Patient blood management (PBM) has been defined as “the timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis and minimize blood loss in an effort to improve patient outcome.”1 Several strategies have been used in the three-pillar approach of optimizing red blood cell mass, minimizing blood loss, and managing anemia in patient blood management.2 Before the introduction of patient blood management strategies, transfusion rates for total hip arthroplasty (THA) and total knee arthroplasty (TKA) were in the vicinity of 18% and 13%, respectively. With the aid of these strategies, however, the current reported transfusion rates are approximately 9% and 4.5%, respectively, in the United States.3 These figures demonstrate a considerable reduction in blood transfusions over the last decade, which is consistent with the decreasing rates reported in similar regions in the literature.4–6 PBM has been developed to minimize the number of transfusions and to avoid risks associated with transfusion and anemia in surgical patients.7 These strategies appear to be effective, showing a steady decline over recent years in both THA and TKA.3 In major orthopaedic surgery (elective joint arthroplasty or traumatic hip fracture repair), perioperative anemia occurs with a prevalence of up to 80%, most of which occurs in the postoperative period.8 When only looking at THA and TKA, perioperative anemia remains high in this subgroup with preoperative anemia approximately 25% and postoperative anemia approximately 50%.8 Perioperative anemia also is associated with increased transfusion rates,8–10 and transfusion is associated with increased morbidity11–13 and mortality.9,14 Patients are particularly at risk of serious bacterial infections, wound breakdown, transfusion reactions and increased hospital length of stay in addition to greater mortality.
One way to improve patient blood management practice is by optimizing red blood cell mass before surgery. Specifically, in THA and TKA, preoperative anemia is independently associated with transfusion, supporting the need for preoperative evaluation and treatment.15 In particular, it is recommended that patients with preoperative anemia are identified, and if iron deficient then preoperative iron therapy has been advocated. Another way to improve patient blood management is through minimizing blood loss. Intraoperative use of the antifibrinolytic agent tranexamic acid (TXA) has shown safety and efficacy in orthopaedic surgery, especially in THA and TKA for controlling perioperative and postoperative bleeding.16 It was initially introduced more than 40 years ago and since has shown application in cardiothoracic,17 trauma,18 obstetrics and gynecology,19,20 gastrointestinal,21 hepatic,17 urologic,22 and ear, nose, throat (ENT)17,23 surgery. It is being increasingly utilized in orthopaedics and has shown efficacy in reducing perioperative bleeding.16 The final pillar of patient blood management is treating anemia holistically within an organization. The authors believe this to encompass the multimodal approach on an organizational level, with strategies ranging from educational resources, specific staff training, and application of internal protocols that are driven by a national standard such as the National Blood Authority.
The aim of this study was to outline how the development of a multimodal PBM approach occurred in our large metropolitan tertiary network over 7 yr (2009-2015) and evaluate its effectiveness over this period. The primary outcomes were the number of allogenic blood transfusions administered and whether the blood transfusions were administered appropriately in accordance with National Blood Authority guidelines.
MATERIALS AND METHODS
Orthopaedic and Anaesthetic Department approval was obtained for this study. Research was carried out with the consent of all participants involved. We prospectively collected blood transfusion data over a yearly quarter (3 mo) in the years of 2009, 2012, 2014 and 2015 with patients undergoing primary or revision THA and TKA. Patients were excluded if they had an acquired coagulopathy, congenital or acquired thrombophilia, history of thromboembolism, or an allergy to tranexamic acid. Patient data were de-identified using hospital identification and episode numbers. Informed consent was gained from participating individuals. The data were then retrospectively analyzed, observing rates and appropriateness of blood transfusions in the context of changes in national guidelines, requirements, and evidence-based patient blood management strategies. Throughout this period, patient blood management strategies had been implemented in a sequential order within the health service, leading to a timeline of events (Figure 1). At each time-point the audit tool was amended to include additional hospital and National Blood Authority guidelines, and data were collected after the implementation of additional blood management strategies.
The requirement for blood transfusion and the TXA dosing schedule was determined by the case anesthetist during the intraoperative period. The treating orthopaedic team monitored hemoglobin levels and patient symptoms in the postoperative phase and therefore determined the requirement for blood transfusion during this period. Transfusion practice was strictly in accordance with the Australian Blood Management Perioperative guidelines that was published at the time.24,25 The internal hospital educational resource ‘We-Learn’ blood management modules were implemented as part of the National Safety and Quality Health Service Standards (NSQHS) Standard 7 ‘Blood and Blood Products’.26 The module included activities and readings pertaining to pretransfusion testing, how to request blood and blood products, as well as consent, prescribing and adverse reaction management and reporting. The implementation of the internal intravenous TXA protocol for arthroplasty (see Table 1) was authorized internally by the Drug and Therapeutics Committee27 following national recommendation by the Patient Blood Management Guidelines: Module 225 and was created in a conjoined effort by the orthopaedic and anesthesia departments. Compulsory training of this TXA protocol was undertaken by both anesthesia consultants and registrars in order to meet hospital standard and was visually displayed in each operating theater. Finally, the introduction of the preoperative anemia optimization protocol and treatment of anemia (men <130 g/L and women <120 g/L) included resident medical officers arranging an iron transfusion of 1 g of iron carboxymaltose before surgery (Figure 2). All patient transfusion data were recorded by a single transfusion nurse at each time point (SM).
Data were collected on a total of 200 THA and 242 TKA primary and revision procedures between 2009 and 2015 that met inclusion criteria. The number of revisions are detailed in Table 2 for each sample and make up the minority of the data. Statistical analysis was performed using Statistica 6.0 (Statsoft Inc) using an ANOVA multivariate analysis for baseline characteristics and Pearson Chi-squared test for transfusion analysis. The level of significance for all statistical tests was set at 0.05.
The mean age for THA males and females was 65.6±11.4 yr and 69.3±12.6 yr, respectively. The mean age for TKA males and females was 67.7±8.6 yr and 67.3±8.8 yr, respectively. Significant age difference was found in the THA sample, showing older patients in 2009 compared with other samples (F (2, 149)=4.76, P<0.05). As expected, in both THA and TKA, males had a significantly greater preoperative hemoglobin (mean 14.1±1.5 for THA; and 14.4±1.5 for TKA, P<0.05) compared with females (mean 13.0±1.3 for THA; and 13.1±1.1 for TKA, P<0.05). The proportion of primary and revision cases within each sample was not statistically different between sample groups.
Chi square analysis showed significant reduction in transfusion rates from 2009 to 2015 in both THA (38.5%; 24.4%; 8.5%; and 12.5% for 2009; 2012; 2014; and 2015; χ2=17.9, P<0.05), and TKA (12.4%; 6.1%; 7.8%; and 2.1% for 2009; 2012; 2014; and 2015; χ2=4.2, P<0.05). This coincided with an increased adherence to give the blood transfusion in line with national guidelines in both THA and TKA (χ2=7.19, P=0.027) (Table 2 and Figure 3). Importantly, the TXA protocol was implemented after sampling in 2009. After its introduction, the most significant reductions in transfusions occurred when compared to baseline in both THA (38.5% to 24.4%) and TKA (12.4% to 6.1%), with these numbers continuing to drop in subsequent years once further initiatives were introduced.
Our study demonstrated the effectiveness of implementing several patient blood management strategies, including educational packages, a TXA protocol, and preoperative anemia optimization protocol. We found a stepwise reduction of allogenic transfusion rates, which coincided with an increased adherence in appropriateness to give a blood transfusion with national clinical practice guidelines at our institution. Previous studies have looked at the adherence of certain aspects of their respective national guidelines and a relationship to transfusion from a ‘before and after’ perspective. To our knowledge, however, this is the first study to implement multiple strategies and collect data across several years as the patient blood management landscape changed within Australia from an orthopaedic perspective. Recently, Norgaard et al.28 undertook a large patient blood management study in Denmark, which included both medical and surgical patients. They implemented a patient blood management program from their evidence-based guidelines and demonstrated significant reductions in transfusions and an overall increase in compliance with their national guidelines. Within Australia, Kopanidis et al.29 performed a before and after study that aimed to define an optimal strategy for blood management in the setting of major orthopaedic joint surgery using both preoperative and intraoperative measures. The authors compared usual care (no preoperative anemia optimization, no intraoperative TXA use) with an intervention (preoperative anemia optimization and intraoperative TXA). They found a reduction in incidence of preoperative anemia and a lower incidence of allogenic blood transfusions. Other authors have analyzed the effect of instituting a blood management program that included the use of preoperative iron transfusions with erythropoietin and intraoperative TXA with cell salvage devices.30 This program significantly reduced the rate of allogenic blood transfusions and length of stay.
In reviewing the literature regarding the three-pillar approach2 (optimizing red blood cell mass, minimizing blood loss, and managing anemia) there are studies that have discussed each of these aspects individually. Regarding the optimization of red blood cell mass, Kearney et al.31 demonstrated that 17% of orthopaedic arthroplasty patients were anemic, with half of these being iron-deficient. They were able to improve and treat their anemia, which subsequently resulted in reducing perioperative transfusion rates.31 Secondly, minimizing blood loss has been improved with the introduction of TXA. Evangelista et al.32 performed a cost and comparative effective analysis, which demonstrated that TXA implementation was safe and decreased both THA and TKA transfusions. It also significantly reduced hospital costs. With respect to overall management of anemia, which broadly includes education, Champion et al.33 implemented educational transfusion modules to their surgical residents. The authors demonstrated that transfusion knowledge was improved. The clinical implications of our findings suggest that improvements can be made in patient blood management by taking on the recommendations and guidelines that are provided on a national level and individualizing them to a specific health network. Importantly, our study illustrates that a multimodal approach to blood management strategies over time rather than single interventions are important, particularly in large health networks.
There are several limitations to this study. First, the numbers in each cohort were small, and the incidence of transfusion within each cohort was small, therefore small differences can appear larger when expressed as a percentage. Second, the most significant reduction in transfusion rates were demonstrated after the 2009 sample. Our data suggested that patients in the 2009 cohort were statistically older than those in subsequent groups, raising the possibility that a younger demographic in cohorts following the 2009 sample may have contributed to these cohorts receiving fewer transfusions. It does not, however, explain the ongoing reduction in transfusion for subsequent years, nor does it explain the increase in adherence with national guidelines. Third, because of the progressive nature of implementing interventions across time, we recognize that there are many confounders to the trend in the data. We are not able to determine, which intervention(s), or which combination of interventions is most significant in causing a change in transfusion practice nor if an improvement in surgical technique may have contributed to a reduction in transfusion rates. This, however, was not the aim of the study because it was not intended to be a true ‘before and after’ study. The aim of the study was to simply outline a real-life example of implementing patient blood management strategies over time within a large network. Finally, the generalizability of our results to other hospitals is limited, since we collected data and implemented internal guidelines, despite these being based on national guidelines.
In conclusion, the introduction of several patient blood management strategies reduced the number of allogenic blood transfusions administered to patients undergoing THA and TKA at our institution. The reduction coincided with an increase in adherence to national blood transfusion guidelines. A multimodal and individualized approach is the most effective way to achieve this in a large health service and outlines how in reality these approaches and strategies are implemented over time.
1. Society for the Advancement of Blood Management Professional definition. Patient Blood Management, 2005-2017. Available at: http://www.sabm.org/
. Accessed May 5, 2017.
2. National Blood Authority Three pillars of patient blood management. Adapted from: Spahn DR, Goodnough LT. Alternatives to Blood Transfusion
2013; 381: 1855-1865; Hoffman A, Farmer S, Towler SC. Strategies to preempt and reduce the use of blood products: an Australian perspective. Curr Opin Anaesthesiol
. 2012; 25: 66-73; and Isbister JP. The three-pillar matrix of patient blood management – an overview. Best Pract Res Clin Anaesthesiol
. 2013; 27: 69-84. Available at: https://www.blood.gov.au/system/files/documents/pbm- 3-pillars.pdf
. Accessed October 17, 2017.
3. Bedard NA, Pugely AJ, Lux NR, et al. Recent trends in blood utilization after primary hip and knee arthroplasty
. J Arthroplasty
. 2017; 32:724–727.
4. Frew N, Alexander D, Hood J, et al. Impact of a blood management protocol on transfusion rates and outcomes following total hip and knee arthroplasty
. Ann R Coll Surg Engl. 2016; 98:380.
5. Holt JB, Miller BJ, Callaghan JJ, et al. Minimizing blood transfusion
in total hip and knee arthroplasty
through a multimodal approach. J Arthroplasty
. 2016; 31:378.
6. Loftus TJ, Spratling L, Stone BA, et al. A patient blood management program in prosthetic joint arthroplasty
decreases blood use and improves outcomes. J Arthroplasty
. 2016; 31:11.
7. Rineau E, Chaudet A, Chassier C, et al. Implementing a blood management protocol during the entire perioperative period allows a reduction in transfusion rate in major orthopedic surgery: a before-after study. Transfusion. 2016; 56:673–681.
8. Spahn DR. Anemia and patient blood management in hip and knee surgery: a systematic review of the literature. Anesthesiology. 2010; 113:482–495.
9. Beattie WS, Karkouti K, Wijeysundera DN, et al. Risk associated with preoperative anemia in non-cardiac surgery. Anesthesiology. 2009; 110:574–581.
10. Rosencher N, Kerkkamp HE, Macheras G, et al. Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty
in Europe. Transfusion. 2003; 43:459–469.
11. Carson JL, Altman DG, Duff A, et al. Risk of bacterial infection associated with allogeneic blood transfusion
among patients undergoing hip fracture repair. Transfusion. 1999; 39:694–700.
12. Innerhofer P, Klingler A, Klimmer C, et al. Risk for postoperative infection after transfusion of white blood cell-filtered allogeneic or autologous blood components in orthopedic patients undergoing primary arthroplasty
. Transfusion. 2005; 45:103–110.
13. Weber EW, Slappendel R, Prins MH, et al. Perioperative blood transfusions and delayed wound healing after hip replacement surgery: effects on duration of hospitalization. Anesth Analg. 2005; 100:1416–1421.
14. Glance LG, Dick AW, Mukamel DB, et al. Association between intraoperative blood transfusion
and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology. 2011; 114:283–292.
15. Jans O, Jorgensen C, Kehlet H, et al. Role of preoperative anemia for risk of transfusion and postoperative morbidity in fast-track hip and knee arthroplasty
. Transfusion. 2014; 54:717–726.
16. Lin ZX, Woolf SK. Safety, efficacy, and cost-effectiveness of tranexamic acid
in orthopaedic surgery
. Orthopaedics. 2016; 39:119–130.
17. Dunn CJ, Goa KL. Tranexamic acid
: a review of its use in surgery and other indications. Drugs. 1999; 57:1005–1032.
18. Pusateri AE, Weiskopf RB, Bebarta V, et al. Tranexamic acid
and trauma: current status and knowledge gaps with recommended research priorities. Shock. 2013; 39:121–126.
19. Peitsidis P, Kadir RA. Antifibrinolytic therapy with tranexamic acid
in pregnancy and postpartum. Expert Opin Pharmacother. 2011; 12:503–516.
20. Naoulou B, Tsai MC. Efficacy of tranexamic acid
in the treatment of idiopathic and non-functional heavy menstrual bleeding: a systematic review. Acta Obstet Gynecol Scand. 2012; 91:529–537.
21. Gluud LL, Klingenberg SL, Langholz SE. Systematic review: tranexamic acid
for upper gastrointestinal bleeding. Aliment Pharmacol Ther. 2008; 27:752–758.
22. Rannikko A, Petas A, Taari K. Tranexamic acid
in control of primary hemorrhage during transurethral prostatectomy. Urology. 2004; 64:955–958.
23. Abbasi H, Behdad S, Ayatollahi V, et al. Comparison of two doses of tranexamic acid
on bleeding and surgery site quality during sinus endoscopy surgery. Adv Clin Exp Med. 2012; 21:773–780.
24. National Health & Medical Research Council / Australian Society of Blood Transfusion
Inc. Clinical Practice Guidelines on the use of Blood Components. Report for the Commonwealth of Australia. Endorsed September 2001. Available at: https://www.nhmrc.gov.au/guidelines-publications/cp78
. Accessed October 17, 2017.
25. National Health & Medical Research Council / National Blood Authority Commonwealth of Australia. Patient Blood Management Guidelines: Module 2 – Perioperative. Approved November 2011. Available at: https://www.blood.gov.au/pbm-module-2
. Accessed October 17, 2017.
26. Australian Commission on Safety and Quality in Health Care National Safety and Quality Health Service Standards. September 2012. Sydney. Available at: https://www.safetyandquality.gov.au/our-work/assessment-to-the-nsqhs-standards/resources-to-implement-the-nsqhs-standards/
. Accessed October 17, 2017.
27. Drug and Therapeutics Committee at Western Health Guidelines for the Perioperative Administration of Tranexamic Acid for Orthopaedic Arthroplasty Surgery Western Health
2014. pp. 1-5.
28. Norgaard A, Stensballe J, de Lichtenberg TH, et al. Three-year follow-up of implementation of evidence-based transfusion practice in a tertiary hospital. Vox Sanguinis. 2017; 112:229–239.
29. Kopanidis P, Hardidge A, McNicol L, et al. Perioperative blood management program reduces the use of allogenic blood transfusion
in patients undergoing total hip and knee arthroplasty
. J Orthop Surg Res. 2016; 11:1–8.
30. Kotze A, Carter L, Scally A. Effect of a patient blood management program on preoperative anaemia, transfusion rate, and outcome after primary hip or knee arthroplasty
: a quality improvement cycle. Br J Anaesth. 2012; 108:943–952.
31. Kearney B, To J, Southam K, et al. Anaemia in elective orthopaedic surgery
– Royal Adelaide Hospital, Australia. In Med J. 2016; 46:96–101.
32. Evangelista PJ, Aversano MW, Koli E, et al. Effect of tranexamic acid
on transfusion rates following total joint arthroplasty
: a cost and comparative effective analysis. Orthop Clin North Am. 2017; 48:109–115.
33. Champion C, Saidenberg E, Lampron J, et al. Blood transfusion
knowledge of surgical residents: is an educational intervention effective? Transfusion. 2017; 57:965–997. 301.