Institution-Wide Blood Management Protocol Reduces Transfusion Rates Following Spine Surgery

Abstract

Background: Spine surgery is associated with significant intraoperative blood loss, often leading to transfusion. Patients who receive transfusions have an increased length of stay and risk of perioperative complications. To decrease the transfusion rate, we implemented an evidence-based institution-wide restrictive transfusion blood management guideline. The goal of this study is to describe the impact of this guideline on our spine surgery patients. Methods: We analyzed the incidence of transfusion following 3709 single-institution, inpatient spine procedures before and after implementation of a revised blood transfusion protocol. The baseline period (1742 patients) from January 2014 to March 2015 was compared to the study period (1967 patients) of April 2015 to July 2016. One patient was excluded because of incomplete medical records. The revised protocol included establishing a postoperative blood transfusion trigger at hemoglobin , 7g/dL, instituting a computerized provider order entry, and appointing a physician champion to monitor and report progress. Results: Transfusion rate decreased from 16.2% to 9.7% from baseline to study period, respectively (P , .001). The number of transfusions in patients with hemoglobin. 7g/dL decreased to 4.9% from 6.1% (P ¼ .09). The rate of transfusions with a prior hemoglobin test increased from 42.0% to 59.1% (P , .001). Length of stay was reduced from 3.67 to 3.46 days (P ¼ .04), and postsurgical infection rate was reduced from 1.5% to 0.6% (P ¼ .01). There was no significant difference in total hospital costs following protocol implementation. Conclusions: Implementation of a restrictive transfusion protocol through use of a computerized provider order entry and a physician champion to oversee clinician compliance led to a 40.1% reduction in blood transfusion following spine surgery. Behavior changes were visible with a 40.7% increase in hemoglobin documentation before transfusion, and patients benefited from a reduction in length of stay and postsurgical infection rate. Future study is encouraged to understand the long-term impact of this intervention and its role in hospital expenditure.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care

“…The implementation of a restrictive blood management protocol in a group of 3709 patients with a transfusion trigger of less than 7 g dl −1 could reduce the number of transfusions from 16.2 to 9.7% without negative side effects 972 …”

“…971 The implementation of a restrictive blood management protocol in a group of 3709 patients with a transfusion trigger of less than 7 g dl À1 could reduce the number of transfusions from 16.2 to 9.7% without negative side effects. 972 A recent meta-analysis included 23 studies (1621 patients) investigating the efficacy of i.v. TXA on peri-operative blood loss and transfusion in elective, multilevel spine surgery.…”

Single-Surgeon Versus Dual-Surgeon Strategy in Spinal Tumor Surgery

“…15,19 These advantages correlate independently with improved postoperative morbidity and mortality following elective spine surgery, [28][29][30][31][32] and decreasing blood transfusion lead to a significant decrease in surgical site infection rates and decreased length of hospital stay. 31,[33][34][35] Likewise, operative time reduction can lead to a significant decrease in the wound and pulmonary complications, sepsis, venous thromboembolism, postoperative transfusion, length of stay, reoperation, and unplanned readmission 31,32,36 ; it also leads to significant cost reduction. 37,38 In the present study, we did not find significant differences in intraoperative complications or postoperative morbidity between the dual-surgeon and single-surgeon cohorts.…”

Systematic review and meta-analysis of the clinical utility of Enhanced Recovery After Surgery pathways in adult spine surgery

“…Nevertheless, there is robust level III support in spine patients for smoking cessation, restrictive transfusion limits, intraoperative normothermia, goal-directed intraoperative fluid replacement, and expedited discontinuation of urinary catheters and surgical drains. 27,70,71 Some of these interventions, such as smoking, rely heavily on patient adherence and may not be amenable to RCTs. However, transfusion strategies and drain removal policies are potential points of investigation and merit further exploration in prospective randomized trials.…”