Patient Blood Management: Implementation of a Preoperative Anemia Clinic for Elective Orthopedic Surgical Patients
Authors: Letendre Paul , Coberly Emily , Dettenwanger Katie , Huang Kan 
Published: October 2019

Abstract
Background: Patient blood management (PBM) programs aim to implement best practices and encourage blood stewardship. Judicious use of red blood cell transfusions improves patient safety, decreases hospital length of stay (LOS) and reduces cost. A 2010 World Health Organization statement asserted "…before surgery every reasonable measure should be taken to optimize the patient's own blood volume, minimize the patient's blood loss and to harness and optimize physiological tolerance of anemia…". A comprehensive PBM program includes a preoperative anemia clinic to facilitate these goals. At our institution, 21% of surgical patients are anemic prior to their elective surgery and these patients consume approximately 67% of our transfused operating room blood. Our aim was to reduce red blood cell transfusions in elective orthopedic surgical patients by 25% and decrease hospital LOS through the implementation of a preoperative anemia clinic.
Methods: After enlisting the support of hospital leadership, a preoperative anemia clinic referral/consult order was added the electronic medical record. Appropriate patients for referral were undergoing elective orthopedic surgery and had anemia defined as a Hgb <11.0 g/dl. Additional non-anemic patients with extenuating circumstances such as religious objection to transfusion were also referred. Every effort was made to see patients at least 2 weeks prior to the date of scheduled surgery or within 48 hours if the referral was not placed that far in advance. Work-up of anemia was individualized based on a patient's laboratory abnormality and medical profile. Interventions were targeted at treating the underlying cause of anemia and included but were not limited to parenteral iron, erythropoietin receptor agonists, and vitamin B12 injections. The primary measures assessed were the average LOS from day of surgery to discharge and the number of red blood cell units transfused during that stay.
Findings: Early data since implementing our preoperative anemia clinic has demonstrated a reduction in LOS from 5.5 days for anemic patients undergoing elective surgery without a referral versus 3.5 days for those with a referral. A relative decrease in LOS of 36%. Reductions in hospital LOS were observed across the spectrum of all elective surgical procedures. The overall red blood cell transfusion rate in patients without referral versus with referral was 1.5% and 1.2% respectively; and of those requiring a transfusion, the mean red blood cell units transfused in the perioperative period was 2.31 units versus 1.19 units, resulting in a relative reduction of 48%. Additionally, 2 patients were diagnosed with a gastric ulcer and 2 patients with multiple myeloma during work-up and referred appropriately for treatment.
Discussion: Expansion of the PBM program at our institution to include a preoperative anemia clinic has led to significant reductions in both red blood cell transfusions and hospital LOS in elective orthopedic surgical patients. Early results indicate a near doubling of our goal of a 25% reduction in red blood cells transfused. This has positively impacted our patients and led to both direct and indirect financial savings at our institution. Given the initial success, we hope to expand our preoperative anemia clinic to include all surgical specialties and streamline workflow. To facilitate growth additional staffing will be required. We have created patient education videos about the benefits of correcting their anemia prior to an elective surgery and hope to further engage primary care practitioners to refer patients earlier in their surgical evaluation. We conclude that the creation of a preoperative anemia clinic at our institution is a valuable resource and has led to a decreased use of red blood cell transfusions, a decreased average hospital LOS, improved patient safety and considerable financial savings.
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Disclosures
No relevant conflicts of interest to declare.