Likosky Donald S, Surgenor Stephen D, Dacey Lawrence J, DeFoe Gordon R, Maislen Elizabeth L, Clark Jean A, Aubuchon James P, Higgins John H, Beaulieu Peter A, O'Connor Gerald T, Ross Cathy S
Department of Surgery, The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
Qual Saf Health Care. 2010 Oct;19(5):392-8. doi: 10.1136/qshc.2009.033456.
Transfusion of red blood cells, while often used for treating blood loss or haemodilution, is also associated with higher infection rates and mortality. The authors implemented an initiative to reduce variation in the number of perioperative transfusions associated with cardiac surgery.
The authors examined patients undergoing non-emergent cardiac surgery at a single centre from the third quarter 2004 to the second quarter 2007. Phase I focused on understanding the current process of managing and treating perioperative anaemia. Phase II focused on (1) quality-improvement project dissemination to staff, (2) developing and implementing new protocols, and (3) assessing the effect of subsequent interventions. Data reports were updated monthly and posted in the clinical units. Phase III determined whether reductions in transfusion rates persisted.
Indications for transfusions were investigated during Phase II. More than half (59%) of intraoperative transfusions were for low haematocrit (Hct), and 31% for predicted low Hct during cardiopulmonary bypass. 43% of postoperative transfusions were for low Hct, with an additional 16% for failure to diurese. The last Hct value prior to transfusion was noted (Hct 25-23, p=0.14), suggestive of a higher tolerance for a lower Hct by staff surgeons. Intraoperative transfusions diminished across phases: 33% in Phase I, 25.8% in Phase II and 23.4% in Phase III (p<0.001). Relative to Phase I, postoperative transfusions diminished significantly over Phase II and III.
We report results from a focused quality-improvement initiative to rationalise treatment of perioperative anaemia. Transfusion rates declined significantly across each phase of the project.
红细胞输血常用于治疗失血或血液稀释，但也与较高的感染率和死亡率相关。作者实施了一项倡议，以减少心脏手术围手术期输血数量的差异。
作者研究了2004年第三季度至2007年第二季度在单一中心接受非急诊心脏手术的患者。第一阶段重点是了解当前管理和治疗围手术期贫血的过程。第二阶段重点是：（1）向工作人员传播质量改进项目；（2）制定和实施新方案；（3）评估后续干预措施的效果。数据报告每月更新并张贴在临床科室。第三阶段确定输血率的降低是否持续。
在第二阶段对输血指征进行了调查。超过一半（59%）的术中输血是因为血细胞比容（Hct）低，31%是因为体外循环期间预计Hct低。43%的术后输血是因为Hct低，另有16%是因为利尿失败。记录了输血前的最后Hct值（Hct 25 - 23，p = 0.14），提示外科医生对较低Hct的耐受性更高。术中输血在各阶段有所减少：第一阶段为第三阶段为23.4%（p < 0.001）。相对于第一阶段，术后输血在第二阶段和第三阶段显著减少。
我们报告了一项旨在使围手术期贫血治疗合理化的重点质量改进倡议的结果。在项目的每个阶段，输血率均显著下降。 33%，第二阶段为25.8%，
