1. National Comparative Audit of Blood Transfusion National Blood Service National Comparative Audit of the use of blood in Primary, Elective, Unilateral Total Hip Replacement Prepared by John Grant-Casey Project Manager November 2007 Yorkshire & The Humber RTC

2. National Comparative Audit of Blood Transfusion National Blood Service The National Comparative Audit Programme 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 Background information

3. 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

4. National Comparative Audit of Blood Transfusion National Blood Service What were the audit aims & objectives? Blood use in Hip Replacements 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

5. National Comparative Audit of Blood Transfusion National Blood Service 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 Yorkshire & The Humber RTC = 644 Blood use in Hip Replacements Participation

6. National Comparative Audit of Blood Transfusion National Blood Service Methodology – the audit sample –Data collected for 40 consecutive hip replacement operations –All patient ages were eligible Blood use in Hip Replacements Methodology

7. National Comparative Audit of Blood Transfusion National Blood Service The Audit Results – Key performance indicators 2 key performance indicators were used - % patients transfused and average number of units transfused per patient Blood use in Hip Replacements

8. National Comparative Audit of Blood Transfusion National Blood Service The Audit Results – Key performance indicators 2 key performance indicators were used - % patients transfused and average number of units transfused per patient Blood use in Hip Replacements

9. National Comparative Audit of Blood Transfusion National Blood Service Patients having a pre-operative Hb taken National Blood use in Hip Replacements

10. National Comparative Audit of Blood Transfusion National Blood Service Patients going for surgery with an Hb <12 g/dl Blood use in Hip Replacements

11. National Comparative Audit of Blood Transfusion National Blood Service Patients having a post-operative pre-transfusion Hb taken Blood use in Hip Replacements

12. National Comparative Audit of Blood Transfusion National Blood Service Transfused patients having a pre-transfusion Hb of <8 g/dl Blood use in Hip Replacements

13. National Comparative Audit of Blood Transfusion National Blood Service % Patients possibly over-transfused Blood use in Hip Replacements

14. National Comparative Audit of Blood Transfusion National Blood Service Recommendations Blood use in Hip Replacements 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.

15. National Comparative Audit of Blood Transfusion National Blood Service Acknowledgements Blood use in Hip Replacements 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

16. National Comparative Audit of Blood Transfusion National Blood Service National Comparative Audit of the use of blood in Primary, Elective, Unilateral Total Hip Replacement Prepared by John Grant-Casey Project Manager November 2007 Yorkshire & The Humber RTC