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

BMJ 2004; 328 doi: (Published 15 April 2004) Cite this as: BMJ 2004;328:934

This article has a correction. Please see:

  1. Urs Müller, senior research fellow in orthopaedic surgery1,
  2. Aristomenis Exadaktylos, specialist registrar in anaesthesiology2,
  3. Christoph Roeder, clinical research associate1,
  4. Markus Pisan, consultant orthopaedic surgeon3,
  5. Stefan Eggli, consultant orthopaedic surgeon4,
  6. Peter Jüni (juni{at}, senior research fellow in clinical epidemiology5
  1. 1Institute for Evaluative Research in Orthopaedic Surgery, University of Berne, 3001 Berne, Switzerland
  2. 2Department of Anaesthesiology, Inselspital, University of Berne, 3010 Berne
  3. 3Department of Orthopaedic Surgery, Kantonsspital Winterthur, 8400 Winterthur, Switzerland
  4. 4Department of Orthopaedic Surgery, University of Berne, 3010 Berne
  5. 5Departments of Social and Preventive Medicine and Rheumatology, University of Berne, 3012 Berne
  1. Correspondence to: P Jüni
  • Accepted 22 December 2003


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.


  • Contributors UM conceived the study and had main responsibility for the development of protocol and flow chart, data collection, and management. AE participated in developing the flow chart and reviewed the protocol. CR and SE reviewed the protocol and participated in data preparation. MP participated in developing the flow chart and was responsible for data collection. PJ reviewed the protocol, had main responsibility for data preparation, analysis, and interpretation, and wrote the first draft of the paper. All investigators participated in data interpretation and contributed to the final draft. UM and PJ are the guarantors.

  • Funding PJ is a senior research fellow funded by the Swiss National Science Foundation (grants 32-66377.01 and 32-66378.01) and is also affiliated with the UK Medical Research Council's Health Services Research Collaboration at the Department of Social Medicine at the University of Bristol.

  • Competing interests None declared

  • Ethical approval None required

  • Accepted 22 December 2003
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