Minimizing Blood Transfusion in Total Hip and Knee Arthroplasty Through a Multimodal Approach

doi:10.1016/j.arth.2015.08.025

The Journal of Arthroplasty

Volume 31, Issue 2, February 2016, Pages 378-382

https://doi.org/10.1016/j.arth.2015.08.025 Get rights and content

Abstract

Background

We introduced a multimodal, multidisciplinary approach to perioperative blood management aimed at reducing blood transfusions in primary knee (TKA) and hip (THA) arthroplasty. The protocol included (1) preoperative hemoglobin optimization through a multidisciplinary approach, (2) minimization of perioperative blood loss, and (3) adherence to evidence-based transfusion guidelines.

Methods

Evaluation of 1010 consecutive patients undergoing primary TKA (488) or THA (522) was performed.

Results

A significant reduction in the overall transfusion rate (1.4% vs 17.9%, P < .0001) resulted after algorithm introduction, when compared with the 1814 previous patients. Zero (0%) TKA and 4 (0.8%) THA patients adherent to protocol, and 4/488 (0.8%) TKA and 10/522 (1.9%) THA patients overall received transfusions.

Conclusion

Adoption of a multimodal blood management algorithm can significantly reduce blood transfusions in primary joint arthroplasty.

Section snippets

Materials and Methods

The institutional registry of prospectively collected data on 1010 consecutive patients undergoing primary THA (522) or TKA (488) was reviewed after the initiation (May 2012) of the multimodal perioperative blood management algorithm outlined below. Study approval was granted from the institutional review board. The inclusion criteria were primary scheduled THA or TKA. Cases involving revision total joint arthroplasty or fracture were excluded. No patients were excluded for underlying medical

Statistical Methods

Continuous data are expressed as the mean and SD. Differences between groups with regard to age, body mass index (BMI), Hb measures, and American Society of Anesthesiologists (ASA) class were analyzed with use of t test. Categorical data were analyzed with the Fisher exact test.

Results

There was a significant reduction in the overall transfusion rate (1.4% vs 17.9%, P < .0001) for all patients undergoing primary joint arthroplasty after introduction of our protocol, when compared with the historic cohort. There were no significant clinical differences in age, gender, BMI, or ASA class when comparing the study group with the historic cohort (Table 1). There was a nonsignificant decrease in the incidence of observed postoperative stroke (0.13% vs 0.24%, P = .67) and DVT/PE (0.4% vs

Discussion

Implementation of a multimodal, multidisciplinary blood management protocol for all patients undergoing primary scheduled hip or knee arthroplasty resulted in a significant reduction in allogeneic blood transfusions compared with patients undergoing similar procedures just prior to its implementation. This significant reduction in transfusion rates occurred at a tertiary care teaching hospital, in all patients undergoing scheduled arthroplasty, across multiple surgeons of variable subspecialty,

References (36)

L.T. Goodnough et al.
Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines
Br J Anaesth
(2011)
M. Al-Khabori et al.
Validation of a non-invasive pulse CO-oximetry based hemoglobin estimation in normal blood donors
Transfus Apher Sci
(2014)
J.A. Browne et al.
Transfusion rates are increasing following total hip arthroplasty: risk factors and outcomes
J Arthroplasty
(2013)
M.S. Noticewala et al.
Predicting need for allogeneic transfusion after total knee arthroplasty
J Arthroplasty
(2012)
T.C. Wind et al.
The effect of tranexamic acid on blood loss and transfusion rate in primary total knee arthroplasty
J Arthroplasty
(2013)
J. Tan et al.
A meta-analysis of the effectiveness and safety of using tranexamic acid in primary unilateral total knee arthroplasty
J Surg Res
(2013)
C.M. Duncan et al.
Venous thromboembolism and mortality associated with tranexamic acid use during total hip and knee arthroplasty
J Arthroplasty
(2015)
J.R. Tuttle et al.
Cost benefit analysis of topical tranexamic acid in primary total hip and knee arthroplasty
J Arthroplasty
(2014)
R.N. Harris et al.
Does tranexamic Acid reduce blood transfusion cost for primary total hip arthroplasty? A case-control study
J Arthroplasty
(2015)
S. Kurtz et al.
Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030
J Bone Joint Surg Am
(2007)

P.C. Hebert et al.

A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group

N Engl J Med

(1999)

J.L. Carson et al.

Liberal or restrictive transfusion in high-risk patients after hip surgery

N Engl J Med

(2011)

N. Rosencher et al.

Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe

Transfusion

(2003)

H. Gombotz et al.

Blood use in elective surgery: the Austrian benchmark study

Transfusion

(2007)

American Society of Anesthesiologists task force on perioperative blood transfusion and adjuvant therapies: practice guideline for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task force on Perioperative blood transfusion and adjuvant therapies

Anesthesiology

(2006)

J.L. Carson et al.

Red blood cell transfusion: a clinical practice guideline from the AABB

Ann Intern Med

(2012)

S. Morais et al.

Blood transfusion after primary total knee arthroplasty can be significantly minimised through a multimodal blood-loss prevention approach

Int Orthop

(2014)

N. Shah et al.

Accuracy of noninvasive hemoglobin and invasive point-of-care hemoglobin testing compared with a laboratory analyzer

Int J Lab Hematol

(2013)

Cited by (79)

Risk of blood transfusion following total hip arthroplasty: A national database study from 367,894 patients
2023, Journal of Orthopaedics
A growing elderly population in the United States coupled with improvement in surgical techniques have resulted in more elderly individuals undergoing total hip arthroplasty (THA). As such, risk factors associated with increased risk of blood transfusion following THA, which has been linked to various detrimental outcomes, must be better understood. This study aims to identify co-morbidities associated with blood transfusion following THA.
Using the Nationwide Inpatient Sample (NIS) database, we selected patients that received a THA from 2016 to 2019 using ICD-10CMP codes. Patients were classified into a “blood transfusion” or “no transfusion” groups and data pertaining to demographics, co-morbidities, and events during hospital stays were compared between the groups.
Our study dataset included 367,894 patients from the NIS database that underwent a THA from 2016 to 2019. 12,900 (3.5 %) patients received a blood transfusion after their THA and were classified as “blood transfusion group.” The remaining 354,994 patients were classified as the “no transfusion group.” Elective admission was found to decrease the odds of a blood transfusion following a THA (compared to nonelective THA: odd's ratio 0.283; p value < 0.001). Multivariate analysis demonstrated sickle cell disease, liver cirrhosis, and dialysis exhibited the greatest increase in odds of blood transfusion after a THA by 4.81- (p < 0.001), 3.02- (p < 0.001), and 2.22-fold (p < 0.001), respectively. Looking at patient demographics, male sex increased odds of postoperative transfusion by 1.99 (p < 0.001) while Caucasian ethnicity decreased odds of postoperative transfusion by 0.65 (p < 0.001).
Blood transfusion has a low occurrence in the early post-operative period following THA (3.6 % of patients). Sickle cell disease, liver cirrhosis, dialysis, SLE, and heart pathologies were the comorbidities found to be most significantly associated with an increased risk of blood transfusion after a THA. Additionally, both mortality and non-elective admissions were significantly more prevalent in the “blood transfusion” group.
Routine Type and Screens Are Unnecessary in Primary Total Joint Arthroplasty: Follow-up After a Change in Practice
2023, Arthroplasty Today
Citation Excerpt :
These reduced rates are likely secondary to improved preoperative treatment of anemia and appropriate use of evidence-based transfusion thresholds. Furthermore, administration of tranexamic acid (TXA) has enhanced perioperative hemostasis [5–9]. Institutions have begun updating protocols for use of blood products and related testing to minimize unnecessary costs without sacrificing patient safety.
Routine type and screens (T&S) prior to total hip (THA) and total knee arthroplasty (TKA) are common despite low transfusion rates. Our institution implemented a practice change after previously demonstrating a transfusion rate of 1.06%. The purpose of this study is to present the follow-up data 1 year after the practice change of discontinuing routine T&S orders in primary total joint arthroplasty.
A practice change was implemented discontinuing routine T&S orders prior to elective primary total joint arthroplasties. We retrospectively reviewed prospectively collected data on preoperative T&S, hemoglobin values, transfusion rates, bleeding disorders, and anticoagulation status.
A total of 663 patients were included in the study (273 THAs and 390 TKAs). The cumulative transfusion rate was 0.75. No patients received an intraoperative transfusion. Three patients (1.1%) received a postoperative transfusion after THA, and 3 patients (0.5%) received a transfusion after TKA. The mean preoperative hemoglobin in the transfused patients was 12.1 g/dL. Thirteen patients underwent a preoperative T&S (2.0%), and only 2 required transfusion (15.4%). Only 1 patient who required transfusion was on preoperative anticoagulation, and no patients with bleeding disorders required transfusions. Discontinuing routine T&S resulted in an estimated cost savings of $124,325.50.
Discontinuation of routine T&S did not result in any adverse consequences. If required, T&S can safely be performed intraoperatively or postoperatively. Surgeons may consider obtaining a T&S if their preoperative hemoglobin is less than 11-12 g/dL or if significant blood loss is expected in a complex primary total joint arthroplasty.
Who Is Still Receiving Blood Transfusions After Primary and Revision Total Joint Arthroplasty?
2022, Journal of Arthroplasty
Incidence of blood transfusions after primary and revision total hip and knee arthroplasty (primary total hip arthroplasty [pTHA], revision THA [rTHA], primary total knee arthroplasty [pTKA], and revision TKA [rTKA]) has been decreasing for a multitude of reasons. The purpose of this study was to assess whether transfusion rates have continued to decline and evaluate patient factors associated with transfusions.
The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing pTHA, pTKA, rTHA, and rTKA between 2011 and 2019. Patients undergoing bilateral procedures and arthroplasty for fracture, infection, or tumor were excluded. Trends in blood transfusions were assessed. Patient factor association with blood transfusions was evaluated using 2018 and 2019 data.
Transfusion rates decreased from 21.4% in 2011 to 2.5% in 2019 for pTHA (P < .0001). For pTKA, transfusion rates declined from 17.6% to 0.7% (P < .0001). In rTHA, the transfusion rate decreased from 33.5% to 12.0% from 2011 to 2019 (P < .0001). Transfusion rates declined from 19.4% to 2.6% for rTKA during the study period (P < .0001). Transfusions were more frequent in patients who were older, female, with more comorbidities, with lower hematocrit, receiving nonspinal anesthesia, and with longer operative time. Lower preoperative hematocrit, history of bleeding disorders, and preoperative transfusion were associated with greater odds for postoperative transfusion after multivariate analysis.
Transfusions after both primary and revision total joint arthroplasty have continued to decrease. Studies of arthroplasty complications should account for decreasing transfusions when assessing overall complication rates. Future studies should consider interventions to further reduce transfusions in revision arthroplasty.
Response to Letter to the Editor on “In the Era of Tranexamic Acid, Are Type and Screens for Primary Total Joint Arthroplasty Obsolete?”
2021, Journal of Arthroplasty
Home Discharge Has Increased After Total Hip Arthroplasty, However Rates Vary Between Large Databases
2021, Journal of Arthroplasty
There have been significant advancements in perioperative total hip arthroplasty (THA) care and it is essential to quantify efforts made to better optimize patients and improve outcomes. The purpose of this study is to assess trends in discharge destination, length of stay (LOS), reoperations, and readmissions following THA.
Patients undergoing primary THA were identified using International Statistical Classification of Diseases and Current Procedural Terminology codes in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Humana claims databases. Discharge destinations were assessed and categorized as home or not home. Trends in discharge destination, LOS, readmissions, reoperation, and comorbidity burden were assessed.
In ACS NSQIP, 155,637 patients underwent THA and the percentage of patients discharging home increased from 72.2% in 2011 to 87.0% in 2017 (P < .0001). In Humana, 84,832 THA patients were identified, with an increase in home discharge from 56.6% to 72.8% (P < .0001). LOS decreased and proportion of patients with an American Society of Anesthesiologists score ≥3 or Charlson Comorbidity Index ≥2 increased significantly for both home and nonhome going patients. Patients discharged home had a decrease in readmissions in both databases.
Patients undergoing THA more often discharged home and had shorter hospital LOS with lower readmission rates, despite an increasingly comorbid patient population. It is likely these changes in disposition and LOS have resulted in significant cost savings for both payers and hospitals. The efforts necessary to maintain improvements should be considered when changes to reimbursement are being evaluated. ACS NSQIP hospitals had a larger proportion of patients discharged home and the source of data used to benchmark hospitals should be considered as findings may differ.
More Patients Are Being Discharged Home After Total Knee Arthroplasty, However Rates Vary Between Large Databases
2021, Journal of Arthroplasty
Citation Excerpt :
Improvements in hospital LOS, percentage of patients discharging home, and reduction in perioperative complications requiring readmission or reoperation are likely a result of the extensive preoperative efforts to optimize patients prior to these elective procedures and advancements in perioperative care, such as rapid recovery protocols. These have been demonstrated to reduce LOS and decrease overall costs of care [14–25]. By year 2016, ACS NSQIP participating hospitals discharged 81.7% of patients home compared to 74.7% of those with Humana plans.
There have been significant advancements in perioperative care for total knee arthroplasty (TKA). It is essential to quantify the impact of efforts to better optimize patients and deliver care. The purpose of this study is to assess trends in discharge destination, length of stay (LOS), and complications.
Patients undergoing primary TKA were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Humana claims databases using procedural codes. Patients were classified as being discharged home or not home (skilled nursing facility, acute rehab, other non-home destinations). Changes in discharge destination, LOS, comorbidity burden, readmissions, and reoperation were assessed.
In total, 254,195 ACS NSQIP patients underwent TKA, with an increase in home discharge from 67.2% in 2011 to 85.3% in 2017 (P < .0001). There were 178,071 TKA patients in the Humana database and home discharge increased from 62.1% in 2007 to 74.7% in 2016 (P < .0001). LOS decreased and proportion of patients with an American Society of Anesthesiologists score ≥3 or Charlson Comorbidity Index ≥2 increased significantly for both home and non-home going patients. Home going patients had a decrease in 30-day readmissions (ACS NSQIP: 2011: 3.6%, 2017: 2.7%, P = .001; Humana: 2007: 4.0%, 2016: 2.4%, P < .0001).
Patients undergoing TKA were discharged home more often, had shorter LOS, and had significantly lower readmission rates, despite an increasingly comorbid patient population. It is likely that these improvements in postoperative care have resulted in significant cost savings, for both payers and hospitals. The efforts necessary to create and maintain such improvements, as well as the source of data, should be considered when changes to reimbursement are being evaluated. The metrics studied in this paper should provide a comparison for further improvement with continued transition to bundle payments and transition to outpatient surgery with removal of TKA from the inpatient-only list.

View all citing articles on Scopus

: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements, refer to http://dx.doi.org/10.1016/j.arth.2015.08.025.

View full text

Minimizing Blood Transfusion in Total Hip and Knee Arthroplasty Through a Multimodal Approach

Abstract

Background

Methods

Results

Conclusion

Section snippets

Materials and Methods

Statistical Methods

Results

Discussion

Br J Anaesth

Transfus Apher Sci

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Surg Res

J Arthroplasty

J Arthroplasty

J Arthroplasty

Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030

J Bone Joint Surg Am

A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group

N Engl J Med

Liberal or restrictive transfusion in high-risk patients after hip surgery

N Engl J Med

Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe

Transfusion

Blood use in elective surgery: the Austrian benchmark study

Transfusion

Anesthesiology

Red blood cell transfusion: a clinical practice guideline from the AABB

Ann Intern Med

Blood transfusion after primary total knee arthroplasty can be significantly minimised through a multimodal blood-loss prevention approach

Int Orthop

Accuracy of noninvasive hemoglobin and invasive point-of-care hemoglobin testing compared with a laboratory analyzer

Int J Lab Hematol