Transfusion strategy for primary knee and hip arthroplasty: impact of an algorithm to lower transfusion rates and hospital costs.

BACKGROUND Blood transfusion strategies should reduce both blood transfusion and costs. Possible solutions include autologous donation for selected patients and the prescription of erythropoietin (EPO). METHODS We conducted a quality improvement program to examine the effect of a transfusion strategy algorithm in primary knee (TKA) and hip arthroplasty (THA). Our algorithm is presented as a diagram and is based on tolerated and expected blood losses. Patient characteristics, blood loss, transfusions given, autologous blood wastage, and costs were examined during an initial evaluation and after implementation of the algorithm. RESULTS Analysis of 302 (initial evaluation) and 173 (post-implementation) arthroplasties demonstrated a 55% reduction in the prescription of autologous blood donation. The proportion of EPO prescriptions increased from 6.6% to 17.3% (P<0.05). There was a 56% overall reduction in transfusions to fewer autologous (32% vs 12%, P<0.0001) and allogeneic transfusions (21% vs 13%, NS). There were 50% fewer wasted autologous blood units (P=0.002) and a 50% reduction in hospital costs (euro345 vs 169) with no significant change in overall costs (euro439 vs 407). Anaesthetists applied the algorithm in 97% of patients, and it is still in use 1 yr after evaluation. CONCLUSIONS In this study, the implementation of an algorithm for transfusion strategy changed practice and improved quality of care. The costs for EPO, its administration, and monitoring outside hospital were offset by the reduction in hospital transfusion costs.