better than international peers, but our transfusion rates (7.98%, 9.66%) were higher than peer hospitals (7.2%) in some months. Further analysis found that certain surgical categories had higher transfusion rates than international peers. The blood transfusion rate of our hospital in 2019 was 9.00%, higher than the 2018 rate of 8.7%.

In phase I (March 2020) the whole-hospital blood transfusion intervention was discussed by the Blood Transfusion Committee. It was determined that it was necessary to communicate that the blood transfusion rate was higher than that of the international peers. We built a Blood Transfusion Power BI dashboard to highlight blood transfusion case list and facilitate clinical case discussion.

This was made available to the surgical management committee and hospital executives. The NSQIP blood transfusion rate in our hospital dropped from 6.66% (October 2019–February 2020 average) to 5.38% (March 2020–September 2020 average), and the average blood transfusion rate in the whole hospital dropped from 9.16% to 7.98%. The blood transfusion rate in the whole hospital showed a downward trend (Figure 1).

Additional analysis found that there was still 1 unit (1U) blood transfusion being performed in our hospital. The indications for 1U blood transfusion are older age, anemia, lower BMI, and high cardiovascular risk. The Blood Transfusion Committee recommended increasing monitoring of intraoperative blood loss and the timing

of blood transfusion (intraoperative/postoperative) in the Power BI dashboard for ongoing analysis. In addition, cross-professional case-by-case discussions found that the most reasonable indications for 1U blood transfusion were high-risk factors such as advanced age, low preoperative hemoglobin, low BMI, coronary heart disease, and intraoperative complications (vital sign abnormality, blood loss, etc.).

Reasons for unnecessary blood transfusion were found through interviews with surgeons and observations, and included:

• Preventive blood transfusion: In the past, there were cases of stroke in elderly patients and delayed bleeding after tourniquet
• Ordering blood products early: surgeons are worried that blood delivery is too slow, so they order blood early. The proportion of unused blood product in 2020 was 64%, higher than 0.54% in 2019.

Further analysis indicated that intraoperative blood transfusion in our hospital accounted for 88.6% of all blood transfusions, of which 1U blood transfusion accounted for 12.9%, and orthopedics accounted for 91.6%. According to the Pareto principle, the Blood Transfusion Committee recommended priority intervention in 1U intraoperative blood transfusion and some key departments as the means to accurately reduce unnecessary blood transfusion and bleeding (Figure 2).

Taipei Medical University Hospital (TMUH) was founded in 1976, providing patient-centered comprehensive medical services with over 800 beds, 39 specialty/subspecialty medical departments, and 2,000 medical staff. Since 2009, TMUH has been accredited four times by JCI (Joint Commission International), which recognizes the high-quality services and world-class patient care we provide.

Our commitment to providing the highest quality patient care can best be exemplified by past recognitions awarded to TMUH. ACS NSQIP helps TMUH promote cross-team collaboration, improve surgical quality, achieve patient safety, and realize cost savings through different aspects of analysis.

Goal Specification

SMART Goals

Specific: In order to avoid unnecessary blood transfusion in orthopedic surgery, we plan to reduce 1U blood transfusion in orthopedic surgery 80% (from 3.9% to 0.78%).

Measurable: We will evaluate our progress using NSQIP registry and hospital administrative data.

Achievable: The primary issue is administration of unnecessary blood transfusions during surgeries. We will work with the individual departments to improve this process.

Relevant: We aim to decrease preventative blood transfusions and reduce early ordering of blood products. This will reduce waste and allow more blood products to be available for other patients. This is especially important now as the COVID-19 pandemic has resulted in limited blood supply. Additionally, there is a risk of infection associated with blood transfusions. These are important issues to address.

Timeline: Phase II intervention in September 2020. This project is ongoing. The committee monitors data monthly.

Strategic Planning

We are a quality improvement team of 8 people including the Director of Orthopedics, Director of Anesthesiology, Chairman of Blood Transfusion Committee, Division Head of Blood Bank, Director and Assistant Director of Medical Quality Department, ACS NSQIP Surgeon Champion, and ACS NSQIP Surgical Clinical Reviewers.

Key stakeholders include all orthopedic surgeons, anesthesiologists, and assistants; operating room nursing staff; blood bank staff; transfer staff; and administrative staff.

The Blood Transfusion Committee monitors quality indicators to ensure the quality of our hospital. The committee discovered a rate of blood transfusion specifically for total knee replacement (TKA) and total hip replacement (THA) higher than NSQIP peer hospitals (Figure 3).

The team met with the Orthopedic, Anesthesia, Blood Bank, and Surgical Departments to further review the data. We discovered that most of the orthopedic patients in our hospital were elderly and had coronary heart disease. Additionally, the high blood transfusion rate was specific to some orthopedic surgeons who had previously experienced poor surgical outcomes due to delays in receiving intraoperative blood and/or postoperative stroke. Consequently, the orthopedic surgeons began implementing prophylactic 1U blood transfusions for patients undergoing TKA and THA procedures to prevent stroke. We hope that in the future, we can reduce bleeding and unnecessary intraoperative blood transfusion through teamwork.

Based on this review and on our previous experience, we updated our blood transfusion process to include the following:

• Improved protocol for initiating transfusion: The suitability of blood transfusion is determined by the patient’s intraoperative The surgeon and the anesthesia team are strengthening communication on the patient’s age, preoperative hemoglobin, BMI, medical history (e.g. coronary heart disease), intraoperative vital signs, operation time, blood loss, and other information during operation.^3-8

• Improved timeliness of blood delivery: We are ensuring timely delivery (within 5–30 minutes) of intraoperative blood to the patient. The blood bank staff randomly checks the time to deliver blood to the surgical patients, including the time when the blood bank staff receives the blood collection request in the operating room, the preparation time of the blood bank, and the blood delivery time.

There were no funding sources or additional costs for this project.

We presented our finalized processes to the Blood Transfusion Committee and received approval to move forward.

Process Evaluation

The Phase I intervention found that although there was a downward trend in blood transfusion in the whole hospital, intraoperative 1U blood transfusions were more concentrated in the orthopedics department. This led to the initiation of the phase II intervention.

Our hospital improves surgical quality through teamwork. Each team involved in this intervention contributed specific and important work, outlined below.

• Department of Orthopedics
  • Literature review: The department conducted a thorough literature search 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.3-8
  • Publicity and implementation: The department agreed to use hemostatic drugs (TRANSAMIN) during and after surgery and did not use tourniquets during operations, and also publicized the approach in the morning meeting of the department.
  • Individual communication: The director of the department communicated with specific physicians and used literature research as interview materials to improve the publicity effect.
• Department of Anesthesiology
  • Strategy: The department discussed the strategy of reducing unnecessary blood transfusion and publicize the decision of the Blood Transfusion Committee in the department and anesthesia nursing meeting.
  • Operating room support: Discusses the necessity of blood transfusion with the chief surgeon according to the patient’s current vital signs, body temperature, blood loss, etc. during the operation.
• Blood Transfusion Committee
  • Case analysis: Analyzes 1U blood transfusion cases on a quarterly basis through preoperative and intraoperative case data to confirm whether there are still unnecessary blood transfusions.
  • Onsite inspection: Confirms the process of requesting blood from the operating room to the blood bank, preparing blood from the blood bank and sending blood to the operating room to ensure the timeliness of blood delivery.
• Department of Quality Management
  • Accountability: Continuously reviews medical records to collect blood transfusion events during surgery according to NSQIP specifications. 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, etc.) are presented through the Power BI dashboard so that the clinical team can quickly monitor the blood transfusion situation.

Outcome Evaluation

We accept cases according to ACS NSQIP guidelines. Patients had to meet criteria which was deemed to be in their best interest to transfuse blood products (specifically red blood cell and whole blood products) or reinfuse autologous red blood cell or cell-saver products, and to quantify the units utilized/initiated during the primary procedure and up to 72 hours from the surgical start time, postoperatively. Exclusion criteria included outpatient procedures, patients under 18 years of age, patients with an ASA score of 6, patients admitted to treat an injury caused by trauma or abuse, and cases involving Hyperthermic Intraperitoneal Chemotherapy (HIPEC). In addition, according to the needs of cross-team experts, we collected blood transfusion timing (intraoperative and postoperative) and blood loss to facilitate judgment. We used a combination of chart review, automated Power BI dashboards, and drill-down analysis and continuous monitoring of blood transfusion across team members.

After phase II intervention in September 2020, the intraoperative blood transfusion rate during orthopedic surgery decreased slightly from 14.94% to 11.41% (P=0.139) (Figure 4), and intraoperative 1U blood transfusion rate for orthopedic surgery decreased significantly from 3.9% to 0.2957% (P < 0.05) (Figure 5). We were pleased to see this substantial reduction in intraoperative 1U blood transfusion rate. Additionally, postoperative length of stay (LOS) of orthopedics decreased from 6.1 to 5.7 (P=0.49) (Figure 6).

Limitations

• This project is focused on our hospital and is a small sample size. It would be useful to conduct a multi-center or larger project on this
• The project is focused on personal experience. We changed our culture and behaviors, but we are unsure if this type of experience has occurred in other hospitals.

Cost Evaluation

We estimate that we reduced blood transfusions for 126 patients per year. Assuming the average blood transfusion cost per patient is $219, this intervention may reduce the annual cost of blood transfusions for orthopedic surgery by $27,594.⁹

Knowledge Acquisition

• Communication of data is The Power BI system is a useful tool. We will continue to utilize this system to monitor patients, identify problems, educate, and share data between colleagues and surgeons.
• Interdepartmental cooperation is The project involved the cooperation of three departments: Department of Orthopedic Surgery, Blood Bank and Blood Transfusion Committee, and Department of Quality Management. We worked together to review the data, determine the transparency, and develop solutions.

• Quality improvement enhances patient-centeredness. This project has encouraged our hospital and surgeons to increase our focus on We have increased our focus on the patient by monitoring their medical condition more closely. This is a valuable lesson; we can do more for patient safety and patient care.

End-of-Project Decision-Making

• We have shared our results within our We would like to communicate our results with other hospitals and hope our example may influence other surgeons or hospitals to share their experiences.

• It would be beneficial to share our concerns with other surgeons and discuss how to reduce surgical risk.
• For this QI project, we focused on monitoring the blood transfusion rate. We plan to drill down into the data to determine if there are additional procedures or issues to monitor. For example, some problems may not be surgical but rather related to the specific patient case.
• This project is We will continue to monitor our data in the Power BI dashboard. We will continue to review the suitability of blood transfusion through intraoperative blood loss, blood transfusion time, and procedures. The Blood Bank and Blood Transfusion Committee will continue to conduct discussions based on the NSQIP case list, on a case-by-case basis.

References

1. Kracalik I, Mowla S, Basavaraju SV, and Sapiano (2021). Transfusion-related adverse reactions: Data from the National Healthcare Safety Network Hemovigilance Module - United States, 2013-2018. Transfusion, 61(5), 1424-1434.
2. Raval JS, Griggs JR, and Fleg A. (2020). Blood Product Transfusion in Adults: Indications, Adverse Reactions, and Am Fam Physician, 102(1), 30-38.
3. Vaish A, Belbase RJ, and Vaishya R. (2020). Is blood transfusion really required in simultaneous bilateral Total Knee Replacement: A retrospective observational study. J Clin Orthop Trauma, 11(Suppl 2), S214-S218.
4. Cao G, Huang Z, Huang Q, Zhang S, Xu B, and Pei F. (2018). Incidence and Risk Factors for Blood Transfusion in Simultaneous Bilateral Total Joint Arthroplasty: A Multicenter Retrospective Study. J Arthroplasty, 33(7), 2087-2091.
5. Dömötör H, Varga ÁL, Sződy R, Tóth F, and Nardai G. (2021). Institutionally Adopted Perioperative Blood Management Program Significantly Decreased the Transfusion Rate of Patients Having Primary Total Hip Replacement Surgery. Adv Orthop,
6. Donovan RL, Lostis E, Jones I, and Whitehouse MR. (2021). Estimation of blood volume and blood loss in primary total hip and knee replacement: An analysis of formulae for perioperative calculations and their ability to predict length of stay and blood transfusion requirements. J Orthop, 24, 227-232.
7. Rao SS, Chaudhry YP, Hasan SA, Puvanesarajah V, Amin RM, Oni JK, Sterling RS, and Khanuja (2021). Factors Associated with Perioperative Transfusion in Lower Extremity Revision Arthroplasty Under a Restrictive Blood Management Protocol. J Am Acad Orthop Surg, 29(8), e404-e409.

8. Song K, Pan P, Yao Y, Jiang T, and Jiang Q. (2019). The incidence and risk factors for allogenic blood transfusion in total knee and hip arthroplasty. J Orthop Surg Res, 14(1), 273.
9. Forbes JM, Anderson MD, Anderson GF, Bleecker GC, Rossi EC, and Moss GS. (1991). Blood transfusion costs: a multicenter study. Transfusion, 31(4), 318-23.