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

Abstract

Paul N Morgan,1 Patrick L Coleman,2 Cintia Mayel Martinez-Garduno,3 Anoja W Gunaratne,3 Elizabeth McInnes,3 Sandy Middleton3 1Quality Improvement Unit, The Mater Private Hospital (Sydney), St. Vincent’s Health Australia, North Sydney, NSW, Australia; 2Dale Street Medical Specialists Pty Ltd, Brookvale, NSW, Australia; 3Nursing Research Institute, St Vincent’s Health Australia (Sydney) and the Australian Catholic University School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, NSW, Australia Background: Preoperative anemia in surgical patients has been linked to increased rates of allogeneic blood transfusion (ABT) and associated adverse patient outcomes such as prolonged ventilation in intensive care, increased length of hospital stay, and infections. We conducted a multifaceted implementation for orthopedic surgeons to improve preoperative patient assessment of anemia and iron deficiency to reduce perioperative blood transfusions. Materials and methods: Using a before-and-after study design of independent samples, we recruited a convenience sample of surgeons who performed primary total hip arthroplasty at 1 Australian private hospital. Our implementation intervention consisted of: executive support, interactive education, and peer-to-peer support to encourage adherence to the National Blood Authority’s Patient Blood Management Program (PBMP) guidelines. We also used monthly reminders, e-learning access, and posters. Pre and post medical record audits evaluated preoperative blood tests, preoperative anemia, and number of blood units transfused between day of surgery until discharge. The primary outcome was an increase in the proportion of patients with preoperative blood tests undertaken prior to total hip arthroplasty surgery as recommended by the PBMP guidelines. Results: Audits from 239 pre- and 263 postimplementation patients from 3 surgeons were conducted. Our primary outcome showed a significantly increased proportion of patients who had all the required preoperative tests postimplementation (0% to 94.6%; P<0.0001). Administration of ABT significantly decreased (pre: 9.2%, n=22; post: 2.3%, n=6; P=0.001) as well as the standard 2 blood units transfused (pre: 73%, n=16; post:17%, n=1; P=0.022). The time between preoperative tests and day of surgery increased from 16 to 20 days (P<0.0001), allowing more time for physician’s review of test results. Conclusion: Our results demonstrated successful implementation of a targeted PBMP to improve preoperative assessment to diagnose and treat anemia and/or iron deficiency prior to orthopedic surgery. This avoided unnecessary ABT and therefore mitigated potential risk to the patient. Keywords: anemia, allogeneic blood transfusion, iron deficiency, patient blood management, clinician behavior change, implementation research

Keywords

• anaemia
• allogeneic blood transfusion
• iron deficiency
• patient blood management
• clinician behaviour change
• implementation research