Moving from a culture of ‘tranfusion practice’ to one of’ patient blood management’ improves patient outcomes, reduces transfusion of allogeneic blood products and cost

Introduction: Continuous practice improvement initiatives that enhance patient outcomes are a goal of high-performing surgical, anaesthesia and critical care departments. Patient outcomes are negatively impacted by excessive bleeding post cardiac surgery. Treatment of bleeding invariably involves transfusion with blood products which may further exacerbate post-operative complications. Despite the existence of multiple guidelines that address bleeding management, there appears to be reluctance to incorporate these recommendations into standard practice, possibly due to: a lack of awareness of ‘Patient Blood Management’ (PBM) guidelines, limited confidence in available evidence, resistance from clinicians who have “always managed before”, economic and logistical obstacles to implementing complex practice change, or a combination of factors. We aimed to embed a service-wide practice change, from a culture of ‘transfusion practice’ to a culture of ‘PBM’, through the development and implementation of a formalised bleeding management protocol that included:(i) identifying the patient at high risk of bleeding, (ii) supported by point care diagnostic testing and (iii) providing algorithm driven treatment options. Methods: A retrospective cohort study was performed to analyse the implementation of a formalised bleeding management protocol, where transfusion and patient outcome data for 15 months pre- and post-implementation of PBM were compared. The analysis was performed on all patients who underwent cardiac surgery with cardiopulmonary bypass, excluding heart and/or lung transplantation, or surgery with mechanical circulatory support. Results: The implementation of PBM resulted in a significant decrease in the transfusion of PRBCs (47.3% to 32.4%; p<0.001), FFP (26.9% to 7.3%; p<0.001) and platelets (36.1% to 13.5%; p<0.001). In the intraoperative period, the percentage of patients receiving cryoprecipitate increased (2.7 to 5.1; p = 0.002), as did the number of units transfused (248 vs. 692; p<0.001). The proportion of patients who received tranexamic acid increased (13.9% vs. 68.8%; p<0.001). Mean length of stay from operation to discharge was 12% lower (95%: 9-16%, p<0.001) and there were reductions in re-exploration for bleeding (5.6 vs. 3.4; p=0.01), the incidence of superficial chest wound (3.3 vs.1.4; p=0.002) and leg wound infection (4.6 vs. 2.0; p<0.001). Based on the Queensland Blood product acquisition price, the cost of blood products decreased by $1 029 118 in the 15 month period after implementation of PBM. Discussion: Implementing a service wide change in practice to embrace ‘patient blood management’ utilising a perioperative bleeding management protocol was associated with significant reductions in the transfusion of allogeneic blood products, improved patient outcomes and reduced cost.