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Rationalising the treatment of anaemia in cardiac surgery: short and mid-term results from a local quality improvement initiative
  1. Donald S Likosky1,2,3,4,5,6,
  2. Stephen D Surgenor1,2,3,4,5,
  3. Lawrence J Dacey1,2,3,4,5,
  4. Gordon R DeFoe1,2,3,4,5,
  5. Elizabeth L Maislen1,2,3,4,5,
  6. Jean A Clark1,2,3,4,5,
  7. James P Aubuchon1,2,3,4,5,
  8. John H Higgins1,2,3,4,5,
  9. Peter A Beaulieu1,2,3,4,5,
  10. Gerald T O'Connor1,2,3,4,5,6,
  11. Cathy S Ross1,2,3,4,5,6
  1. 1Department of Surgery, Dartmouth Medical School, Hanover, New Hampshire, USA
  2. 2Department of Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire, USA
  3. 3Department of Anesthesiology, Dartmouth Medical School, Hanover, New Hampshire, USA
  4. 4Department of Pathology, Dartmouth Medical School, Hanover, New Hampshire, USA
  5. 5Department of Medicine, Dartmouth Medical School, Hanover, New Hampshire, USA
  6. 6The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth Medical School, Hanover, New Hampshire, USA
  1. Correspondence to Dr Donald S Likosky, Department of Surgery and The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA; likosky{at}


Background Transfusion of red blood cells, while often used for treating blood loss or haemodilution, is also associated with higher infection rates and mortality. The authors implemented an initiative to reduce variation in the number of perioperative transfusions associated with cardiac surgery.

Methods The authors examined patients undergoing non-emergent cardiac surgery at a single centre from the third quarter 2004 to the second quarter 2007. Phase I focused on understanding the current process of managing and treating perioperative anaemia. Phase II focused on (1) quality-improvement project dissemination to staff, (2) developing and implementing new protocols, and (3) assessing the effect of subsequent interventions. Data reports were updated monthly and posted in the clinical units. Phase III determined whether reductions in transfusion rates persisted.

Results Indications for transfusions were investigated during Phase II. More than half (59%) of intraoperative transfusions were for low haematocrit (Hct), and 31% for predicted low Hct during cardiopulmonary bypass. 43% of postoperative transfusions were for low Hct, with an additional 16% for failure to diurese. The last Hct value prior to transfusion was noted (Hct 25–23, p=0.14), suggestive of a higher tolerance for a lower Hct by staff surgeons. Intraoperative transfusions diminished across phases: 33% in Phase I, 25.8% in Phase II and 23.4% in Phase III (p<0.001). Relative to Phase I, postoperative transfusions diminished significantly over Phase II and III.

Conclusions We report results from a focused quality-improvement initiative to rationalise treatment of perioperative anaemia. Transfusion rates declined significantly across each phase of the project.

  • Cardiopulmonary bypass grafting
  • anaemia
  • transfusion
  • surgery
  • statistical process control

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  • Funding Funding for this research was provided by the Quality Research Grant Program which is supported by Dartmouth-Hitchcock Medical Center and Dartmouth Medical School.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval Ethics approval was provided by the Dartmouth College.

  • Provenance and peer review Not commissioned; externally peer reviewed.