1. David Mold and Dr. Shubha Allard
A Survey of Pre-operative Assessment Clinics In the North Thames Region
David Mold and Dr. Shubha Allard
North Thames Regional Transfusion Committee

2. Introduction
The Health Service Circular Better Blood Transfusion (HSC 2002/009) states that Trusts must ensure that mechanisms are in place for the pre-operative assessment of patients for planned surgical procedures. Guidance on Pre–operative assessment has been provided by the Better Blood Transfusion Appropriate Use of Blood Toolkit (BBT Toolkit) and recommends that:
The patient’s haemoglobin is optimised
Haemostasis is optimised
Cell salvage is used where appropriate.
North Thames Regional Transfusion Committee

3. Purpose of Survey
The purpose of this survey is to ascertain whether Trusts within the North Thames Region are implementing the recommendations of the BBT Toolkit and also to find out how pre-operative assessment clinics are being organised.
North Thames Regional Transfusion Committee

4. Methodology
A questionnaire was designed using the West Midlands Regional Transfusion Committee Audit Group questionnaire as a template.
In the first instance this was posted to the Transfusion Consultant, Specialist Practitioner of Transfusion and Lead Nurse for Pre-operative Assessment for every Trust in the North Thames Region.
Follow up to non-responders was done by to transfusion consultants and SPOTs.
North Thames Regional Transfusion Committee

5. Main Endpoints
Establish how many trusts have pre-operative assessments clinics and for what specialities
Determine how many pre-operative assessment clinics have protocols for:
Diagnosis and management of anaemia
Diagnosis and management of clotting disorders
Discontinuation of anti-platelet drugs and oral anticoagulants
Identification of problems requiring specialist intervention e.g. Thalassaemia, Sickle cell disease.
Management of patients refusing transfusion
Assessment of blood component requirements e.g. MSBOS
Find out how many trusts are using cell salvage and are informing patients about it and obtaining consent for its use.
North Thames Regional Transfusion Committee

6. Response rate
There were 20 responses which represented replies from 14 NHS Trusts (20 hospitals) and 3 private sector hospitals.
Most questionnaires were filled in by
Specialist Practitioners of Transfusion - 11
Lead Nurses for Pre-Operative Assessment Clinics - 6.
SPOTs and Lead Nurses together - 3.
All respondents replied that their hospital was running pre-operative assessment clinics.
North Thames Regional Transfusion Committee

7. Most Common Clinic Specialities
Clinic speciality
Number of Clinics
Orthopaedic surgery 17
Vascular surgery 13
Urology
General surgery
Gynaecology 12
ENT
Plastic surgery 9
Cardiac surgery 6
Oncology 3
Breast surgery 2
North Thames Regional Transfusion Committee

8. Are patients assessed by medical or nursing staff?
North Thames Regional Transfusion Committee

9. How long before admission are patient’s assessed?
The time interval between assessment and admission was found to vary between specialities and also within specialities.
Several respondents commented that if the patient had cancer then the time period between assessment and admission was shortened.
North Thames Regional Transfusion Committee

10. Number of days before admission- most common clinics
Speciality
Minimum No.
of days
Maximum No.
Number of
Clinics
Orthopaedic surgery 1
168 17
Vascular surgery 7 13
Urology
General Surgery 6
Gynaecology 12
ENT
Plastic surgery 84 9
Cardiac surgery 56
Oncology 14 28 3
Breast surgery 2
North Thames Regional Transfusion Committee

11. Do you have written protocols for the following?
Yes No
Diagnosis and management of anaemia
54 (48%)
58(52%)
Diagnosis and management of clotting disorders
57 (51%)
55 (49%)
Discontinuation of anti-platelet drugs and oral anticoagulants
103 (92%)
9 (8%)
Identification of problems requiring specialist intervention e.g. Thalassaemia, Sickle cell disease.
66 (59%)
46 (41%)
Management of patients refusing transfusion
94 (84%)
18 (16%)
Assessment of blood component requirements e.g. MSBOS
86 (77%)
26 (23%)
North Thames Regional Transfusion Committee

12. Does your Trust use cell salvage?
15 respondents are using some form of cell salvage.
13 respondents using intra-operative cell salvage
Eight respondents using intra-operative cell salvage also used post-operative cell salvage.
Two respondents using post operative cell salvage only. (BelloVac system).
North Thames Regional Transfusion Committee

13. What procedures is cell salvage used for?
Commonest specialities where intra-operative cell salvage is used are
Cardiac (3)
Vascular (6)
Orthopaedic surgery (8).
Three respondents also reported usage in other procedures such upper GI bleeds, liver lacerations, splenectomys and radical cystectomys.
North Thames Regional Transfusion Committee

14. Cell salvage continued
Only one respondent specified usage in obstetrics.
Three respondents commented that usage was dependent on the enthusiasm of the surgical and anaesthetics staff for cell salvage and two of them were facilitating training in the near future.
Post operative cell salvage was almost exclusively used for orthopaedic procedures (6)
Three respondents specifying usage in total knee replacements.
Two respondents said that post-operative cell salvage was used for heavy post-op bleeding but did not specify the procedures where it was used.
North Thames Regional Transfusion Committee

15. Do you inform patients about the use of cell salvage
Do you inform patients about the use of cell salvage? Do you obtain consent for the use of cell salvage?
Inform patient
Consent patient No
4 (27%)
11 (73%)
Yes
4 (26%)
North Thames Regional Transfusion Committee

16. Who reviews Hb results
North Thames Regional Transfusion Committee

17. Who performed the initial assessment and who reviewed the Hb result.
Initial Assessment by
Hb result reviewed by
Total
Nurse and Doctor 13
Doctor only
Nurse only 40 5 10 18
112
North Thames Regional Transfusion Committee

18. Haemoglobin level at which action is taken in fit patients under the age of 65.
Hb level (g/dl)
Total
Less than 7 5 12 2
Less than 8 7 13 1 8 9
Females 10-11g/dl
Males 12g/dl
Between 8-10 3
Consultant dependent 22
Dependent on patient's history
Less than 10 15
Not known 10 23
No response 18 11
112
North Thames Regional Transfusion Committee

19. Haemoglobin level at which action is taken in patients over the age of 65.
Hb level (g/dl)
Total
Less than 8 11 12 1
Less than 9
Females 10-11g/dl male12g/dl
Between 8-10 3
Dependent on history 20
Between 9-10 6
Consultant dependent 22
Less than 10 14
Not known 10
No response 9
112
North Thames Regional Transfusion Committee

20. Haemoglobin level at which action is taken in patients with ischaemic heart disease
Hb level (g/dl)
Total
Less than 8 6
Not known 1
Lees than 9
Females 10-11g/dl males 12g/dl 10 33
Consultant dependent 22
Less than 10 14
Dependent on patient's history 12
Between 9-10
No response 9 11
112
North Thames Regional Transfusion Committee

21. Action taken if Haemoglobin level is found to be low
Refer to GP - 49% (54/112) (Some respondents commented that this only happened if time allowed)
Refer to other speciality - 14% (16/112) (usually haematology)
Other action 37% (41/112)
Mainly refer to back to admitting consultant or anaesthetist.
Many comments action dependent on how urgent the surgery was.
North Thames Regional Transfusion Committee

22. Discussion
Many hospitals are using pre-assessment clinics in a wide variety of specialities.
Approximately 50% of clinics had no protocol for anaemia or clotting disorders.
Wide variation in length of time before admission
Wide variation in the haemoglobin level that triggers referral or deferral
Wide variation in procedures where cell salvage is routinely used
North Thames Regional Transfusion Committee