Effect of Hospital Culture on Blood Transfusion in Cardiac Procedures

Jin, Ruyun; Zelinka, Edy S.; McDonald, Julie; Byrnes, Thomas; Grunkemeier, Gary L.; Brevig, James

doi:10.1016/j.athoracsur.2012.08.008

Cited by 52 publications

(38 citation statements)

References 23 publications

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“…First, we cannot rule out the effect of unmeasured confounding, including other institutional or physician-related practices. 14, 15 We employed standard approaches, including risk adjustment, to address apparent differences in pre-operative characteristics. Second, we recognize that there are a number of clinical reasons and patient level factors that impact the clinical decision to use ANH.…”

Section: Discussionmentioning

confidence: 99%

Greater Volume of Acute Normovolemic Hemodilution May Aid in Reducing Blood Transfusions After Cardiac Surgery

Goldberg

Paugh

Dickinson³

et al. 2015

The Annals of Thoracic Surgery

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Background Perioperative red blood cell transfusions (RBC) are associated with increased morbidity and mortality after cardiac surgery. Acute normovolemic hemodilution (ANH) is recommended to reduce perioperative transfusions; however, supporting data are limited and conflicting. We describe the relationship between ANH and RBC transfusions after cardiac surgery using a multi-center registry. Methods We analyzed 13,534 patients undergoing cardiac surgery between 2010 and 2014 at any of the 26 hospitals participating in a prospective cardiovascular perfusion database. The volume of ANH (no ANH, <400mL, 400–799mL, ≥800mL) was recorded and linked to each center’s surgical data. We report adjusted relative risks reflecting the association between the use and amount of ANH and the risk of perioperative RBC transfusion. Results were adjusted for preoperative risk factors, procedure, BSA, preoperative HCT, and center. Results ANH was used in 17% of the patients. ANH was associated with a reduction in RBC transfusions (RRadj 0.74, p <0.001). Patients having ≥800mL of ANH had the most profound reduction in RBC transfusions (RRadj 0.57, p<0.001). Platelet and plasma transfusions were also significantly lower with ANH. The ANH population had superior postoperative morbidity and mortality compared to the no ANH population. Conclusions There is a significant association between ANH and reduced perioperative RBC transfusion in cardiac surgery. Transfusion reduction is most profound with larger volumes of ANH. Our findings suggest the volume of ANH, rather than just its use, may be an important feature of a center’s blood conservation strategy.

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Section: Discussionmentioning

confidence: 99%

Greater Volume of Acute Normovolemic Hemodilution May Aid in Reducing Blood Transfusions After Cardiac Surgery

Goldberg

Paugh

Dickinson³

et al. 2015

The Annals of Thoracic Surgery

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“…10 In fact, a recent survey of cardiac team members suggests that only 20% had institutional discussions concerning the STS blood management guidelines, while only 14% had formed institutionally-based working groups. 11 Jin et al reported a prospective study across 12 hospitals participating in the Providence Health & Services Cardiovascular Disease Study Group, 12 in which they sought to disentangle physician and institutional contributors to transfusion decisions. They found that the variance of transfusions across institutions was more than twice that of surgeons practicing within a facility; surgeons contributed to 30% of the variation in transfusion practice, while the institution contributed the remaining 70%.…”

Section: Discussionmentioning

confidence: 99%

Geographic variability in potentially discretionary red blood cell transfusions after coronary artery bypass graft surgery

Likosky

Al-Attar

Malenka

et al. 2014

The Journal of Thoracic and Cardiovascular Surgery

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We assessed regional differences in potentially discretionary [<3 units of red blood cell (RBC)] transfusions across 56 medical centers and 11,200 patients undergoing isolated non-emergent coronary artery bypass (CABG) surgery. Regional variation in overall RBC rates remained after risk adjustment, perhaps due to differences in regional practice environments. Objective A number of established regional quality improvement collaboratives have partnered to assess and improve care across their regions under the umbrella of the “Cardiac Surgery Quality IMPROVEment (IMPROVE) Network”. The first effort of the IMPROVE Network has been to assess regional differences in potentially discretionary [<3 units of red blood cell (RBC)] transfusions. Methods We examined 11,200 patients undergoing isolated non-emergent coronary artery bypass (CABG) surgery across 56 medical centers in four IMPROVE Network regions between January 2008 and June 2012. Each center submitted the most recent 200 patients who received 0, 1, or 2 units of RBC transfusion during the index admission. Patient and disease characteristics, intra-operative practices, and percentage of cases receiving RBC transfusions were collected. Region-specific transfusion rates were calculated, after adjusting for pre- and intra-operative factors among region-specific centers. Results There were small, but significant, differences in patient case mix across regions. RBC transfusions of 1 or 2 units occurred among 25.2% (2,826/11,200) of CABG procedures. Significant variation in use and number of RBCs existed across regions [None: 74.8% (min:max 70.0%, 84.1%), 1 unit: 9.7% (5.1%, 11.8%), 2 units: 15.5% (9.1%, 18.2%)], p<0.001. Variation in overall transfusion rates remained after adjustment (9.1% – 31.7%, p<0.001). Conclusions Delivery of small volumes of RBC transfusions was common, yet varied across geographic regions. These data suggest that differences in regional practice environments, including transfusion triggers and anemia management, may contribute to variability in RBC transfusion rates.

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“…Jin and colleagues conducted an observational, multi-center study of 9,329 patients undergoing nonemergency, first-time isolated CABG. 19 The authors found that 86% of the variation in the amount of RBC units transfused could be explained by the hospital, whereas 14% could be explained by surgeon. The authors conclude that “institutional culture,” or the way in which provider socialization influences and/or creates behaviors, is a dominant determinant of blood transfusion practices.…”

Section: Discussionmentioning

confidence: 99%

Organizational Contributors to the Variation in Red Blood Cell Transfusion Practices in Cardiac Surgery: Survey Results From the State of Michigan

Camaj

Zahuranec

Paone

et al. 2017

Anesthesia &Amp; Analgesia

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BACKGROUND While large volumes of red blood cell (RBC) transfusions are given to preserve life for cardiac surgical patients, indications for lower volume transfusions (1–2 units) are less well understood. We evaluated the relationship between center-level organizational blood management practices and center-level variability in low volume transfusion rates. STUDY DESIGN AND METHODS All 33 non-federal, Michigan cardiac surgical programs were surveyed about their blood management practices for isolated, non-emergent coronary bypass procedures, including: (1) presence and structure of patient blood management (PBM) program, (2) policies and procedures, and (3) audit and feedback practices. Practices were compared across low (N=14, rate: 0.8–10.1%) and high (N=18, rate: 11.0–26.3%) transfusion rate centers. RESULTS Thirty-two (97.0%) of 33 institutions participated in this study. No statistical differences in organizational practices were identified between low and high rate groups, including: (1) the membership composition of PBM programs among those reporting having a blood management committee (p=0.27–1.0), (2) the presence of available RBC units within the operating room (4 of 14 low rate vs. 2 of 18 high-rate centers report that they store no units per surgical case, p=0.36), and (3) the frequency of internal benchmarking reporting about blood management audit and feedback practices (low rate: 8 of 14 vs. high rate: 9 of 18, p=0.43). CONCLUSION We did not identify meaningful differences in organizational practices between low- and high-rate intra-operative transfusion centers. While a larger sample size may have been able to identify differences in organizational practices, efforts to reduce variation in 1–2-unit, intra-operative transfusions may benefit from evaluating other determinants, including organizational culture and provider transfusion practices.

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Effect of Hospital Culture on Blood Transfusion in Cardiac Procedures

Cited by 52 publications

References 23 publications

Greater Volume of Acute Normovolemic Hemodilution May Aid in Reducing Blood Transfusions After Cardiac Surgery

Greater Volume of Acute Normovolemic Hemodilution May Aid in Reducing Blood Transfusions After Cardiac Surgery

Geographic variability in potentially discretionary red blood cell transfusions after coronary artery bypass graft surgery

Organizational Contributors to the Variation in Red Blood Cell Transfusion Practices in Cardiac Surgery: Survey Results From the State of Michigan

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