PREOPERATIVE ANEMIA MANAGEMENT
IN ELECTIVE JOINT REPLACEMENT
Issue
The prevalence of anemia is increasing as the current population ages and its presence can complicate every
diagnosis. Anemia is often treated with blood transfusions which studies have shown are associated with
complications, increased morbidity and mortality, and not substantiated by evidence. The greatest risk factor for a
peri-operative blood transfusion is pre-operative anemia. The Joint Commission has identified transfusions as an
overused procedure and a recent study concluded 88 percent of transfusions were inappropriate.
Project Description
Cincinnati’s TriHealth Good Samaritan Hospital (GSH) decided to pursue a goal of zero transfusions for elective
cases by developing a self-sustaining anemia clinic that both qualified for reimbursement and utilized existing
budget, FTEs and space. The clinic initially was limited to elective hip and knee replacement patients by design.
Despite having reduced its blood transfusion rate to 3 percent, 20 percent of these patients were still entering surgery
with hemoglobins less than 13 gm/dl for men and 12 gm/dl for women. Further review elucidated 75 percent of
transfused patients were anemic prior to surgery. Results were less than ideal when attempts were made to treat
these patients by the physician offices. Delays in surgery and out-of-pocket expenses to patients for pre-surgical
anemia drugs were problematic. An anemia clinic business plan was presented to and approved by the hospital
administration. Physician champions and key stakeholders were identified. Joint replacement preoperative orders
and pre-defined anemia treatment orders based on appropriate diagnosis codes were developed. The clinic opened in
July 2012.
Results
The 2013 transfusion rate decreased to 0.49%for elective hip and knee arthroplasty.
A 0% transfusion rate has been maintained from November 2013 thru March 2014.
Length of stay: 2010 average: 3.2days, hips and 3.0 days, knees
2013 average: 2.5 days, hips and 2.6 days, knees (Benchmark 3.8days)
Hospital revenues increased and expenses decreased. Adverse patient outcomes and the costs related to blood
transfusions were eliminated. Several patients were newly diagnosed with other disease entities, including GI bleed,
factor deficiencies and myelofibrosis. Within 21 months of implementation, the anemia clinic services at GSH
expanded from hip and knee to include shoulder replacement, cardiothoracic surgery and vascular surgery patients.
No elective procedures were canceled by the actions of the clinic. Physician and patient satisfaction improved.
Lessons Learned
Teamwork is essential in optimizing efficiency and outcomes. The anemia clinic is a sustainable practice expandable
to multiple procedures, specialties and settings. It establishes communication pathways visible to all service
providers, and increases patient, nurse and physician satisfaction. An anemia clinician identify and treat preoperative anemia patients, reduce the risk for a blood transfusion and optimize patient safety.
Submitters
Katy_Loos@trihealth.com
Kathryn_Eten@trihealth.com
Mark_Snyder@trihealth.com
John_Robinson3@trihealth.com