Dr Weber Lau

1
Reduction of Blood Transfusion Following TURP

• Dr Weber Lau
• Senior Consultant
• Department of Urology
• Singapore General Hospital

2
Mission Statement

• To eliminate inappropriate blood transfusion
  following TURP and to reduce overall transfusion
  by 50 in 6 months

3
Team Members

• Team Leader Dr Weber Lau
  Urology
• Quality Advisor A/Prof Chris Cheng
  Urology
• Team Members Dr Ng Lay Guat
  Urology
• Dr Colin Teo
  Urology
• A/Prof Ong Biauw Chi Anaesthesia
• Dr Lee Lai Heng Haematology
• Ulina Santoso
  Quality Mgt
• Chern Kim Suan
  Urology OT
• Mahmood Idrose
  Urology OT

4
Evidence for There Being a Problem Worth Solving
TURP Through The Decades - A Comparison of
Results over The Last Thirty Years in a Single
Institution in Asia.

• 44 (74) required blood transfusion in the 1970s,
  with 11 (19) in 1989 and 4 (11) in 1999.

Lim KB et al, Ann Acad Med Singapore, 2004 Nov
33(6)775-9.

• Safer TURP Coagulating Intermittent Cutting
  Reduces Hemostatic Complications.
• Intra-operative and post-operative blood
  transfusions were required in 7 patients (2.6)

Berger AP et al, J Urol, 2004 Jan171(1)289-91.
5
Evidence for There Being a Problem Worth Solving
Blood Transfusion Following TURP (Jan - Sep 05)
25
20
Median Before Intervention 6
15
Rate
10
5
0
Jan_05
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Month
6
Definition of Inappropriate Blood Transfusion

• Stable patients who receive a red cell
  transfusion with a pre transfusion Hb of gt10
  g/dL.
• Stable patients who receive a red cell
  transfusion with a pre transfusion Hb between 7
  10 g/dL without a clinical indication.

7
Evidence for There Being a Problem Worth Solving
TURP Data Jan Sep 2005

• Pre-op Hb vs significant intra-operative bleeding
  with Hblt10g/dL (No of units transfused)
• Required 66
• Inappropriate 33

8
Customer Expectations List

• A survey on patients that underwent TURP was
  conducted to get feedback on the patients
  concern and knowledge on blood transfusion
  (n10)
• Aware of the risk for transfusion in TURP 100
• Aware of transfusion related complications 10
• Bothered by transfusion related complications 0
• Interested to know more about transfusion related
  complications 0
• Would agree to transfusion if needed 100
• Patients are generally old, not bothered by any
  complications and
• commented that transfusion was only 1 of many
  potential
• complication counselled.

9
Flow Chart of Process
Admission for TURP
Bleeding Intra-op
Group and Match
Assessment
Arrive in OT
Check availability of blood with BTS
Surgeon / Anaesthetist requests for blood
TURP
Call for blood to BTS
Recovery Area
Blood arrives in OT
HD / GW
Blood returns to BTS within 1 hour
Blood transfused
Discharge
Blood transfused
10
Flow Chart of Process
Admission for TURP
Bleeding Post-op
Group and Match
Assessment
Arrive in OT
Check availability of blood with BTS
Surgeon requests for blood
TURP
Call for blood to BTS
Recovery Area
Blood arrives
HD / GW
Blood returns to BTS within 1 hour
Blood transfused
Discharge
Blood transfused
11
Cause Effect Diagram
Surgeon
Patient
Resected prostatic tissue gt40g
Inadequate diathermization
Junior Registrar
High risk
Inexperienced surgeon
Long resection time
Comorbidity (blood disorder)
Ineffective hemostasis
New Registrar
Hypotensive intra/post-op
Large gland size
Poor communication
Anemia
Poor surgical technique
Low Hb pre-op
Surgeon did not consult Senior
Patient looks pale
Faulty resectoscope
Difficult resection
High Blood Transfusion Rate Following TURP
Lack of coordination
Infection
Heavy hematuria
ARU
Inadequate communication
Not aware of the trigger for transfusion
Non compliance to transfusion guidelines
Avoid wastage of blood
Order blood without informing Surgeon
Failure to check Hb/HCT prior to transfusion
Inappropriate transfusion
Not able to return blood to blood bank
No ownership
Not confident of Surgeon
Request for blood too early
The TURP CCP does not state the criteria for
transfusion
Fear of ongoing blood loss
Anaesthetist
Guidelines
System
12
Pareto Chart
60
110
100
50
90
80
40
70
60
Count
Percent
30
50
40
20
30
20
10
11
11
9
10
7
6
5
0
0
Large gland size
Instrument faulty
Lack of ownership
Inappropriate transf
Anesthetist not conf
Patient comorbiditie
Prolonged operative
Inexperienced surgeo
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Intervention(s)

• Surgical factors
• Senior Staff TURP
• Patient Comorbid medical problem such as IHD,
  CRF, CVA , bleeding tendency and anemia etc.
• Gland gt 40 gm resection or 60cc volume
• Recommended to be done by Senior staff or by
  under their direct (in-theatre) supervision

14
Intervention(s)

• Surgical factors
• Intra-operative TURP Time Out
• Circulating Staff nurse to notify surgeon when
  either
• Resection time gt 40 min
• Irrigation fluid gt 7 bags X 3 L
• Mandatory Action
• Senior staff to take note
• Resident in training to inform senior staff and
  he will assess and decide whether to take over
  the resection

15
Intervention(s)

• Appropriateness of intra-operative transfusion
• Transfusion vetting form
• Indications
• STAT Haematocrit lt 24 or Hb lt 8 g/dL
• Parameters
• Agreed and signed by Surgeon and Anaesthetist
  before transfusion

16
Intervention(s)
Vetting Form
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Intervention(s)

• Post-operative Transfusion
• HB lt 8 g/dL
• Unstable patient
• Active bleeding such as clot retention
• Otherwise consult senior staff in charge before
  transfusion

18
Intervention(s)

• Audit
• All Post TURP transfusions are presented as MM
• Data collection All TURP patients
• Resection details e.g. time, irrigation, gland
  size
• Compliance on TURP Time Out
• Pre-operative, (/- intraoperative), post-op
  transfusion HB, units transfused
• Percentage of appropriate inappropriate
  transfusion
• Complications
• Readmission within 15 days of discharge

19
Results
Compliance to Intra-operative TURP Time Out (Nov
05 - Feb 06)
100
90
80
70
Median 88
60
50
Rate
40
30
20
10
0
Nov
Dec
Jan_06
Feb
Month
T/O compliance towards 100 with OT staff and
Anaesthestist support
20
Results
Blood Transfusion Following TURP (Jan 05 - Feb 06)
25
Median After 1st Intervention 5
Median After 2nd Intervention 2
20
Median Before Intervention 6
15
Rate
10
5
0
Jul
Jun
Nov
Apr
Oct
Feb
Mar
Aug
Feb
Sep
Dec
May
Jan_05
Jan_06
Month
1st Intervention Senior Surgeon TURP,
Intraoperative TURP Time Out
2nd Intervention Weekly TURP Audit
21
Results
Appropriateness of Blood Transfusion (Jan 05 -
Feb 06)
22
Results
Complications (Oct 05 - Jan 06) No incident of
patient complications from non-transfusion Re-adm
ission within 15 days of Discharge (Oct 05 - Jan
06) No re-admissions from non-transfusion
23
Conclusion

• Mission accomplished with improved staff
  education, introduction of transfusion vetting
  and standardized transfusion practice.
• Many benefits in terms of improved patient
  safety, appropriate usage of precious resource
  and cost savings.

24
Strategies for Sustaining and Spreading

• Continue to do intraoperative timeout and
  tranfusion vetting for TURP patients and nurses
  have adopted that as their second nature.
• Potential to spread to other elective surgical
  procedures or disciplines that commonly required
  transfusion.
• Promotion of spread and sustainability of
  improvement, including to other blood products
  using top down policy.

25
Acknowledgement
The success of this project would not have been
possible without the hard work of the other team
members and the significant support of the
nurses. Special thanks go to the Dr Colin Teo,
Ulina Santoso whose commitment and expertise
proved invaluable throughout the project.
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Thank You