Implementation of a patient blood management program in an Australian private hospital orthopedic unit

Figures & data

Table

Preoperative phase: All patients to have preoperative full blood count to examine hemoglobin levels, full iron tests (including ferritin and transferrin saturation), C-reactive protein, and renal function tests (urea and creatinine) added to their standard preoperative blood tests up to 28 days preoperatively.

Anemia (hemoglobin level of <130 g/L in men and <120 g/L in women) and low iron stores (ferritin level of <100 µg/L) to be treated with iron replacement prior to surgery (either oral iron in divided daily doses, or intravenous iron if oral iron not tolerated or effective or where rapid iron repletion is required ie, <2 months to nondeferrable surgery) as indicated by the National Blood Authority’s preoperative algorithm.

As serum ferritin is an acute-phase reactant, it is important to examine both ferritin and transferrin saturation levels to determine the level of iron stores.

Postoperative phase: Patients are not to receive a blood transfusion when the hemoglobin level is ≥100 g/L in the postoperative period from day of surgery until discharge on day 5–7 of the acute postoperative period.

Patients with postoperative anemia should be assessed based on the patient’s clinical status and not on a hemoglobin ‘trigger’ alone. If a transfusion is deemed necessary, then 1 unit of blood is to be administered and the patient reassessed to examine response prior to further transfusion.

Table

Executive support

The Chief Executive Officer of the hospital opened the project launch.

Interactive education

A specialist physician and the CEO of the hospital launched the project and presented the key PBMP messages to surgeons during a 30-minute presentation.

Orthopedic ward nurses and pre-admission clinic nurses were also informed of the implementation project and attended a single 15-minute educational session outlining PBM aims and outcome measures. Nursing education was supported by Blood Safe e-learning module – Patient Blood Management located on the hospital’s intranet.

Peer to peer support

Specialist physician was available by telephone call or email to provide expert clinical advice concerning blood results and treatment.

Principal investigator made daily visits to pre-admission staff to encourage interpretation of blood results emphasising anemia and iron deficiency markers and encouragement to contact the relevant surgeon.

Email and poster reminders

Official National Blood Authority posters were placed in the stairwell and treatment rooms. These posters were changed monthly and communicated key messages such as single unit transfusion and dispelling myths about blood safety, improved healing and no associated cost with blood transfusion.

Monthly short targeted emails were sent to participating surgeons to remind them of the key points from the launch (Box 3), guidelines and relevant articles.

Audit feedback mechanism

Half way through the implementation phase an audit and feedback was conducted and reported back to the surgeons.

Table 1 Patient demographics

Demographics	Preimplementation (n=239) n (%)	Postimplementation (n=261) n (%)	P-value*
Gender
Female	154 (64)	151 (58)	0.132
Male	85 (36)	110 (42)
Age (years)
0–40	3 (1.2)	5 (1.9)	0.402
41–60	72 (30)	50 (19)
61–80	145 (61)	183 (70)
81+	19 (7.9)	23 (8.8)
ASAa
Healthy person	47 (20)	35 (13)	0.87
Mild systemic disease	113 (47)	105 (40)	0.19
Severe systemic disease	26 (11)	51 (20)	0.003*
Severe systemic disease that is a constant threat to life	0	3 (1.1)	0.25b
Not recorded	53 (22)	67 (26)

Notes:

a Physical status system by ASA,

b Fisher’s exact test,

* P-value significant <0.05.

Abbreviation: ASA, American Society of Anesthesiologists.

Table 2 Patient’s preoperative tests and time completed

Preoperative tests	Preimplementation (n=239) n (%)	Postimplementation (n=261) n (%)	P-value*
Full blood count	238 (99.5)	260 (99.6)	0.999
Full iron studies (ferritin and transferrin saturation)	1 (0.4)	254 (97)	<0.0001*
C-reactive protein	132 (55)	245 (94)	<0.0001*
Renal function studies (urea, creatinine, and electrolytes)	238 (99.5)	258 (98.8)	0.625a
All above preoperative tests completed	0	247 (95)	<0.0001*
Time (days) preoperative blood sample obtained to day of surgery (mean)	16 (days)	20 (days)	<0.0001*

Notes:

* P-value significant <0.05;

a Fisher’s exact test.

Table 3 Patient preoperative diagnosis of anemia and iron deficiency and postoperative management

	Preimplementation (n=239) n (%)	Postimplementation (n=261) n (%)	P-value*
Preoperative anemia and iron deficiencya
Patients with anemia (full blood count – hemoglobin)	12 (5.0)	20 (7.6)	0.224
Patients with iron deficiency (full iron studies)	Not known	105 (40)
Patients with anemia and iron deficiency (full blood count and full iron studies)	Not known	13 (4.9)
Iron infusion and intraoperative tranexamic acid injection
Received iron infusion preoperatively	0	12 (4.5)	0.001*
Tranexamic acid used, intraoperatively/postoperatively	155 (65)	242 (93)	<0.0001*
Postoperative ABT
Number of patients who received an ABT	22 (9.2)	6 (2.3)	0.001*
1 blood unit	3/22 (14)	5/6 (83)	0.003a
2 blood units	16/22 (73)	1/6 (17)	0.022a
3–5 blood units	3/22 (14)	0/6	0.999a
Number of preoperative anemic patients (full blood count – hemoglobin) transfused	7/12 (58)	5/20 (25)	0.059
Number of patients with both preoperative anemia and iron deficiency transfused, as % of total patients transfused	Not known	4 (67)	N/A

Notes:

* P-value significant <0.05,

a Fisher’s exact test. Anemia defined as hemoglobin level of <130 g/L in men and <120 g/L in women; iron deficiency defined as ferritin level of <100 µg/L.²¹

Abbreviations: ABT, allogenic blood transfusion; N/A, not applicable.

The National Blood AuthorityPatient Blood Management Guidelines: Module 2 – PerioperativeCanberra, AustraliaNational Health Medical Research Council2012

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