A Simple Guideline Reduces the Need for Red Blood Cell Transfusions in Swiss Hospitals: A Prospective, Multicentre, Before-and-After Study in Elective Hip and Knee Replacement

Abstract

Introduction: Optimising the use of blood has become a core task of transfusion medicine. Because no general guidelines are available in Switzerland, we analysed the effects of the introduction of a guideline on red blood cell (RBC) transfusion for elective orthopaedic surgery. Methods: Prospective, multicentre, before-and-after study comparing the use of RBCs in adult elective hip or knee replacement before and after the implementation of a guideline in 10 Swiss hospitals, developed together with all participants. Results: We included 2,134 patients, 1,238 in 7 months before, 896 in 6 months after intervention. 57 (34 or 2.7% before, 23 or 2.6% after) were lost before follow-up visit. The mean number of transfused RBC units decreased from 0.5 to 0.4 per patient (0.1, 95% CI 0.08-0.2; p = 0.014), the proportion of transfused patients from 20.9% to 16.9% (4%, 95% C.I. 0.7-7.4%; p = 0.02), and the pre-transfusion haemoglobin from 82.6 to 78.2 g/l (4.4 g/l, 95% C. I. 2.15-6.62 g/l, p < 0.001). We did not observe any statistically significant changes in in-hospital mortality (0.4% vs. 0%) and morbidity (4.1% vs. 4.0%), median hospital length of stay (9 vs. 9 days), follow-up mortality (0.4% vs. 0.2%) and follow-up morbidity (6.9% vs. 6.0%). Conclusions: The introduction of a simple transfusion guideline reduces and standardises the use of RBCs by decreasing the haemoglobin transfusion trigger, without negative effects on the patient outcome. Local support, training, and monitoring of the effects are requirements for programmes optimising the use of blood.

Transfusion practice in anemic, non-bleeding patients: Cross-sectional survey of physicians working in general internal medicine teaching hospitals in Switzerland

“…Politsmakher et al showed that the implementation of a hospital monitoring program reduced the rate of RBC transfusion by 38.1% in his study setting, which was associated with a decrease in morbidity and mortality [ 41 , 42 ]. Similar to our study but in the intensive care setting Hebert et al conducted a survey among physicians using case scenarios which showed, that 85% of physicians had modified their approach to transfusion, primarily in response to the publication of a major Canadian clinical trial and institutional guidelines [ 43 ].…”

“…50% of the physicians reported the absence of local transfusion guidelines for RBC administration. At present, no Swiss national guidelines exist regarding RBC transfusion practice in patients without acute blood loss [ 42 ]. The majority of the interviewed physicians (84%) would support the development of national treatment recommendations on transfusion of RBC in non-acutely bleeding patients with anemia.…”

Diagnostic strategies for posttraumatic osteomyelitis: a survey amongst Dutch medical specialists demonstrates the need for a consensus protocol

“…Any delay in diagnosis will obviously also delay the start of treatment and subsequently the recovery of a patient with PTO, hence overall costs will increase. It is known from other orthopaedic studies that, as a general rule, both patients and cost effectiveness benefit from clinical pathways and guidelines [ 30 , 31 ]. There is thus a need for a lean and strict algorithm on diagnosing PTO.…”

The aging human recipient of transfusion products

“…Given such remaining uncertainty it seems reasonable to consider additional risk factors beside a Hb cut-off as criteria for RBC transfusion as proposed by Fontana and coworkers in a recent prospective interventional study in orthopedic patients [41]. Similarly Theusinger and coworkers propose to decide on RBC, FFP and platelet transfusion on a case-per-case basis rather than on a specific medical laboratory profile issued as transfusion trigger [42], an approach bearing biologic variation in mind.…”