BMJ  2004;328:934-938 (17 April), doi:10.1136/bmj.328.7445.934

Quality improvement report

Effect of a flow chart on use of blood transfusions in primary total hip and knee replacement: prospective before and after study

¹ Institute for Evaluative Research in Orthopaedic Surgery, University of Berne, 3001 Berne, Switzerland, ² Department of Anaesthesiology, Inselspital, University of Berne, 3010 Berne, ³ Department of Orthopaedic Surgery, Kantonsspital Winterthur, 8400 Winterthur, Switzerland, ⁴ Department of Orthopaedic Surgery, University of Berne, 3010 Berne, ⁵ Departments of Social and Preventive Medicine and Rheumatology, University of Berne, 3012 Berne

Problem A suspected high proportion of unnecessary blood transfusions occur in patients undergoing total joint replacement.

Design Prospective before and after study evaluating the impact of a one page flow chart aimed at reducing the use of blood transfusions.

Setting Orthopaedic tertiary care centre in Winterthur, Switzerland. 208 patients underwent primary total joint replacement of hips or knees during the control period (October 1998 to September 1999) and 217 during the intervention period (October 1999 to September 2000).

Key measures for improvement Proportion of patients receiving allogeneic blood transfusions.

Strategies for change A simple one page flow chart, which summarised graphically the perioperative decision pathways for anaemic patients, was placed in all charts of patients undergoing total joint replacement and handed out to medical staff from 4 October 1999 onwards. The implementation of the flow chart focused on its endorsement by chief physicians and the development of a sense of "ownership" among physicians and nurses.

Effects of change The proportion of patients receiving allogeneic blood decreased from 35.0% to 19.8% (absolute difference -15.2%, 95% confidence interval -23.3 to -7.0%). The percentage of patients donating and receiving autologous blood also decreased. This led to overall savings of about £23 000 ($42 470; 34 441) (£103.50 per patient undergoing total joint replacement). Differences became more pronounced after adjustment for confounding factors.

Lessons learnt Allogeneic blood transfusions in primary hip and knee replacement surgery may be reduced cost effectively by implementing a one page flow chart. Five key elements may have contributed: simplicity; wide distribution; no requirement for major changes; endorsement by local opinion leaders; and development of a sense of ownership. These elements may be used in other contexts to achieve sustained change of clinical practice.

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This article has been cited by other articles:

• Vamvakas, E. C., Blajchman, M. A. (2009). Transfusion-related mortality: the ongoing risks of allogeneic blood transfusion and the available strategies for their prevention. Blood 113: 3406-3417 [Abstract] [Full text]  
• Tinmouth, A., MacDougall, L., Fergusson, D., Amin, M., Graham, I. D., Hebert, P. C., Wilson, K. (2005). Reducing the Amount of Blood Transfused: A Systematic Review of Behavioral Interventions to Change Physicians' Transfusion Practices. Arch Intern Med 165: 845-852 [Abstract] [Full text]  
• (2005). CORRECTIONS. Qual Saf Health Care 14: 72-72 [Full text]  
• (2004). Simple Flow Chart Decreases Use of Blood Transfusions. JWatch General 2004: 1-1 [Full text]  

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