Müller Urs, Exadaktylos Aristomenis, Roeder Christoph, Pisan Markus, Eggli Stefan, Jüni Peter
Institute for Evaluative Research in Orthopaedic Surgery, University of Berne, 3001 Berne, Switzerland.
BMJ. 2004 Apr 17;328(7445):934-8. doi: 10.1136/bmj.328.7445.934.
A suspected high proportion of unnecessary blood transfusions occur in patients undergoing total joint replacement.
Prospective before and after study evaluating the impact of a one page flow chart aimed at reducing the use of blood transfusions.
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).
Proportion of patients receiving allogeneic blood transfusions.
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.
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 pounds sterling (42,470 dollars; 34,441 euros) (103.50 pounds sterlingper patient undergoing total joint replacement). Differences became more pronounced after adjustment for confounding factors.
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.
在接受全关节置换手术的患者中，疑似存在高比例的不必要输血情况。
前瞻性前后对照研究，评估旨在减少输血使用的单页流程图的影响。
瑞士温特图尔的骨科三级护理中心。在对照期（1998年10月至1999年9月），208例患者接受了初次髋或膝关节全关节置换手术；在干预期（1999年10月至2000年9月），217例患者接受了手术。
接受异体输血的患者比例。
从1999年10月4日起，将一份以图形方式总结贫血患者围手术期决策路径的简单单页流程图放置在所有接受全关节置换手术患者的病历中，并分发给医务人员。流程图的实施重点在于得到主任医师的认可以及在医生和护士中培养“主人翁”意识。
接受异体输血的患者比例从35.0%降至19.8%（绝对差值-15.2%，95%置信区间-23.3至-7.0%）。自体献血和接受自体输血的患者百分比也有所下降。这导致总体节省约23,000英镑（42,470美元；34,441欧元）（每位接受全关节置换手术的患者节省103.50英镑）。在对混杂因素进行调整后，差异变得更加明显。
通过实施单页流程图，可以有效降低初次髋膝关节置换手术中的异体输血成本。可能有五个关键因素发挥了作用：简单性；广泛分发；无需重大改变；得到当地意见领袖的认可；以及培养“主人翁”意识。这些因素可用于其他情况，以实现临床实践的持续变革。
