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Blood Use in a Large North Eastern Italian Academic Hospital During the Period 2009-2013: What Reasons for a Decrease?

Rosanna Quattrin1*, Lucia Lesa2, Vivianna Totis1, Vincenzo De Angelis1 and Silvio Brusaferro2

1Azienda Ospedaliero-Universitaria “Santa Maria della Misericordia”, Udine, Italy

2Department of Medical and Biological Sciences - University of Udine, Italy

Corresponding Author:
Rosanna Quattrin
Department of Medical and Biological Sciences
University of Udine via Colugna 50, 33100 Udine - Italy
Tel: 39432 559903
E-mail: [email protected]
Received date: November 02, 2015; Accepted date: December 08, 2015; Published date: December 14, 2015

Citation: Quattrin R, Lesa L, Totis V, De Angelis V, Brusaferro S (2015) Blood Use in a Large North Eastern Italian Academic Hospital During the Period 2009-2013: What Reasons for a Decrease? Health Care Current Reviews 3:151. doi:10.4172/2375-4273.1000151

Copyright: © 2015 Quattrin R, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Introduction

Blood is a precious and scarce resource and its management needs continuous efforts in order to maintain a balance between supply and demand. Considering that blood components supply depends substantially on voluntary donors, population is getting older and new measures to reduce an unnecessary donor exposure to patients are expensive, the cost to maintain a sufficient provision is notably increased [1].

In the last decade programmes and guidelines for a better use of blood have been introduced in several hospital policies [2-4]. Patient Blood Management guidelines (PBM), for example, concern about a correct preoperative transfusion management based on right preoperative identification of anaemic patient, on control of blood loss and coagulopathy during and after operation and on optimisation of anaemia tolerance during the postoperative period [5].

Recently, several countries all over the world seems to present a decrease of blood products use.

American national data showed a diminution of blood components use of about 3% between 2009 and 2010 [6,7]. Australian data showed an abatement of 7% of consumed blood units after the revision of national blood use guidelines [8].

A recent report of the European Committee on Blood Transfusion revealed that in the last decade red blood cells (RBCs) use has been greatly decremented in all the Member States with an average of 37 total RBCs products per 1.000 inhabitants in 2011 [9]. A remarkable reduction has been registered in England, with a transfusions decrease in surgery due to the new techniques and to the review of the blood use national guidelines. In fact the transfusions rate was diminished from 45,5 RBCs units in "2.000". to 36 units per 100.000 inhabitants in 2009 [10].

Finally, also Italy showed an abatement of blood components use. The first decrement of the RBCs transfusions had been registered in 2013, with a reduction of 2% (about 50.000 units). The decrease was more evident in North regions such as the autonomous province of Bolzano [11] with a diminution of about 8% and in Friuli Venezia Giulia (FVG) with a transfusions abatement of 5.5% (from 60.453 to 57.103 units) [12].

This study consisted in comparing the trends of red cell concentrates (RCCs) consumptions in a large North Eastern Italian Academic Hospital (AH), located in FVG region, during the period 2009-2013 and in analysing some variables to reach hypothesis on reasons of decrement in RCCs use.

Materials and Methods

The study consisted in extracting, choosing and analyzing several data regards RCCs consumptions in an AH during the period 2009- 2013 from different available database.

These variables were extracted by the following database:

• Consumptions of RCCs units and the Maximum Surgical Blood Order Schedule (MSBOS) by the Immunotransfusion Medicine Department Clinical System (EmoNets)

• Hospital outcomes [length of stay, case-mix index (CMI), 30-day readmission rates, mortality rate), Diagnosis Related Groups (DRGs) and patients’ age by the regional business intelligence software (Business Object).

• Hospital activity volumes [hospitalisations. and surgeries – hospital-wide, stratified by departments and single operative units (UOs),urgent admissions (UAs) rate, UAs rate in medical OUs] and typologies of surgical interventions by the hospital informative directional system (SisInfo).

• Hospital guidelines, procedures and protocols by the hospital website (Intranet).

Data collected were analysed using the statistical software SPSS, version 20. Chi-square test and Mann-Whitney test were used. Statistical significance was defined as p≤0,05.

A multi-professional Committee for “good blood use” was present in the hospital according to the current national regulations in order to direct hospital blood utilisation coherently with hospital and regional plans.

Results

Table 1 shows RCCs units consumptions, hospital activity profile (hospitalizations. UAs rate, UAs rate in medical OUs) and outcomes (length of stay, CMI, MSBOS, 30-day readmission rates, mortality rate) during the period 2009-2013.

  2009 2010 2011 2012 2013 Δ 2013-2009/10 %
hospitalisations (n.) 44651 42956 42044 41131 40113 -4538 -10,2%
Urgent admissions rate 45,4% 45,4% 46,1% 46,4% 48,6% -784 -3,9%†
UA* rate in medical units 34,3% 33,4% 32,7% 32,7% 32,6% -585 -8.4%†
Surgeries (n.) 29894 30543 30433 29945 27896 -1998 -6,7%
Length of stay (mean) - days - 8,9 9,0 8,6 8,7 - 0,2 -2,2%
Case-mix index - - - 1,17 1,18 - -
MSBOS ≥4‡ 661 688 675 643 731 70 10,6%
30-day readmission rate   5,0% 4,0% 4,1% 4,1% 4,2% -526 -1,2%†
Mortality rate rates - 4,0% 4,1% 4,3% 4,3% -68 +3,8%

* urgent admissions; † p<0,05 ‡ Maximum Surgical Blood Order Schedule

Table 1: Hospital activity profile and consumed red cell concentrates (RCCs) units during 2009-2013 period.

In detail, transfusions of RCCs were reduced of 1.067 units (5,9%) between 2012 and 2013, of 1.105 units (5,8%) between 2012 and 2011, of 484 (2,5%) units between 2011 and 2010. There was an increase of 0,1% (25 units) between 2009 and 2010. A preliminary analysis on blood consumptions in 2014 found out a use of 16.200 RCCs units with a decrease of 2,3% (396 units) compared to 2013 (Table 2 and Figures 1-3).

  2009 2013 Δ 2013-2009 %
Anesthesia Department
RCCs units 2248 1667 -581 -25,8
hospitalisations (n.) 501 507 6 1,2
Cardiothoracic Surgery Department
RCCs units 3396 2409 -987 -29,1
hospitalisations (n.) 3800 3546 -254 -6,7
Surgeries (n.) 1041 995 -46 -4,4
General Surgery Department
RCCs units 4228 3689 -539 -12,7
hospitalisations (n.) 10137 9309 -828 -8,2
Surgeries (n.) 12010 11032 -978 -8,1
Surgical Specialities Department
RCCs units 124 189 65 52,4
hospitalisations (n.) 6315 5005 -1310 -20,7
Surgeries (n.) 2019 2079 60 3,0
Maternity Department
RCCs units 323 407 84 26,0
hospitalisations (n.) 6801 6506 -295 -4,3
Surgeries (n.) 213 98 -115 -54,0%
Medicine Specialities Department
RCCs units 2571 2353 -218 -8,5%
hospitalisations (n.) 3054 2699 -355 -11,6%
Neuroscience Department
RCCs units 201 296 95 47,3
hospitalisations (n.) 3309 3318 9 0,3
Surgeries (n.) 1383 1345 -38 -2,7
General Medicine Department
RCCs units 3822 2936 -886 -23,2
hospitalisations (n.) 11378 10283 -1095 -9,6
Oncology Department
RCCs units 180 126 -54 -30,0
hospitalisations (n.) 1569 1559 -10 -0,6
Day Hospital
RCCs units 1160 1125 -35 -3,0
Discharges (n.) * 11175 -1812 -13,9

Table 2: Red cell concentrates (RCCs) units, hospitalisations and surgeries per year stratified by hospital departments between 2009 and 2013.

health-care-reviews-Red-cell-concentrates

Figure 1: Red cell concentrates (RCCs) stratified by hospital departments during 2009-2013 period.

health-care-reviews-2009-2013-period

Figure 2: Hospitalisations per year stratified by hospital departments during 2009-2013 period.

health-care-reviews-Surgeries-per-year

Figure 3: Surgeries per year stratified by hospital departments during 2009-2013 period.

Report RCCs units consumptions and volumes of hospitalisations per year stratified by hospital departments during 2009-2013 period.

Table 3 shows the percentages of medical DRGs on total hospitalisations stratified by surgical OUs.

YEAR 2009 2010 2011 2012 2013
  Medical DRGs of total hospitalisations Medical DRGs of total hospitalisations Medical DRGs of total hospitalisations Medical DRGs of total hospitalisations Medical DRGs of total hospitalisations
SURGICAL UNIT % N. % N. % N. % N. % N.
Cardiac 15,3 381/2483 15,5 387/2492 12,1 239/1966 12,9 249/1923 12,9 244/1884
Maxillofacial 30,5 204/668 39,5 245/621 44,0 262/595 41,1 248/604 45,4 246/542
General surgery 32,9 1249/3791 32,1 1175/3659 33,4 1190/3560 29,6 989/3340 28,6 968/3384
Plastic surgery 27,4 240/877 27,5 238/864 32,2 269/835 26,0 244/939 15,4 129/836
Thoracic / / / / 31,0 96/310 14,1 54/382 22,0 80/363
Vascular 16,4 124/755 15,5 104/670 30,0 205/684 22,6 178/787 13,9 110/791
Vertebrobasilar-medullary 18,7 114/609 18,5 105/567 19,4 99/510 20,2 100/495 20,6 99/481
Neurological 31,0 397/1282 30,7 356/1160 29,2 342/1172 29,2 357/1222 25,5 337/1319
Orthopaedics - traumatology 16,1 317/1968 13,9 270/1949 12,4 234/1894 12,8 235/1831 13,4 244/1820
Obstetrics - gynaecology 58,6 1647/2810 62,4 1635/2621 62,1 1505/2423 64,3 1576/2451 64,2 1601/2492
Otorhino - laryngology 50,0 654/1308 49,5 586/1183 46,1 518/1124 40,9 481/1177 37,9 448/1181
Urology 32,5 403/1239 35,4 369/1042 38,4 406/1057 35,7 374/1047 34,1 362/1062
Total 32,2 5730/17790 32,5 5470/16828 33,3 5365/16130 31,4 5085/16198 30,1 4868/16155

Table 3: Medical DRGs percentages of total hospitalisations in surgical operative units during 2009-2013 period.

Table 4 reports age averages of transfused patients, means of RCCs units per patients and cases treated with a single RCCs unit stratified by the major hospital blood consumers (heart surgery, orthopaedics, haematology, first aid, transfusion medicine) during 2009-2013 period.

YEAR 2009 2010 2011 2012 2013
Hearth Surgery
RCCs units per patient mean (SD*) 5,0 (5,6) 4,6 (4,5) 4,4 (4,4) 4,1 (4,6) 3,6 (3,1)
Cases transfused with a single unit of RCCs [% (n)] 9,8 (47/477) 11,2 (56/498) 9,1 (40/438) 15,2 (66/435) 14,3 (50/350)
Patients’ age mean (SD) 72,6 (9,2) 70,1 (10,7) 70,3 (11,2) 71,7 (10,4) 67,0 (11,6)
Orthopedics
RCCs units per patient mean (SD*) 2,9 (1,5) 2,9 (1,7) 2,9 (2,2) 3,1 (1,9) 3,0 (2,0)
Cases transfused with a single unit of RCCs [% (n)] 3,0 (11/380) 4,4 (16/361) 4,4 (14/316) 2,9 (10/347) 4,5 (16/358)
Patients’ age mean (SD) 80,8 (13,4) 79,3 (14,1) 77,7 (15,7) 79,5 (14,5) 76,3 (13,5)
Hematology
RCCs units per patient mean (SD*) 11,6 (12,2) 10,2 (9,4) 11,8 (13,2) 9,4 (10,6) 8,8 (9,7)
Cases transfused with a single unit of RCCs [% (n)] 6,9 (11/160) 13,7 (25/182) 9,0 (17/168) 17,1 (36/210) 14,8§ (29/196)
Patients’ age mean (SD) 56,9 (12,8) 54,3 (15,0) 56,7 (14,7) 56,3 (14,9) 53,4 (14,2)
First Aid
RCCs units per patient mean (SD*) 3,9 (7,3) 4,6 (9,7) 4,1 (7,8) 4,1 (7,3) 4,2 (7,7)
Cases transfused with a single unit of RCCs [% (n)] 9,1 (32/353) 5,1 (16/353) 9,4 (31/328) 10,6 (31/292) 14,1§ (39/276)
Patients’ age mean (SD) 75 (13,7) 72,3 (16,8) 71,8 (17,7) 69,5 (17,8) 70,2 (15,3)
Transfusional Medicine
RCCs units per patient mean (SD*) 9,9 (14,1) 8,4 (13,2) 10,6 (14,6) 9,7 (12,8) 10,5§ (16,4)
Cases transfused with a single unit of RCCs [% (n)] 4,8 (5/103) 10,7 (11/103) 6,7 (7/104) 4,4 (5/114) 4,0 (4/100)
Patients’ age mean (SD) 78,8 (11,6) 76,6 (12,6) 76,9 (11,4) 76,4 (12,8) 74,8 (12,2)

Table 4: Red cell concentrates (RCCs) units per patient, cases transfused with a single unit of RCCs and average patients’ age in the five major blood consumers during 2009-2013 period.

An analysis of more frequent surgeries in the hospital showed a diminution of heart surgery interventions from 774 in 2010 to 647 in 2013 (-16%). Regards to the typologies of the more frequent ones, aortocoronary bypasses (CABs) and CABs with surgical aortic valve replacements (AVRs) was abated respectively from 201 to 177 and from 64 to 44, AVRs and heart transplants incremented respectively from 41 to 83 and from 0 to 23. Also global orthopaedics interventions decremented from 3.261 in 2010 to 2.397 in 2013: neurolysises of the median were reduced from 463 to 370 while plate and screw osteosynthesises and intramedullary osteosynthesises increased respectively from 0 to 313 and from 94 to 172.

During the period 2008 to 2013, the transfusion department, coordinated by “good blood use” Committee, wrote and implemented eleven guidelines about PBM.

Discussion

This study represents the first Italian attempt to analyse reasons of recent reduction in blood use in a hospital setting. Results showed a decrease of consumed RCCs units in accordance with regional and national data and also with international ones [1,6,13,14]. Between 2014 and 2009 the diminution of consumed RCCs units was of 17%, while between 2012 and 2013 was of (5,9%), higher than global regional value of (5,5%) [13]. Also in 2014 blood consumptions were abated but with a percentage of (2,3%), half of the previous year.

Over the years general surgery department kept the first place regards to RCCs consumptions followed by internal medicine UOs. A special mention should be addressed to cardiothoracic department. In fact, in 2009 and 2010 it was 17% of the global hospital one and then it decremented to 15%. Cardiothoracic surgery areas contributed significantly to global hospital reduction in the RCCs use. This trend was in part due to a decrease of surgeries (-16%), but on the other hand it was in agreement with the Transfusion Requirements After Cardiac Surgery (TRACS) that had recently demonstrated the safety of a restrictive strategy of transfusion compared with a liberal strategy in patients undergoing elective cardiac surgery [15]. The appropriate use of blood was also confirmed by the statistically significant diminution in the consumptions of RCCs units per patient over the years (from 5 to 3,6) while typology of cardiac interventions became more complex. In fact heart transplants and AVRs increased at the detriment of CABs. Also in orthopaedics surgery the more complexity interventions such as plate and screw osteosynthesises and intramedullary osteosynthesises incremented.

In the anaesthetic area the abatement in blood use could be due to the application of the international guidelines for transfusions in trauma patients [16]. The hypothesis can be confirmed by the fact that the volume of admissions in the anaesthesia department was maintained during the years and, at the same time, the hospital represented the hub for traumatic pathology in FVG region.

In the medicine department an important aspect was the possible correlation between RCCs consumptions and the volumes of UAs from the first aid. The trend during the considered period was fluctuating. In fact between 2009 and 2010 there was a decrement in UAs of 4%, in the following years the absolute number of them remained constant, while the fraction of UAs on the global hospital admissions incremented from 45% in 2009 to 48% in 2013. One third of the UAs resulted in a hospitalisation in an internal medicine OUs. A consideration about this trend is that the hospital represented a point of regional reference for acute internistic illnesses instead of planned interventions or of high speciality performances. The hypothesis was confirmed by the percentage of patients with a medical DRGs discharged by surgical OUs. The overall hospital value was of 30% with a range from 13% in cardiac surgery OU to 64% in maxillofacial surgery OU.

This study also showed that the global reduction in blood utilisation occurred with a concurrent statistical significant decrease of the wide hospital activity. A detailed analysis showed an important diminution of discharges (10,2%) and a lower abatement of surgeries (6,7%). The decrement of hospitalisations and surgical interventions, stratified by hospital departments, kept pace with the reduction in blood consumptions of each one. The decrease in hospitalisations during the years could be correlated with regional and national policies that aimed to diminish hospital patients’ admissions by using other health settings (i.e. Day Hospital, long-term health facilities, outpatient services). The abatement of surgeries could be explain by the introduction of alternative therapies to surgery, the spread of cancer screening, the rationalisation of resources use and the hospital turnover of surgeons with different expertise in blood use during interventions.

Incremented consumptions in blood use were observed for the department of surgical specialities, neuroscience and oncology, but consumed RCCs units were few. Therefore the increase could be due to the management of single cases required a large amount of blood.

The mean of RCCs transfusions units per patients was evaluated for the major RCCs consumers. The higher decrement in the average number of RCCs units per patient were recorded in cardiac surgery and in haematology. The percentages of patients transfused with a single unit of RCCs incremented in the years even if the absolute numbers were stable. The World Health Organization strongly discourages single unit transfusions in adults and many countries regarded them as a bad practice [17,18].

A result of this study in contrast with literature, reported that elderly patients are transfused at higher rates than younger patients, was the significant statistically reduction of average age of transfused patients especially in heart surgery (from 73 to 67 years) and in first aid (from 75 to 70 years) [19-21]. Furthermore transfusion guidelines from several national societies emphasized the need to consider the clinical setting and patient symptoms, but none mentioned age as a primary factor to consider [22-24].

The analysis of clinical patient outcomes demonstrated that length of stay, mortality and 30-day readmission rates were stable during the years despite the decrease of RCCs utilisation, while CMI and number of complex interventions with a MSBOS > 4 incremented. This finding was in accordance with clinical recent clinical trials demonstrating that more restrictive transfusion practices were associated with equivalent or improved patient outcomes, when compared to more liberal transfusion practices [15,25-29].

Finally, over the years the transfusion department with the contribution of “good blood use” Committee wrote guidelines and procedures to implement patients’ safety, to limit the exposure to RCCs transfusions (with their inherent risks) and to contain the costs [6,30]. Literature confirmed that mandatory hospital-wide programs to improve transfusion practices should be an effective method leading to success in reducing blood use [31].

In conclusion this study represents a starting point to investigate the reduction of blood use in a hospital setting during a period of five years. The analysis of the data explained the phenomenon by the decrease of hospital activities, in terms of admissions and surgeries, associated to a “good blood use” through implementation of specific guidelines and to application of specific correct procedures especially in cardiothoracic surgery and anesthetic departments.

Acknowledgements

This study was conducted without external funding. QR and LL performed the research, designed the study, analysed the data and wrote the paper, TV designed the research study and interpreted the data, DAV interpreted the data, BS revised the paper critically. The authors have no competing interests. We thank all the components of the Hospital Blood Committee.

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