Page 20 - ANZCP Gazette MAY 2014

Original Article
RATIONALISING RED BLOOD CELL TRANSFUSION IN CARDIAC SURGERY: A MULTICENTRE QUALITY IMPROVEMENT INITIATIVE.
Submitted by Richard Newland, Rob Baker, Alan Merry, on behalf of the Perfusion Downunder Collaboration.
The Perfusion Downunder Collaboration has initiated a quality improvement initiative that aims to rationalise red blood cell transfusion in our patients. This article provides an outline of the project that is currently underway.
Introduction
Red blood cell (RBC) transfusion is often used during cardiac surgery to increase oxygen carrying capacity in the setting of blood loss or anaemia, but has been associated with an increase in risk of bacterial infections, low-output failure, longer intensive care unit stay and increased mortality (Chelemer 2008, Corwin 2004, Koch et al. 2006, Surgenor et al. 2006).
A single centre study on reducing variation in the number of perioperative transfusions associated with cardiac surgery demonstrated a reduction in transfusion rates in a three phase initiative, involving understanding current processes, implementing new protocols and monitoring progress of protocol implementation (Likosky 2010). The most frequent indication for transfusion was anaemia, with 90% of intraoperative and 43% postoperative transfusions given for actual or predicted low haematocrit.
We plan a a multicenter study using the Perfusion Downunder Collaboration registry to monitor progress. This will show how institutional variation in the process of care influences the incidence of anaemia and transfusion. We will aim to drive quality improvement initiatives through benchmarking. We have previously reported baseline data for various cardiopulmonary bypass (CPB) process of care that highlight the potential for process improvement in this way (Baker et al 2012). We aim to reduce overall RBC transfusion in a multicenter setting, through reducing the incidence of anaemia and improving adherence to institutional protocols in sites contributing to the Perfusion Downunder Collaboration.
Methods
This study will follow the SQUIRE publication guidelines for reporting healthcare quality improvement research [Davidoff et al., 2008] and the approval of local ethics committees will be obtained.
Setting
Collaborating perfusionists collect data routinely from procedures performed in the nine Australian and New Zealand cardiac centres currently contributing to the Perfusion Downunder Collaborative Database (PDUCD), as previously described (Baker at el, 2012). Data collected from Jan 2007 – Feb 2013 will be used to report baseline measures of outcome.
Interventions
This quality improvement initiative will be undertaken in three phases;
Phase I:
The initial phase focused on understanding current protocols and processes of care in relation to perioperative blood management, the incidence of perioperative anaemia and RBC transfusion. Each centre was given the opportunity to present their current protocols and data collected since participation in the PDUCD. Presentations were given at a dedicated session at the Perfusion Downunder Meeting, September 1st – 3rd, 2013. Using benchmarking, discussion during this session was focussed towards identification of best performing centres and the lessons to be learnt from these – their processes of care, unit culture and protocols. Results of the session were summarised and provided to each centre for dissemination at unit level.
Phase II:
The second phase will involve: firstly, dissemination of information at individual centres to guide adoption or modification in processes of care; and secondly, the prospective collection of information on indications for RBC transfusion over a three month period in order to determine adherence to institutional protocols. This phase will be implemented once approval has been granted from institutional ethics committees. Clinical interventions will be considered at each centre based on the clinical practice guidelines for blood conservation published by the Society of Thoracic Surgeons (STS) and the Society of Cardiovascular Anesthesiologists (SCA) (Ferraris et al 2011). A local quality improvement (LQI) team at each centre comprising of cardiothoracic surgeons, anaesthetists, perfusionists and nursing staff will be responsible for co- ordination of the project, and implementation of protocols for RBC transfusion. Each institution will be required to
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