National Comparative Audit of the use of
blood in Primary, Elective, Unilateral Total
Hip Replacement
East of England RTC
Prepared by
John Grant-Casey
Project Manager
November 2007
National Comparative Audit of Blood Transfusion
National Blood Service
The National Comparative Audit Programme
Background information
• A series of audits designed to look at the use and
administration of blood and blood components
• Open to all NHS Trusts and Independent
hospitals in the UK
• Collaborative programme between NHS Blood
and Transplant & Royal College of Physicians
• Endorsed by the Healthcare Commission
National Comparative Audit of Blood Transfusion
National Blood Service
Blood use in Hip Replacements
Why was this audit necessary?
• Orthopaedic surgery accounts for 10% of red cells used in hospital.
• Studies have demonstrated wide variation in practice in the use of red cells
for total hip replacement surgery.
• Despite the availability of national guidelines for red cell transfusion, several audits
have shown that a significant amount (10 – 15%) of red cell transfusions could be
avoided in the perioperative period.
• In view of the recognized risks of transfusion and the decreasing availability of donor
blood, every effort should be made to minimize inappropriate transfusions.
• Health Service Circular 2002/009(BBT2) sets out a programme of action for Chief
Executives of NHS Trusts to avoid unnecessary use of red cells in clinical practice
National Comparative Audit of Blood Transfusion
National Blood Service
Blood use in Hip Replacements
What were the audit aims & objectives?
• The collection of sufficient credible data from a large and representative sample
of hospitals
• The production of a report that is widely disseminated to those stakeholders who
have the ability to influence and improve the practice of using blood for this
procedure
• The commencement of a dialogue which will lead to meaningful multidisciplinary
discussion on the appropriateness of blood transfusions in patients undergoing
this procedure
• A reduction in the inappropriate use of red blood cells in patients undergoing this
procedure
National Comparative Audit of Blood Transfusion
National Blood Service
Blood use in Hip Replacements
Participation
We invited
• 183 NHS hospitals
• 187 Independent hospitals
Who took part
• 149 (81%) NHS hospitals sent information
• 102 (55%) Independent hospitals sent information
Number of patients audited
• Nationally = 7465 East of England RTC = 895
National Comparative Audit of Blood Transfusion
National Blood Service
Blood use in Hip Replacements
Methodology
• Methodology – the audit sample
– Data collected for 40 consecutive hip
replacement operations
– All patient ages were eligible
National Comparative Audit of Blood Transfusion
National Blood Service
Blood use in Hip Replacements
The Audit Results – Key performance indicators
2 key performance indicators were used - % patients transfused
and average number of units transfused per patient
100
90
80
70
60
%
50
40
30
20
10
AA
Z
Y
X
W
V
U
T
R
Q
P
O
N
M
L
K
J
H
G
F
E
D
C
B
A
N
at
io
na
l
0
Hospitals
National Comparative Audit of Blood Transfusion
National Blood Service
Blood use in Hip Replacements
The Audit Results – Key performance indicators
2 key performance indicators were used - % patients transfused and
average number of units transfused per patient
4.5
4
3.5
3
%
2.5
2
1.5
1
0.5
AA
Z
Y
X
W
V
U
T
R
Q
P
O
N
M
L
K
J
H
G
F
E
D
C
B
A
N
at
io
na
l
0
Hospitals
National Comparative Audit of Blood Transfusion
National Blood Service
National Blood use in Hip Replacements
Patients having a pre-operative Hb taken
100
90
80
70
60
%
50
40
30
20
10
AA
Z
Y
X
W
V
U
T
R
Q
P
O
N
M
L
K
J
H
G
F
E
D
C
B
A
N
at
io
na
l
0
Hospitals
National Comparative Audit of Blood Transfusion
National Blood Service
Blood use in Hip Replacements
Patients going for surgery with an Hb <12 g/dl
50
45
40
35
30
%
25
20
15
10
5
AA
Z
Y
X
W
V
U
T
R
Q
P
O
N
M
L
K
J
H
G
F
E
D
C
B
A
N
at
io
na
l
0
Hospitals
National Comparative Audit of Blood Transfusion
National Blood Service
Blood use in Hip Replacements
Patients having a post-operative pre-transfusion Hb taken
100
90
80
70
60
%
50
40
30
20
10
AA
Z
Y
X
W
V
U
T
R
Q
P
O
N
M
L
K
J
H
G
F
E
D
C
B
A
N
at
io
na
l
0
Hospitals
National Comparative Audit of Blood Transfusion
National Blood Service
Blood use in Hip Replacements
Transfused patients having a pre-transfusion Hb of <8 g/dl
100
90
80
70
60
%
50
40
30
20
10
AA
Z
Y
X
W
V
U
T
R
Q
P
O
N
M
L
K
J
H
G
F
E
D
C
B
A
N
at
io
na
l
0
Hospitals
National Comparative Audit of Blood Transfusion
National Blood Service
Blood use in Hip Replacements
% Patients possibly over-transfused
100
90
80
70
60
%
50
40
30
20
10
AA
Z
Y
X
W
V
U
T
R
Q
P
O
N
M
L
K
J
H
G
F
E
D
C
B
A
N
at
io
na
l
0
Hospitals
National Comparative Audit of Blood Transfusion
National Blood Service
Blood use in Hip Replacements
Recommendations
•
In order to minimize the likelihood of a patient receiving a donor blood transfusion, pre-operative anaemia should be
corrected as far as possible.
•
Hospitals should have a written policy for identification and management of anaemia in pre-assessment clinics.
•
Surgeons seeing patients at initial consultation must ensure that patients have a full blood count, and that anaemic
patients are investigated and steps taken to correct the anaemia before surgery.
•
General Practitioners referring patients for surgery should take measures to optimize the haemoglobin.
•
Every hospital should have a transfusion policy to guide transfusion in the peri- / post-operative period, based upon
one or more of the following:
· Symptoms
· Haemoglobin concentration
· Estimated blood loss
•
Trusts should ensure that their prescribers are aware that it is not necessary to transfuse patients who are
asymptomatic, not bleeding and have a haemoglobin of >8g/dl.
•
In order to avoid over-transfusion, single-unit transfusions may be appropriate. Hospitals should review the number
of units transfused against their patients’ post-transfusion Hb at regular intervals.
•
Nationally, orthopaedic representation at Hospital Transfusion Committees needs to be improved and more
consistent attendance encouraged.
National Comparative Audit of Blood Transfusion
National Blood Service
Blood use in Hip Replacements
Acknowledgements
• Project team: Hari Boralessa, Karen Madgwick,
Keith Tucker, Sandy Kidd, Andy Mortimer, John
Grant-Casey, and David Dalton
• Hospital staff who collected the audit data
National Comparative Audit of Blood Transfusion
National Blood Service
National Comparative Audit of the use of
blood in Primary, Elective, Unilateral Total
Hip Replacement
East of England RTC
Prepared by
John Grant-Casey
Project Manager
November 2007
National Comparative Audit of Blood Transfusion
National Blood Service