Utility of pre-operative haemoglobin concentration to guide peri-operative blood tests for hip and knee arthroplasty: A decision curve analysis.

OBJECTIVE: Assess the prognostic value of pre-operative haemoglobin concentration (Hb) for identifying patients who develop severe post-operative anaemia or require blood transfusion following primary total hip or knee, or unicompartmental knee arthroplasty (THA, TKA, UKA). BACKGROUND: Pre-operative group and save (G&S), and post-operative Hb measurement may be unnecessary for many patients undergoing hip and knee arthroplasty provided individuals at greatest risk of severe post-operative anaemia can be identified. METHODS AND MATERIALS: Patients undergoing THA, TKA, or UKA between 2011 and 2018 were included. Outcomes were post-operative Hb below 70 and 80 g/L, and peri-operative blood transfusion. Logistic regression assessed the association between pre-operative Hb and each outcome. Decision curve analysis compared strategies for selecting patients for G&S and post-operative Hb measurement. RESULTS: 10 015 THA, TKA and UKA procedures were performed in 8582 patients. The incidence of blood transfusion (4.5%) decreased during the study. Using procedure specific Hb thresholds to select patients for pre-operative G&S and post-operative Hb testing had a greater net benefit than selecting all patients, no patients, or patients with pre-operative anaemia. CONCLUSIONS: Pre-operative G&S and post-operative Hb measurement may not be indicated for UKA or TKA when adopting restrictive transfusion thresholds, provided clinicians accept a 0.1% risk of patients developing severe undiagnosed post-operative anaemia (Hb < 70 g/L). The decision to perform these blood tests for THA patients should be based on local institutional data and selection of acceptable risk thresholds.

How do we use electronic clinical decision support and feedback to promote good transfusion practice.

This report describes the evolution of the electronic clinical decision support system (CDSS) and feedback methods at our center and the challenges and lessons learned. The electronic blood product order with integrated CDSS ensures collection of data regarding the patient's clinical condition and the justification for the blood product order. An alert is generated in real time if the order is placed outside agreed guidelines. We have provided feedback in several ways. We began with monthly review meetings with the junior hematology clinicians responsible for ordering blood. This was successful in reducing unjustified transfusions in this setting. We expanded the feedback to the rest of our hospitals in two ways. First, a dashboard was developed allowing visualization of ordering data by clinicians. Second, these data were summarized on a quarterly basis into a report circulated to the senior clinical staff by e-mail. Finally, a daily report collates all orders placed for blood products that have triggered a CDSS alert from the previous day. A multidisciplinary team reviews these daily. If an order appears unjustified the specialist transfusion clinician contacts the prescribing clinician to ask for further information and, if necessary, provides education. The CDSS and feedback, allied with other patient blood management measures, have reduced total blood product costs for our hospitals by 26% over 6 years. The description of how we have developed and implemented CDSS and feedback to influence transfusion practice may be of particular value to others developing their own systems.