The impact of a multidisciplinary blood conservation protocol on patient outcomes and cost after cardiac surgery

Patient Blood Management as an Emerging Concept in Quality: The Role of Nurses

BACKGROUND

Transfusion of blood components has long been considered lifesaving therapy. While blood transfusion may be clinically indicated as a treatment option for some patients, the benefits of transfusion in asymptomatic, hemodynamically stable patients are questionable.

PROBLEM

Blood component transfusion is routinely used as a default therapy when not clinically indicated, increasing the risk of poor patient outcomes, adverse events, pressures on blood supply and availability, and increased health care costs.

APPROACH

Nurses have the responsibility to advocate for patients and reduce/avoid unnecessary blood transfusion through the implementation of patient blood management (PBM). The PBM paradigm includes treatment of anemia, minimizing blood loss and bleeding, optimization of coagulation, and employing true patient-centered decision making.

CONCLUSIONS

PBM should become the standard of care with the goal of improving health care quality and patient outcomes while using the multidisciplinary team for its implementation. As advocates for their patients, nurses can play a major role in the development, implementation, and promotion of PBM.

Implementation of Patient Blood Management in Orthotopic Heart Transplants: A Single Centre Retrospective Observational Review

BACKGROUND

Blood transfusion in the perioperative cardiothoracic setting has accepted risks including deep sternal wound infection, increased intensive care unit length of stay, lung injury, and cost. It has an immunomodulatory effect which may cause allo-immunisation. This may influence long-term survival through immune-mediated factors. Targeting coagulation defects to reduce unnecessary or inappropriate transfusions may reduce these complications.

METHODS

In 2012, an institution-wide patient blood management evidence-based algorithmic bleeding management protocol was implemented at The Prince Charles Hospital, Brisbane, Australia. The benefit of this has been previously reported in our lung transplant and cardiac surgery (excluding transplants) cohorts. This study aimed to investigate the effect of this on our orthotopic heart transplant recipients.

RESULTS

After the implementation of the protocol, despite no difference in preoperative haemoglobin levels and higher risk patients (EuroSCORE 20 vs 26; p=0.013), the use of packed red blood cells (13.0 U vs 4.4 U; p=0.046) was significantly lower postoperatively and fresh frozen plasma was significantly lower both intra- and postoperatively (7.4 U vs 0.6 U; p<0.001, and 3.3 U vs 0.6 U; p=0.011 respectively). Concurrently, the use of prothrombin complex concentrate (33% vs 78%; p<0.001) and desmopressin (5% vs 22%; p=0.0028) was significantly higher in the post-protocol group, while there was less use of recombinant factor VIIa (15% vs 4%; p=0.058). Intraoperative units of cryoprecipitate also rose from 0.9 to 2.0 (p=0.006).

CONCLUSIONS

We have demonstrated that a targeted patient blood management protocol with point-of-care testing for heart transplant recipients is correlated with fewer blood products used postoperatively, with some increase in haemostatic products and no evidence of increased adverse events.

Institutional Variability in Red Blood Cell Transfusion With Coronary Bypass in a Statewide Database

BACKGROUND

The decision to perform transfusion is common but varies among centers and surgeons. This study looked at variables associated with red blood cell (RBC) transfusion in a statewide database. The study aimed to understand discrepancies in transfusion rates among hospitals and to establish whether the hospital itself was a significant variable in transfusion, independent of variables known to affect transfusion in patients undergoing cardiac surgical procedures.

METHODS

The Maryland Cardiac Surgery Quality Initiative is a consortium of centers in the state. Patients undergoing isolated coronary artery bypass grafting from January 2018 to June 2020 from 10 centers in Maryland were included. Multivariable logistic regression was used to determine probability of RBC transfusion with covariates, including age, preoperative hemoglobin value, The Society of Thoracic Surgeons predicted risk of mortality, emergency status, preoperative adenosine diphosphate receptor blocker use, sex, body mass index, and off-pump status.

RESULTS

A total of 5343 patients were included and had an overall RBC transfusion rate of 30.3% (range, 11.3%-55.8%). There was significant variability in the incidence of RBC transfusion among hospitals (χ2 = 604.7; P < .001). After covariate adjustment, a significant effect of hospital on transfusion remained (Wald = 547.3; P < .001). Hospital variation in RBC transfusion was not correlated with hospital variation in median age (P = .467), hemoglobin (P 0 855), The Society of Thoracic Surgeons predicted risk of mortality (P = .855), or sex (P = .726).

CONCLUSIONS

In a statewide analysis, wide variability in transfusion rates was observed, with hospital-specific management strongly associated with RBC transfusion. This study suggests that RBC transfusion may be affected by the culture and practices of an institution independent of clinical and demographic variables.

ERAS Cardiac Society turnkey order set for patient blood management: Proceedings from the AATS ERAS Conclave 2023

OBJECTIVES

There are multiple published guidelines on comprehensive patient blood management (PBM), centered on the 3 pillars of PBM: managing preoperative anemia, minimizing blood loss, and tolerating intraoperative/postoperative anemia. We sought to create an order set to facilitate widespread implementation of evidence-based PBM for cardiac surgery patients.

METHODS

Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set (TKO) for PBM. Orders derived from consistent class I, class IIA, or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistently class I or IIA, class IIB, or supported by published evidence are presented in italic type.

RESULTS

Preoperatively, there are strong recommendations to screen and treat preoperative anemia with iron replacement and erythropoietin and to discontinue dual antiplatelet therapy if the patient can safely wait for surgery. Intraoperative orders outline the routine use of an antifibrinolytic agent, cell saver, point of care viscoelastic testing, and use of a standard transfusion algorithm. The order set also reflects strong recommendations intraoperatively and postoperatively for agreed-upon hemoglobin thresholds to consider transfusion of packed red blood cells. A hemoglobin threshold should be adopted according to local team consensus and should trigger a discussion regarding transfusion.

CONCLUSIONS

The benefit of a multidisciplinary PBM care pathway in cardiac surgery has been well established, yet implementation remains variable. Using recommendations from existing guidelines, we have created a TKO to facilitate the implementation of PBM.

Perioperative Anemia and Transfusions and Late Mortality in Coronary Artery Bypass Patients

BACKGROUND

Perioperative anemia and transfusions are associated with adverse operative outcomes after coronary artery bypass graft surgery (CABG). Their individual association with long-term outcomes is unclear.

METHODS

Patients aged 65 years and older who had undergone CABG and were in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (n = 504,596) from 2011 to 2018 were linked to Centers for Medicare and Medicaid Service data to assess long-term survival. The association of intraoperative anemia defined by intraoperative nadir hematocrit (nHct) and red blood cell (RBC) transfusions, and their interactions, on long-term mortality were assessed with Kaplan-Meier estimates and multivariable Cox regression. Restricted cubic splines were used to explore the association between nHct as a continuous variable and long-term mortality.

RESULTS

258,398 on-pump CABG STS Adult Cardiac Surgery Database patients surviving the perioperative period were linked to Centers for Medicare and Medicaid Service claims files. Per World Health Organization criteria, 41% had preoperative anemia. Mean intraoperative nHct was 24%; RBC transfusion rate was 43.7%. Univariable analysis associated both RBC transfusion and lower nHct with worse survival. Lower nHct was only marginally associated with risk-adjusted mortality: adjusted hazard ratio (AHR) 1.04 (95% CI, 1.01-1.06) and 1.07 (95% CI, 1.00-1.14) at nHct 20% and at nHct 14%, respectively. RBC transfusion was associated with significantly higher adjusted mortality irrespective of timing of transfusion: AHR intraoperative 1.21 (95% CI, 1.18-1.27); AHR postoperative 1.26 (95% CI, 1.22-1.30); AHR both 1.46 (95% CI, 1.40-1.52) and across all levels of nHct. RBC transfusion was not associated with improved survival at any level of nHct.

CONCLUSIONS

Among Medicare CABG patients, RBC transfusions were associated with increased risk-adjusted late mortality across all levels of nHct whereas intraoperative anemia was only marginally so. Tolerance of lower intraoperative nHct than currently accepted may be preferable to transfusions.

Improving Patient Blood Management Programs: An Implementation Science Approach

Organized patient blood management (PBM) programs function in numerous hospitals and health systems around the world contributing to improved patient outcomes as well as increased patient engagement, decreased resource use, and reductions in health care costs. PBM "programming" ranges from the implementation of single strategies/initiatives to comprehensive programs led by dedicated clinicians and PBM committees, employing the use of multiple PBM strategies. Frontline health care professionals play an important role in leading, implementing, operationalizing, measuring, and sustaining successful PBM programs. In this article, we provide practical implementation guidance to support key clinical, administrative, leadership, and structural elements required for the safe and comprehensive delivery of care in PBM programs at the local level.

Patient Blood Management: Improving Outcomes for Millions While Saving Billions. What Is Holding It Up?

Patient blood management (PBM) offers significantly improved outcomes for almost all medical and surgical patient populations, pregnant women, and individuals with micronutrient deficiencies, anemia, or bleeding. It holds enormous financial benefits for hospitals and payers, improves performance of health care providers, and supports public authorities to improve population health. Despite this extraordinary combination of benefits, PBM has hardly been noticed in the world of health care. In response, the World Health Organization (WHO) called for its 194 member states, in its recent Policy Brief, to act quickly and decidedly to adopt national PBM policies. To further support the WHO's call to action, this article addresses 3 aspects in more detail. The first is the urgency from a health economic perspective. For many years, growth in health care spending has outpaced overall economic growth, particularly in aging societies. Due to competing economic needs, the continuation of disproportionate growth in health care spending is unsustainable. Therefore, the imperative for health care leaders and policy makers is not only to curb the current spending rate relative to the gross domestic product (GDP) but also to simultaneously improve productivity, quality, safety of patient care, and the health status of populations. Second, while PBM meets these requirements on an exceptional scale, uptake remains slow. Thus, it is vital to identify and understand the impediments to broad implementation. This includes systemic challenges such as the so-called "waste domains" of failure of care delivery caused by malfunctions of health care systems, failure of care coordination, overtreatment, and low-value care. Other impediments more specific to PBM are the misperception of PBM and deeply rooted cultural patterns. Third, understanding how the 3Es-evidence, economics, and ethics-can effectively be used to motivate relevant stakeholders to take on their respective roles and responsibilities and follow the urgent call to implement PBM as a standard of care.

Establishment and Validation of a Nomogram to Predict Hospital-Acquired Infection in Elderly Patients After Cardiac Surgery

Background

Hospital-acquired infection (HAI) after cardiac surgery is a common clinical concern associated with adverse prognosis and mortality. The objective of this study is to determine the prevalence of HAI and its associated risk factors in elderly patients following cardiac surgery and to build a nomogram as a predictive model.

Methods

We developed and internally validated a predictive model from a retrospective cohort of 6405 patients aged ≥70 years, who were admitted to our hospital and underwent cardiac surgery. The primary outcome was HAI. Multivariable logistic regression analysis was used to identify independent factors significantly associated with HAI. The performance of the established nomogram was assessed by calibration, discrimination, and clinical utility. Internal validation was achieved by bootstrap sampling with 1000 repetitions to reduce the overfit bias.

Results

Independent factors derived from the multivariable analysis to predict HAI were smoking, myocardial infarction, cardiopulmonary bypass use, intraoperative erythrocytes transfusion, extended preoperative hospitalization days and prolonged duration of mechanical ventilation postoperatively. The derivation model showed good discrimination, with a C-index of 0.706 [95% confidence interval 0.671–0.740], and good calibration [Hosmer–Lemeshow test P = 0.139]. Internal validation also maintained optimal discrimination and calibration. The decision curve analysis revealed that the nomogram was clinically useful.

Conclusions

We developed a predictive nomogram for postoperative HAIs based on routinely available data. This predictive tool may enable clinicians to achieve better perioperative management for elderly patients undergoing cardiac surgery but still requires further external validation.

Simple and Effective Blood Salvage Technique for Extracorporeal Membrane Oxygenation Circuit

Return of circuit blood after discontinuing extracorporeal membrane oxygenation (ECMO) is an important blood conservation strategy for reducing the need for blood transfusion. This follows the current standard of circuit blood salvaging after cardiopulmonary bypass (CPB). There is a variety of strategies and techniques of blood salvage described associated with CPB but not with ECMO. We describe a simplified technique to salvage the blood in the ECMO circuit that requires no special equipment, is safe, and maximizes blood salvage.

Number and Type of Blood Products are Negatively Associated With Outcomes Following Cardiac Surgery

BACKGROUND

The association between blood transfusion and adverse outcome is documented in cardiac surgery. However, the incremental significance of each unit transfused, whether red blood cell (RBC) or non-RBC, is uncertain. This study examined the relationship of patient outcomes with type and number of blood product units transfused.

METHODS

Statewide data from adult cardiac surgery patients were included (N=24,082). Relationship with blood transfusion was assessed for morbidity and 30-day mortality using total number of RBC and non-RBC units transfused, specific type of non-RBC units, and different combinations of transfusion (only RBC, only non-RBC, RBC+non-RBC). Multivariable logistic regressions examined these associations.

RESULTS

Median age was 66 years (30% female) with 51% of patients transfused (31%-66% across hospitals). Risk-adjusted analyses found each blood product unit associated with 9%, 7%, and 4% greater odds for 30-day mortality, major morbidity, and minor morbidity (all P<0.001). Odds for 30-day mortality were 13% greater with each RBC unit (P<0.001) and 6% greater for each non-RBC unit (P<0.001). Each unit of fresh frozen plasma (P<0.001) and platelets (P<0.001) increased odds for 30-day mortality, but no effect for cryoprecipitate (P=0.725). Odds for 30-day mortality were lower for non-RBC only (OR=0.52, P=0.030) and greater for RBC+non-RBC (OR=2.98, P<0.001) compared to RBC only transfusion.

CONCLUSIONS

Independent of center variability on transfusion methods, each additional unit transfused was associated with increased odds for complications, with RBC transfusion carrying greater risk compared to non-RBC. Comprehensive evidence-based clinical approaches and coordination are needed to guide each blood transfusion event following cardiac surgery.

[Results of implementation of a perioperative Patient Blood Management program in cardiovascular surgery]

BACKGROUND AND OBJECTIVE

Cardiovascular surgery (CCV) patients have a high incidence of perioperative anemia and bleeding that determines a high rate of allogeneic blood transfusion (AST). This is associated with an increase in morbidity, mortality and prolongs length of stay in hospital. Unnecessary transfusion is one of the measures to avoid and Patient Blood Management (PBM) programs have proven their effectiveness. Our objective was to reduce the transfusion of patients in cardiac surgery, without inferior results in morbidity and mortality, length of stay in hospital and being cost-effective, through the implementation of a PBM program.

MATERIAL AND METHODS

A mixed cohort study of 226 patients divided into 2 groups: retrospective pre-PBM (GP), from 2016, and intervention group (IG), prospective from 2018, with the results of the implementation of the guide.

RESULTS

The clinical results obtained allowed reducing the TSA from 92.59% to 79.69% (P<.001), saving 2.59 units of CH and 2.5 of PFC per patient (P<.001). A decrease was found in patients with fever (12.35% vs 1.56% with P=.006) and the need to escalate antibiotics (64.8% vs 42.19%, P=.002). The rest of postoperative complications and mortality at 3months did not present statistically significant differences. The length of stay was reduced by an average 3.6days in the IG, (95%CI: -8.10 to 0.9, P=.18). The cost decreased by 163.29€ per patient, taking into account exclusively the saving of blood components.

CONCLUSION

The PBM program is effective in reducing TSA in cardiac surgery in a tertiary hospital with high complexity patients and high transfusion rate. There are signs suggestive of a decrease in infections and a tendency to decrease the length of stay and mortality. In the economic approximation carried out, the cost of the intervention was lower than the savings implied by the decrease in transfusion.

Pancreatic resections in patients who refuse blood transfusions. The application of a perioperative protocol for a true bloodless surgery

BACKGROUND

The refusal of blood transfusions compels surgeons to face ethical and clinical issues. A single-institution experience with a dedicated perioperative blood management protocol was reviewed to assess feasibility and short-term outcomes of true bloodless pancreatic surgery.

METHODS

The institutional database was reviewed to identify patients who refused transfusion and were scheduled for elective pancreatic surgery from 2010 through 2018. A protocol to optimize the hemoglobin values by administration of drugs stimulating erythropoiesis was systematically used.

RESULTS

Perioperative outcomes of 32 Jehovah's Witnesses patients were included. Median age was 67 years (range, 31-77). Nineteen (59.4%) patients were treated with preoperative erythropoietin. Twenty-four (75%) patients underwent pylorus-preserving pancreaticoduodenectomy, 4 (12.5%) distal pancreatectomy (DP) with splenectomy, 3 (9.4%) spleen-preserving DP, and 1 (3.1%) total pancreatectomy. Median estimated blood loss and surgical duration were 400 mL (range, 100-1000) and 470 min (range, 290-595), respectively. Median preoperative hemoglobin was 13.9 g/dL (range, 11.7-15.8) while median postoperative nadir hemoglobin was 10.5 g/dL (range, 7.1-14.1). The most common histological diagnosis (n = 15, 46.9%) was pancreatic ductal adenocarcinoma. Clavien-Dindo grade I-II complications occurred in fourteen (43.8%) patients while one (3.1%) patient had a Clavien-Dindo grade IIIa complication wich was an abdominal collection that required percutaneous drainage. Six (18.8%) patients presented biochemical leak or postoperative pancreatic fistula grade B. Median hospital stay was 16 days (range, 8-54) with no patient requiring transfusion or re-operation and no 90-day mortality.

CONCLUSIONS

A multidisciplinary approach and specific perioperative management allowed performing pancreatic resections in patients who refused transfusion with good short-term outcomes.

Quality Improvement in Transfusion Practice of Orthotopic Liver Transplantation Reduces Blood Utilization, Length of Hospital Stay, and Cost

OBJECTIVES

Orthotopic liver transplantation (OLT) can require substantial usage of blood products. Higher rates of transfusion have been associated with increased length of hospital stay, higher rates of infection, graft failure, and mortality. This study was a retrospective analysis to assess the impact of quality improvement interventions in OLT.

METHODS

Data collection included demographics, preoperative and intraoperative data, blood utilization, and cost data. Statistical analysis was performed using R software.

RESULTS

Total blood product utilization was reduced by approximately 50%. Statistically significant decreases were noted in blood product usage in the intraoperative and first 48-hour postoperative utilization, the number of OLTs using fewer than five RBC units, length of hospital stay, and cost.

CONCLUSIONS

This study showed successful implementation of quality improvement team interventions to reduce blood utilization during OLT. Reduced transfusion significantly correlated with decreased length of hospital stay and cost.

Implementation of a Blood Conservation Initiative to Effectively Reduce Blood Transfusions in Cardiac Surgery Patients

Perioperative and postoperative blood transfusions in cardiac surgery patients are associated with as much as a 16% increased risk of mortality and a significantly increased risk in morbid outcomes. At the project site, red blood cell transfusions in cardiac surgery patients undergoing isolated coronary artery bypass graft were above national benchmarks. The aim of the project was to reduce blood transfusions in cardiac surgery patients by 10% over 8 weeks. Primary interventions included engagement for the team and use of a shared decision-making tool for patients. Use of the Any RBC Transfusion online risk calculator was implemented with initiation of anemia protocol orders, chart identification, and blood conservation coordinator referral. There was no decrease in the blood transfusion rate during project implementation. However, this project heightened blood conservation awareness among team members and clinical leaders, brought attention to the need for evidence-based practice, and stimulated conversation about change.

Predictors of Cardiac Surgery Patients Who Tolerate Blood Conservation in Cardiac Surgery

BACKGROUND

Whether there is a cardiac surgical patient population that does not incur harm from blood conservation is unknown. This study aimed to identify patient characteristics associated with patients who safely tolerate blood conservation.

METHODS

We conducted a retrospective review of consecutive patients undergoing isolated coronary artery bypass graft surgery or isolated aortic valve replacement, or concomitant coronary artery bypass graft surgery and aortic valve replacement between 2011 and 2016, during which blood conservation intervention took place. Logistic regression derived from the preintervention cohort was applied to the postintervention cohort to identify patient characteristics associated with those predicted to be transfused in the preintervention era but were not in the postintervention era.

RESULTS

In this series of 2,701 adult patients undergoing cardiac operations, blood conservation intervention in 2014 led to a 52% reduction in red blood cell transfusion. Between preintervention and postintervention cohorts, there was no significant difference in the measured outcomes. A regression model derived from the preintervention cohort was applied to the postintervention cohort to identify predictors of cohort that do not derive benefit from liberal transfusion. This model demonstrated such patient characteristics to be age more than 75 years (odds ratio [OR] 1.71, 95% confidence interval [CI]: 1.09 to 2.68, p = 0.033), body mass index less than 30 kg/m² (OR 1.5, 95% CI: 1.02 to 2.20, p = 0.044), lowest intraoperative hematocrit between 22 and 25 (OR 1.77, 95% CI: 1.16 to 2.68, p < 0.001), and cardiopulmonary bypass use (OR 4.50, 95% CI: 2.25 to 9.01, p < 0.001).

CONCLUSIONS

Blood conservation can successfully yield reduction in perioperative blood product use, with associated decrease in the risk of postoperative renal failure. A select patient population who may tolerate blood conservation safely was identified, and that may guide a targeted blood conservation effort.

Transfusion Medicine and Coagulation Management in Organ Transplantation

Organ transplantation recipients present unusual challenges with regard to blood transfusion. Although this patient population requires a larger proportion of blood product resources, liberal transfusion of allogeneic blood products can lead to a plethora of complications. Recent trends suggest that efforts to minimize bleeding, conserve products, and target transfusion to specific deficits and needs are increasingly becoming the standard practice; these must all occur with optimization of graft function and preservation in mind. With newer monitoring modalities and factor concentrates, the approach toward transfusion and bleeding in organ transplantation has rapidly improved in recent years.

The Effect of Blood Transfusion on Outcomes in Aortic Surgery

The use of blood transfusion in cardiac surgery varies widely. The beneficial effects of blood products are offset by an increase in morbidity and mortality. Despite multiple studies showing an association between blood product exposure and adverse short- and long-term events, it is difficult to determine causality. Nevertheless, the implication is sufficient to warrant the search for alternative strategies to reduce the use of blood products while providing a standard of care that optimizes postoperative outcomes. Aortic surgery, in particular, is associated with an increased risk of bleeding requiring a blood transfusion. There is a paucity of evidence within aortic surgery regarding the deleterious effects of blood products. Here, we review the current evidence regarding patient outcomes after blood transfusion in cardiac surgery, with special emphasis on aortic surgery.