Red blood cell transfusion practices in patients undergoing orthopedic surgery: a multi-institutional analysis.

This retrospective review analyzed and compared transfusion practices in patients undergoing orthopedic surgery in five Massachusetts hospitals with current practice guidelines; opportunities for improvement were identified. Patient-specific clinical information and data about transfusion practices were obtained from the medical records of 384 Medicare patients undergoing orthopedic surgery between January 1992 and December 1993. The number of patients who donated autologous blood preoperatively differed significantly among hospitals as did the number of autologous units that were unused. The number of blood units transfused at each transfusion event also differed significantly; some surgeons transfused > or =2 units in the majority of their patients, while others transfused 1 unit at a time. This variation in practice was not explained by differences in patients' clinical status. The mean pretransfusion hematocrit was higher for autologous versus allogeneic blood, suggesting more liberal criteria to transfuse autologous blood. Nearly half of all transfusion events were determined to have been potentially avoidable. Avoidable transfusions were also three to seven times more likely with autologous than with allogeneic blood. Significant inter-hospital differences existed in the number of elective surgery patients exposed to allogeneic blood. The major determinant of allogeneic blood use in these patients was the availability of autologous blood. Each additional autologous blood unit available decreased the odds of allogeneic blood exposure twofold. Differences in intraoperative and postoperative blood salvage use also were noted. These findings indicate that significant variations in practice exist. Comparative data enabled hospitals to identify and target specific areas for improvement.

Evaluating the appropriateness of red blood cell transfusions: the limitations of retrospective medical record reviews.

OBJECTIVE: Several studies have looked at the appropriateness of red blood cell transfusions, using retrospective chart reviews to assess compliance with guidelines. The goal of this study was to determine the quality of medical chart documentation, and assess the validity and the feasibility of using retrospective chart review data as part of a quality improvement (QI) program, to evaluate the appropriateness of peri-operative transfusions. DESIGN: The charts of 188 patients admitted for elective orthopedic surgery were reviewed. Both intra-operative and post-operative transfusion events (n = 353) were analyzed. RESULTS: Only 68% of post-operative transfusion events on the day of surgery and 35% of transfusion events on days after surgery were accompanied by documentation of blood loss and/or change in vital signs. Symptoms were recorded in only 10% of post-operative transfusion events. The rationale for transfusion was recorded in only 16% of post-operative transfusion events on the day of surgery, in 27% on post-operative days and in 95% of intra-operative transfusions. The documentation of rationale was not different for transfusion events involving autologous blood (31%) or allogeneic blood (32%). This study provided information on transfusion practices. Single unit transfusions occurred in only 47 and 34% of patients receiving autologous and allogeneic blood, respectively. Only 19% of patients transfused with more than one allogeneic blood units, were clinically reassessed between blood units, compared to 34% of patients receiving more than one autologous blood unit. We conclude that retrospective chart reviews are limited by inadequate documentation and may not be the optimal source of information to determine the appropriateness of a transfusion. Improved methods (e.g. prospective reviews, or other system-level data collection methods) are needed for QI programs to influence practice. Despite its limitations, the information obtained suggests that current practice could be improved.