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. Figure. Figure. Disclosures No relevant conflicts of interest to declare.

Introduction Unnecessary and inappropriate laboratory testing contributes to increased health care costs, increases length of stay, and increases odds for blood product transfusion. The Choosing Wisely campaign recommends a judicious use of laboratory blood testing to combat iatrogenic anemia. Reducing the number of duplicate test orders may help address these issues. We evaluated duplicate order alert thresholds in our electronic health record for 10 common laboratory tests at an academic medical center. Methods In January 2019, alert intervals for 10 common inpatient laboratory tests (thyroid stimulating hormone, complete blood count, hemoglobin A1c, troponin, lactic acid, hemoglobin and hematocrit, urinalysis, vitamin D, urine beta HCG, and triglycerides) were adjusted to evidence-based, disease-specific thresholds. If a test was ordered within a timeframe shorter than this threshold, an alert interrupted the provider’s workflow. The provider was allowed to override the alert based on clinical judgment. This is a change from the previous settings, which alerted any test if ordered more frequently than 8 hours. Postintervention duplicate order alerts were compared to baseline rates and adjusted for number of inpatient discharges. Results In total, 914 orders were cancelled in 1 month as a result of tailored duplicate order alerts versus the baseline mean of 710 (95% CI, 633-786) and a predicted 552 (95% CI, 475-628) when adjusted for number of inpatient discharges, with the majority of cancelled orders being for CBC (530 accepted alerts). Overall, this reduction in unnecessary duplicate tests is equivalent to 3,092 mL of blood not collected from patients per month. Conclusion Tailoring duplicate order alert interval thresholds to evidence-based criteria helps reduce unnecessary testing, reduces costs, and may play an important role in reducing hospital-acquired anemia.