Anaemia is associated with significant postoperative risks, but if present pre-operatively it could be addressed before surgery. A surgical team’s pre-operative anaemia service reduced both risks and costs
Citation: Mitchell E et al (2017) a pre-operative anaemia service to avoid unnecessary blood transfusions. Nursing Times [online]; 113: 2, 53.
Authors: Emma Mitchell and Louise Pidhoreckyj are pre-operative sisters; Kirsten Wheeler is pre-operative service manager; all at Stepping Hill Hospital, Stockport.
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Pre-operative anaemia has been linked to an increased risk of 30-day post-operative mortality and is an independent risk factor for post-operative morbidity and peri-operative transfusion (Sarhane et al, 2013). National Blood Transfusion Committee (2014) guidance on avoiding unnecessary transfusion through better management of pre-operative patients and anaemia, recommends that services:
- Provide arrangements for the timely identification and correction of anaemia before elective surgery that is likely to involve significant blood loss;
- Develop and implement protocols for the management of patients taking anticoagulants and antiplatelet drugs that may increase the risk of bleeding;
- Avoid transfusion for patients with anaemia by using alternatives such as oral iron or intravenous iron.
Identifying the problem
At our trust patients diagnosed with anaemia pre-operatively were referred back to their GP for it to be managed before surgery, but we felt these patients were not treated effectively. We carried out a retrospective audit of those diagnosed with anaemia during their pre-operative assessment between July 2014 and July 2015 and identified 103 who could have benefited from pre-operative anaemia management. Eighty-six of these went on to have surgery, and 23 had a longer-than-average hospital stay due to post-operative complications and transfusions. A total of 24 patients were transfused, costing £10,488 (based on an average transfusion of 2.7 units per patient at £437); there were 22.5 excess bed days at an average cost of £146 per day (£3,285) and five patients had their surgery cancelled on the day as a direct result of their anaemia, costing £12,290 in lost revenue.
We carried out a prospective audit from September 2015 to May 2016 on 23 patients with iron deficiency anaemia who were referred back to primary care. Only seven had their blood results optimised by admission, four had not had their results rechecked by their GP or the admitting ward before surgery and 12 had not been optimised. Of the 12 unoptimised patients, four had a longer stay due to transfusion, one had a three-day readmission requiring a blood transfusion and one had surgery cancelled on the day. This group had 11 units of blood transfused and the complications experienced cost £8,287.
Our results confirmed that effective pre-operative management of anaemia could improve outcomes and safety and result in financial savings.
Implications for practice
A pre-operative anaemia assessment service can:
- Improve safety – by reducing unnecessary blood transfusions, length of hospital stay and post-operative complications
- Improve quality – by reducing cancellations, improving the patient experience and streamlining the patient pathway
- Improve cost-effectiveness – by reducing unnecessary costs and using existing resources
What we did
In June 2016 we set up a pre-operative anaemia service run by the pre-operative assessment nursing team; this aims to reduce transfusion rates and length of stay, and improve outcomes and surgical bed use. Patients are:
- Assigned a named nurse in the anaemia clinic who is available to support them and ensure they are informed about their anaemia and treatment options;
- Given dietary advice and a follow-up appointment to check their concordance and the effectiveness of the treatment given.
At any point during treatment they are able to contact their named nurse for advice. The pre-operative team also ensures patients are investigated for causes of their anaemia in primary care.
From 1 June 2016 to 1 December 2016 we identified 39 patients with iron-deficiency anaemia, who were assessed and treated with either oral (n = 26) or IV iron (n = 10). Three patients had an existing prescription of oral iron restarted. Establishing this service means we now provide a more streamlined and effective patient journey, with no increased length of stay, blood transfusions or cancellations to surgery.
National Blood Transfusion Committee (2014) Patient Blood Management: An Evidence-based Approach to Patient Care.
Sarhane KA et al (2013) Preoperative anaemia and postoperative outcomes in immediate breast reconstructive surgery: a critical analysis of 10,958 patients from the ACS-NSQIP database. Plastic Reconstructive Surgery Global Open; 1: 5, e30.