Are we overusing blood transfusing after elective joint replacement?--a simple method to reduce the use of a scarce resource.

OBJECTIVES: To determine the proportion of patients who received a blood transfusion after joint replacement, and to devise a simple method to ensure patients were transfused based on strict clinical and haematological need.
DESIGN: Prospective audit over 2 years. PATIENTS AND METHODS: The study group was 151 patients who underwent total hip and knee arthroplasty in a typical district general hospital (Kettering) over a 2-year period. They were divided into three consecutive groups. Current practice was audited (producing the first group of 62 patients) and transfusion rates were compared to regional figures. Local guidelines were drawn up. A form was introduced on which the indications for any transfusion had to be documented prior to transfusion of the blood. This was designed to encourage transfusion only on strong clinical grounds or an haemoglobin (Hb) level < 8 g/dl. Transfusion practice was then re-audited (producing the second group of 44 patients) to assess whether practice had improved. A year later, all relevant staff were reminded by letter of the guidelines. The process was then re-audited (producing the third group of 45 patients) again to determine whether practice remained improved or not.
RESULTS: In the first audit (current practice) of 62 patients, the overall transfusion rate was 71%, with a higher rate in the hip replacement group (84%) ordered mainly by anaesthetic staff. Ward staff were reluctant not to transfuse patients whose Hb level fell below 10 g/dl. In the second audit, the transfusion rate fell by nearly 50% to 37%, with almost identical figures for knee and hip replacement. In the third audit of 45 patients, a year later, the transfusion rate was 40% overall.
CONCLUSIONS: Patients were being transfused routinely, generally without good clinical evidence of benefit to the patient. The audit process was successful in instituting change for the better in blood transfusion practice for elective joint replacement. The improved practice can be largely maintained provided staff are regularly reminded of appropriate guidelines and encouraged to transfuse for clinical need only. For absolute adherence to guidelines, we would recommend a compulsory form system be introduced for transfusion in the per-operative period, to ensure blood transfusion is only given when absolutely necessary.