David Mold and Dr. Shubha Allard A Survey of Pre-operative Assessment Clinics In the North Thames Region David Mold and Dr. Shubha Allard North Thames Regional Transfusion Committee

Introduction The Health Service Circular Better Blood Transfusion (HSC 2002/009) states that Trusts must ensure that mechanisms are in place for the pre-operative assessment of patients for planned surgical procedures. Guidance on Pre–operative assessment has been provided by the Better Blood Transfusion Appropriate Use of Blood Toolkit (BBT Toolkit) and recommends that: The patient’s haemoglobin is optimised Haemostasis is optimised Cell salvage is used where appropriate. North Thames Regional Transfusion Committee

Purpose of Survey The purpose of this survey is to ascertain whether Trusts within the North Thames Region are implementing the recommendations of the BBT Toolkit and also to find out how pre-operative assessment clinics are being organised. North Thames Regional Transfusion Committee

Methodology A questionnaire was designed using the West Midlands Regional Transfusion Committee Audit Group questionnaire as a template. In the first instance this was posted to the Transfusion Consultant, Specialist Practitioner of Transfusion and Lead Nurse for Pre-operative Assessment for every Trust in the North Thames Region. Follow up to non-responders was done by e-mail to transfusion consultants and SPOTs. North Thames Regional Transfusion Committee

Main Endpoints Establish how many trusts have pre-operative assessments clinics and for what specialities Determine how many pre-operative assessment clinics have protocols for: Diagnosis and management of anaemia Diagnosis and management of clotting disorders Discontinuation of anti-platelet drugs and oral anticoagulants Identification of problems requiring specialist intervention e.g. Thalassaemia, Sickle cell disease. Management of patients refusing transfusion Assessment of blood component requirements e.g. MSBOS Find out how many trusts are using cell salvage and are informing patients about it and obtaining consent for its use. North Thames Regional Transfusion Committee

Response rate There were 20 responses which represented replies from 14 NHS Trusts (20 hospitals) and 3 private sector hospitals. Most questionnaires were filled in by Specialist Practitioners of Transfusion - 11 Lead Nurses for Pre-Operative Assessment Clinics - 6. SPOTs and Lead Nurses together - 3. All respondents replied that their hospital was running pre-operative assessment clinics. North Thames Regional Transfusion Committee

Most Common Clinic Specialities Clinic speciality Number of Clinics Orthopaedic surgery 17 Vascular surgery 13 Urology General surgery Gynaecology 12 ENT Plastic surgery 9 Cardiac surgery 6 Oncology 3 Breast surgery 2 North Thames Regional Transfusion Committee

Are patients assessed by medical or nursing staff? North Thames Regional Transfusion Committee

How long before admission are patient’s assessed? The time interval between assessment and admission was found to vary between specialities and also within specialities. Several respondents commented that if the patient had cancer then the time period between assessment and admission was shortened. North Thames Regional Transfusion Committee

Number of days before admission- most common clinics Speciality Minimum No. of days Maximum No. Number of Clinics Orthopaedic surgery 1 168 17 Vascular surgery 7 13 Urology General Surgery 6 Gynaecology 12 ENT Plastic surgery 84 9 Cardiac surgery 56 Oncology 14 28 3 Breast surgery 2 North Thames Regional Transfusion Committee

Do you have written protocols for the following? Yes No Diagnosis and management of anaemia 54 (48%) 58(52%) Diagnosis and management of clotting disorders 57 (51%) 55 (49%) Discontinuation of anti-platelet drugs and oral anticoagulants 103 (92%) 9 (8%) Identification of problems requiring specialist intervention e.g. Thalassaemia, Sickle cell disease. 66 (59%) 46 (41%) Management of patients refusing transfusion 94 (84%) 18 (16%) Assessment of blood component requirements e.g. MSBOS 86 (77%) 26 (23%) North Thames Regional Transfusion Committee

Does your Trust use cell salvage? 15 respondents are using some form of cell salvage. 13 respondents using intra-operative cell salvage Eight respondents using intra-operative cell salvage also used post-operative cell salvage. Two respondents using post operative cell salvage only. (BelloVac system). North Thames Regional Transfusion Committee

What procedures is cell salvage used for? Commonest specialities where intra-operative cell salvage is used are Cardiac (3) Vascular (6) Orthopaedic surgery (8). Three respondents also reported usage in other procedures such upper GI bleeds, liver lacerations, splenectomys and radical cystectomys. North Thames Regional Transfusion Committee

Cell salvage continued Only one respondent specified usage in obstetrics. Three respondents commented that usage was dependent on the enthusiasm of the surgical and anaesthetics staff for cell salvage and two of them were facilitating training in the near future. Post operative cell salvage was almost exclusively used for orthopaedic procedures (6) Three respondents specifying usage in total knee replacements. Two respondents said that post-operative cell salvage was used for heavy post-op bleeding but did not specify the procedures where it was used. North Thames Regional Transfusion Committee

Do you inform patients about the use of cell salvage Do you inform patients about the use of cell salvage? Do you obtain consent for the use of cell salvage?   Inform patient Consent patient No 4 (27%) 11 (73%) Yes 4 (26%) North Thames Regional Transfusion Committee

Who reviews Hb results North Thames Regional Transfusion Committee

Who performed the initial assessment and who reviewed the Hb result. Initial Assessment by Hb result reviewed by Total Nurse and Doctor 13 Doctor only Nurse only 40 5 10 18 112 North Thames Regional Transfusion Committee

Haemoglobin level at which action is taken in fit patients under the age of 65. Hb level (g/dl) Total Less than 7 5 12 2 Less than 8 7 13 1 8 9 Females 10-11g/dl Males 12g/dl Between 8-10 3 Consultant dependent 22 Dependent on patient's history Less than 10 15 Not known 10 23 No response 18 11 112 North Thames Regional Transfusion Committee

Haemoglobin level at which action is taken in patients over the age of 65. Hb level (g/dl) Total Less than 8 11 12 1 Less than 9 Females 10-11g/dl male12g/dl Between 8-10 3 Dependent on history 20 Between 9-10 6 Consultant dependent 22 Less than 10 14 Not known 10 No response 9 112 North Thames Regional Transfusion Committee

Haemoglobin level at which action is taken in patients with ischaemic heart disease Hb level (g/dl) Total Less than 8 6 Not known 1 Lees than 9 Females 10-11g/dl males 12g/dl 10 33 Consultant dependent 22 Less than 10 14 Dependent on patient's history 12 Between 9-10 No response 9 11 112 North Thames Regional Transfusion Committee

Action taken if Haemoglobin level is found to be low Refer to GP - 49% (54/112) (Some respondents commented that this only happened if time allowed) Refer to other speciality - 14% (16/112) (usually haematology) Other action 37% (41/112) Mainly refer to back to admitting consultant or anaesthetist. Many comments action dependent on how urgent the surgery was. North Thames Regional Transfusion Committee

Discussion Many hospitals are using pre-assessment clinics in a wide variety of specialities. Approximately 50% of clinics had no protocol for anaemia or clotting disorders. Wide variation in length of time before admission Wide variation in the haemoglobin level that triggers referral or deferral Wide variation in procedures where cell salvage is routinely used North Thames Regional Transfusion Committee