We noted important and significant impacts for patients in Zhejiang who underwent surgery after the implementation of updated PoBM guidelines. In 2007, a considerable number of perioperative transfusions were probably performed on the basis of subjective assessments by medical practitioners. Furthermore, only 383 (6.3%) patients in our survey received cell salvage or ANH. Our data showed that more ASA IV-V patients were accepted operation in 2011. In addition, a larger percentage of orthopedic and cardiovascular cases were performed in the nine survey hospitals in 2011, which indicate that more critical patients were treated in 2011 compared to 2007. However, in 2011, the allogeneic RBC transfusion rate on patient was significantly reduced. Significantly more perioperative blood transfusions in 2011 were given based on patients’ Hb levels and other objective laboratory reports. The rates of appropriate intraoperative and postoperative blood transfusions both increased from 2007 to 2011. Several factors that may have contributed to these improvements in blood management are presented below.
Guideline development and implementation
The Zhejiang PoBM strategies were created based on a national version of guideline (
Guidelines for Clinical Use of Blood [
21]) issued by the State Public Health Department. With its patient-centered philosophy, the updated PoBM guidelines are best implemented within the framework of an organized and recognized program [
22]. Guidelines for Clinical Use of Blood proposed a restrictive transfusion strategy and recommended transfusion at Hb concentrations of 7 g/dl or less; transfusions are unnecessary at Hb concentrations of 10 g/dl or more. Between the 2 thresholds, there are no absolute, universal recommendations in existing guidelines, and transfusion-related decisions should be considered according to clinical factors, such as cardiopulmonary function, the severity of anemia, basic metabolic rate, and age. In this context, inappropriate blood transfusions are sometimes ordered. In this study, we assessed the appropriateness of transfusions on the basis of whether surgeons and anesthesiologists considered clinical factors before ordering blood transfusions for patients.
Several problems existed among the hospitals in Zhejiang prior to the implementation of the new guidelines. Many clinicians permitted blood transfusions when Hb levels were 10 g/dl or higher in 2007, which resulted in a high number of allogeneic RBC transfusions: many of these were unnecessary. Except in special emergency cases, a patient’s Hb level should be measured to determine the need for transfusion. According to our findings, after the implementation of updated PoBM guidelines, the rate of inappropriate blood transfusions decreased from 2007 to 2011.
From 2008 to 2010, a series of educational programs and interventions were conducted in Zhejiang Province to actively promote the implementation of the new PoBM guidelines. Specifically, the AQCZ organized and presented more than 30 continuing education courses between December 2009 and September 2011. Surgeons, anesthesiologists, and transfusion physicians from tertiary and secondary hospitals across Zhejiang Province attended these courses, and the healthcare providers were offered multiple opportunities to interact and discuss issues related to blood management.
Hospitals in Zhejiang were expected to comply with the following regulations: a clinical transfusion management committee must be established at the hospital level; blood transfusions must be monitored in accordance with the PoBM guidelines and evaluations must be performed before and after transfusions to ensure the effective and safe use of blood; strategies must be developed to promote blood conservation techniques including the use of cell salvage or ANH; and, necessary education and training courses must be developed for physicians and surgeons to ensure that knowledge is translated to clinical practice [
14]. These high-profile initiatives not only positioned compliance with PoBM guidelines as a major public health issue on the administrative agenda but also resulted in unprecedented improvements in blood transfusion practices of hospitals in Zhejiang.
Since 2008, all nine hospitals included in our study established clinical transfusion management committees and subsequently implemented the new PoBM guidelines. Seven hospitals regularly provide formal training in transfusion practices to their staff, including surgeons, physicians, anesthesiologists, and nurses.
The proportion of cell salvage or ANH increased from 2007 to 2011. The nine hospitals in this study reported large numbers of cases involving intraoperative cell salvage and ANH in 2011, which possibly explains the significant reduction in allogeneic RBC use [
23‐
25]. Postoperative autologous blood transfusion, reinfusion of RBC harvested from the drainage system, has been reported in the other studies that can contribute to the reduction in allogeneic blood transfusion [
26,
27]. In our study, the postoperative RBC cell salvage was carried out only on two hospitals, giving a total of 28 cases. We suggest to promote the postoperative cell salvage technique to more hospitals and we hope to see further improvements in future.
Role of primary healthcare providers
Typically in China, anesthesiologists are responsible for intraoperative transfusion decisions while surgeons more often make decisions in the postoperative period. In this study, we separately examined the rates of appropriate intraoperative and postoperative blood transfusions and found that both professional groups showed significant improvements in blood transfusion management. We observed a more dramatic improvement during the intraoperative phase than during the postoperative phase. This evidence suggested that anesthesiologists in Zhejiang are, perhaps, more prepared to update their management strategy than their surgery partners when considering blood transfusions in this few years. Nevertheless, there were still 32.5% intraoperative and 28.7% postoperative transfusion occurred in 2011 without laboratory test. Completely eliminating those undesirable blood transfusion cases can be challenged for both anesthesiologists and surgeons during different phases of patient care. We believe that greater efforts should still be aimed at anesthesiologists and surgeons, as they are the primary care delivering and the decision-making person for blood transfusion.
Strengths and limitations
This is the first in a series of reports on blood management practices in China using large-scale patient-based data collected from multiple hospitals. All hospitals included in our study are general hospitals, which provide services to people with serious health problems and are considered the primary targets for quality control in blood management. The data collected from these hospitals and the results presented in this paper accurately represent the blood management situation in the Zhejiang Province of China.
There are several important limitations to this study. First, we only audited blood transfusion quality for patients who underwent surgery; therefore, caution is needed when applying our findings to non-surgery scenarios. Second, data collected from selected hospitals in Zhejiang may represent the majority of blood transfusion cases, but it does not describe the transfusion practices in specialty hospitals such as women and children’s hospitals, dental hospitals, oncology centers, and rehabilitation hospitals. Future research to describe the status of PoBM in China should include data from a wider range of hospitals and cases of non-surgery patients. Third, we reported here the data up to 2011. Data of later years are still collected. We will continue to work on these data and understand the impact of PoBM education and initiatives on the patient safety.