‘Transfuse and Check’ – improving post-operative blood transfusion in line with NICE guidance

Aims:

To implement the NICE guidelines on blood transfusion, (NG24) and ‘quality statement 3’ of the NICE quality standard for blood transfusion (QS138).

Objectives:

• Implement a transfusion threshold of 70g/L with a concentration target of 70 – 90g/L and for patients with acute coronary syndrome a transfusion threshold of 80g/L with a concentration target of 80 – 100g/L.
• Implement ‘one unit transfusions’ for patient who are not bleeding or on a chronic programme and the need to check the patient’s haemoglobin pre and post treatment.
• Introduce our strategy of 'Transfuse and Check' to the trust.
• Audit the outcomes of the 'Transfuse and Check' strategy.

Transfusion requirements in critical care showed that outcomes did not differ significantly between a transfusion threshold of 70g/L and a threshold of 80g/L among patients in intensive care units (1). In 2011, another study on liberal v restrictive transfusion in high risk patients after hip surgery found results consistent with this (2). A Cochrane review supported the findings and suggested the use of a restrictive policy when it comes to (Red Cell Count) transfusion in patients (3). Despite this, practices vary considerably. In 2014, we decided to look at our transfusion practice in Warrington hospital, a 600 bed district general hospital. The cohort we chose to investigate was patients with fractured neck of femur. Every day, 4000 UK hospital beds are occupied by patients with hip fractures.

Severe anaemia is a common post-operative complication in these, often frail, patients and many require blood transfusion. By 2020, estimates indicate that the UK will have 101,000 hip fractures per year. NICE has published a guideline and quality standard on blood transfusion - NG24 and QS138. There are recommendations covering the threshold, target and dose.

• When using a restrictive red blood cell transfusion threshold, consider a threshold of 70 g/litre and a haemoglobin concentration target of 70-90 g/litre after transfusion.
• Consider single-unit red blood cell transfusions for adults (or equivalent volumes calculated based on body weight for children or adults with low body weight) who do not have active bleeding.
• After each single-unit red blood cell transfusion (or equivalent volumes, calculated based on body weight, for children or adults with low body weight), clinically reassess and check haemoglobin levels, and give further transfusions if needed
• Following up on this, NICE published a quality standard setting quality statements for trusts to aspire to. The statements relate to ‘one unit transfusions’ and the need to check the patient’s haemoglobin pre and post treatment. Our in-house audit standards looked at those parameters.

• Standard 1): Requests for blood are deemed appropriate as per the National Blood Transfusion Committee (NBTC) indication codes for transfusion 2016.
• Standard 2): A recent (within 24 hours) haemoglobin result is available prior to ordering a unit of red cells.
• Standard 3): A post transfusion haemoglobin result is available within 24 hours post treatment.

In 2014 we set up a transfusion collaborative task and finish group. The group consisted of clinicians and transfusion department specialists. We carried out a retrospective cohort study of 337 patients admitted between November 2014 and January 2016. Data was collected using the National Hip Fracture Database, the Hospital Transfusion Database (MOLIS), and the pathology system ‘SUNQUEST ICE’. Pre or intra-operative transfusions were excluded.

We recorded the number of units each patient received post-operatively. Transfusions were interrogated for Hb checks after each unit. Serial troponin-I rise, and patient notes were used to assess for acute coronary syndrome (ACS) or major haemorrhage.

Using this information, appropriate post-transfusion Hb ranges were assigned for each patient. The number of blood units transfused per patient was recorded. Pre or intra-operative transfusions were excluded. Serial troponin-I rise and patient notes were used to assess for ACS or major haemorrhage.

Following the audit a number of actions were taken. Our strategy was to 'Transfuse and Check'. The audit outcomes were discussed at the orthopaedic and critical care audit meeting. There was wide support and agreement to introduce our strategy of transfuse and check. We developed a programme to deliver transfusion teaching for doctors and nurses.

The new changes were highlighted in our hospital newsletter “Bloody Matters”. The implementation of the 'Transfuse and Check' protocol was endorsed by Hospital Transfusion Committee. We decided that it might help in delivering the new strategy if we introduced a point-of-care haemoglobin testing (Haemocue) device to our trauma ward.

Following implementation we would then re-audit. The re-audit included 292 patients over 12 months from April 2016-April 2017. Following the first audit the one unit transfuse and check policy was introduced trust-wide with the laboratory trying to encourage clinicians to apply to all patient groups. An additional audit, independent of our NOF audit, looking at outcomes from this was carried out in October 2017.

An audit was undertaken for 337 Patients over 15 Months (November 2014 to January 2016).

• 84 Patients (25%) transfused.
• 99 Transfusions, 198 units.
• 73 transfusions (70.3%) not indicated.
• Single unit & Hb check: 13%.
• 80% resulted in Hb that exceeded NICE recommendations.
• 86% of transfusions were of 2 or more units.
• 159 units, £19,398 worth of packed red cells were transfused against NICE guidance.

Following taskforce actions, a re-audit was undertaken between April 2016 and April 2017. This included:

• 292 patients over 12 months.
• 46 patients transfused (15.7% of sample).
• Total of 67 units transfused.
• 27 patients transfused only a single unit (56%).

Comparison of before (November 2017 – January 2016) and after (April 2016 – April 2017):

Initial audit cycle: Average number of units transfused per patient: 2.36 units £ 293.73 per patient transfused (on average).

Re-audit average number of RBC units transfused per patient: 1.46 units £ 181.71 per patient transfused on average. Savings of £112.02 achieved per patient transfused.

Conclusion

In the initial audit 25% of patients with fractured neck of femur were transfused, this was reduced greatly to 15% in the finding of the re-audit, showing that practice is changing, albeit slowly.

Re-assessing the patient by reviewing the patient and checking their haemoglobin level is paramount for not under or over transfusing a patient. Transfusion carries risk but it is also an effective treatment for some patients. The trust wide audit performed in October 2017, ten months post the re-audit shows 76% were ‘one unit transfusions’ and in ICU particular this was 83% of all their transfusions; positively showing we are starting to embed ‘Transfuse and Check’ into practice. As a result of this we have achieved a significant reduction in the number of red cells transfused per patient reducing the risks of transfusion for the patient, with a cost saving to the trust.

• Build a team to start with: we developed a collaborative team approach with a small number of enthusiastic clinicians working with transfusion specialists.
• Clarify the aims and objectives: We focused on the evidence base and on the current NICE guidelines and standards.
• Have a clear simple strategy: We developed a strategy which in our case we called 'Transfuse and Check'.
• Develop a policy with the Trust’s Hospital Transfusion Committee.
• Audit with a developed database: In this case, the National Hip Fracture Database and the Hospital Transfusion Database (MOLIS). This is almost essential for providing quality data for good quality improvement.

• Communicate and educate: A Point-of-care Haemoglobin testing (Haemocue) device was introduced to our trauma ward. Although it was a useful initiative by our team, we still needed a laboratory sample so was probably unnecessary.

References:

1. Hébert PC et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999;340:409-17.
2. Carson JL. Liberal or Restrictive Transfusion in High-Risk Patients after Hip Surgery, December 29, 2011 vol. 365 no. 26
3. Carson JL.Transfusion thresholds and other strategies for guiding allogenic red blood cell transfusion. Cochrane Database Syst Rev. 2012; 4: CD002042.
4. NICE Guideline: Blood Transfusion, NG24 Publisher 18th November 2015, www.nice.org.uk/guidance/ng24
5. NICE Quality Standard: Blood Transfusion Published 15th December 2016, www.nice.org.uk/guidance/qs138