Hospital Harm: Anemia – Hemorrhage (Procedure-Associated Conditions)
Hemorrhage or hemorrhagic anemia refers to anemia secondary to acute blood loss associated with a medical or surgical procedure. Bleeding is a potential complication of any surgical procedure, and the risk is proportional to the size and complexity of the surgery. High blood loss is associated with certain types of surgery such as cardiac and liver surgeries, certain orthopaedic procedures (such as hip replacement) and obstetric surgery. Mortality may be greatly increased when severe bleeding occurs during the operative procedure (National Institute for Health and Care Excellence (NICE), 2014).
- Topics
- Patient safety
- Hospital harm
- Audience
Point of care provider
Quality or safety improvement lead
Policy advisor or analyst
:quality(80))
Goal
Reduce the incidence of hemorrhage or hemorrhagic anemia secondary to medical or surgical procedures.
Overview and Implications
Healthcare Excellence Canada has developed this Hospital Harm Improvement Resource – a compilation of resources to support patient safety and improvement efforts.
A search of patient safety reporting/alert systems uncovered the following incidents of hemorrhage for patients undergoing medical or surgical procedures:
Hemorrhage after liver biopsy (National Patient Safety Agency (NPSA) & National Reporting and Learning Service (NRLS), 2009)
Hemorrhage following removal of femoral catheter (NPSA & NRLS, 2010b)
Hemorrhage from arteriovenous fistula (NPSA & NRLS, 2011)
Hemorrhage following placement of gastrostomy (NPSA & NRLS, 2010a)
Hemorrhage during dialysis (Veterans Affairs Central Office, National Center for Patient Safety, 2008)
Hemorrhage during/following colonoscopy (Oregon Patient Safety Commission, 2015)
There is a relationship between pre-operative anemia and hemorrhage during surgical procedures. Iron deficiency is a common cause of pre-operative anemia and it should be corrected at prior to surgery to achieve optimal results (Gombotz, 2012; Theusinger et al., 2014; Theusinger et al., 2007). Bleeding that occurs in hospital as a result of a medical or surgical procedure is associated with increased morbidity, mortality and increased length of stay (Clevenger et al., 2015; Ferraris et al., 2012; Gombotz, 2012; Muñoz et al., 2016; Musallam et al., 2011; Spahn, 2010).
For additional information regarding Hospital Harm anemia – hemorrhage, please refer to the Hospital Harm Improvement Resource Anemia – Hemorrhage: Health Care / Medication Associated Condition.
Importance to Patients and Families
Even mild anemia leads to impaired functional capacity, physical performance and a reduced quality of life. As anemia worsens, tissue hypoxia and organ dysfunction become apparent (Clevenger et al., 2015). Hemorrhage is understandably alarming to patients and families. Not only may it be life-threatening, it complicates care and prolongs hospitalization.
Patients who experience hemorrhage may require blood transfusions (Spahn, 2010). Risks of blood transfusions include transmission of bacterial or viral infections, febrile transfusion reactions and transfusion-related acute lung injury (Mazer, 2014; Spahn, 2010; Theusinger et al., 2014).
Patient Stories
We are looking for a patient story related to hemorrhage or hemorrhagic anemia associated with a medical or surgical care. If you have one, please share it with Healthcare Excellence Canada at info@hec-esc.ca.
Clinical and System Reviews, Incident Analyses
Given the broad range of potential causes of anemia - hemorrhage, clinical and system reviews should be conducted to identify potential causes and determine appropriate recommendations.
Occurrences of harm are often complex with many contributing factors. Organizations need to:
Measure and monitor the types and frequency of these occurrences.
Use appropriate analytical methods to understand the contributing factors.
Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
Have mechanisms in place to mitigate consequences of harm when it occurs.
To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for conducting chart audits and analysis methods are included in the Hospital Harm Improvement Resource Introduction.
If your review reveals that your cases of anemia - hemorrhage are linked to specific processes or procedures, you may find these resources helpful:
American Society of Anesthesiologist. www.asahq.org
American Society of Anesthesiologists: Practice Guidelines for Perioperative Blood Management (2015). https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2088825
British Committee for Standards in Haematology. https://www.guidelinecentral.com/summaries/organizations/british-committee-for-standards-in-haematology/
Canadian Medical Association - CPG Infobase: Clinical Practice Guidelines. https://joulecma.ca/cpg/homepage
Canadian Patient Safety Institute - Canadian Surgical Safety Checklist. https://era.library.ualberta.ca/items/c61d7d80-5197-4e1c-b89d-ce6054004d4d
European Society of Anesthesiology. www.esahq.org
European Society of Anaesthesiology: Management of severe perioperative bleeding (2017). https://journals.lww.com/ejanaesthesiology/fulltext/2017/06000/Management_of_severe_perioperative_bleeding__.3.aspx
National Blood Authority- Australia. https://www.blood.gov.au/patient-blood-management-pbm#guidelines
National Institute for Health and Care Excellence (NICE). www.nice.org.uk
Network for the Advancement of Patient Blood Management - Haemostasis and Thrombosis. nataonline.com
Ontario Regional Blood Coordinating Network- Bloody Easy for Healthcare Professionals. https://transfusionontario.org/en/documents/?cat=bloody_easy
Thrombosis Canada. https://thrombosiscanada.ca/
The British Society for Haematology. https://b-s-h.org.uk/guidelines/
World Health Organization - Safe Surgery. https://www.who.int/patientsafety/safesurgery/en/
Measures
Vital to quality improvement is measurement, and this applies specifically to implementation of interventions. The chosen measures will help to determine whether an impact is being made (primary outcome), whether the intervention is actually being carried out (process measures), and whether any unintended consequences ensue (balancing measures). In selecting your measures, consider the following:
:quality(80)){kind=icon}
You may use different measures or modify the measures described below to make them more appropriate and/or useful to your particular setting. However, be aware that modifying measures may limit the comparability of your results to others.
Evaluate your choice of measures in terms of the usefulness of the final results and the resources required to obtain them; try to maximize the former while minimizing the latter.
Whenever possible, use measures you are already collecting for other programs.
Try to include both process and outcome measures in your measurement scheme.
Discharge Abstract Database
Discharge Abstract Database (DAD) Codes included in this clinical category: D01: Anemia – Hemorrhage (Procedure-Associated Conditions)
Concept: Hemorrhage or hemorrhagic anemia associated with a medical or surgical procedure.
Notes:
This clinical group excludes obstetric hemorrhage (refer to A02: Obstetric Hemorrhage and D02: Obstetric Hemorrhage) and hemorrhage or hemorrhagic anemia associated with the delivery of health care or related to the administration of anticoagulants (refer to D01: Anemia — Hemorrhage).
The blood transfusion indicator is optional to code in British Columbia.
Code: Code Description
D62, T81.0: Identified as diagnosis type (2) AND Y60-84 in the same diagnosis cluster AND documentation of blood transfusion (blood received indicator = 1)
Code: Code Description
D62: Acute posthemorrhagic anemia
D81.0: Hemorrhagic and haematoma complicating a procedure, not elsewhere classified
Additional Codes: Inclusions
Y60-Y84: Complications of medical surgical care (refer to Appendix A of the Hospital Harm Indicator General Methodology Notes)
Success Stories
Sunnybrook Health Sciences Centre, Toronto, Ontario (Sunnybrook Health Sciences Centre, 2013)
The greatest predictor of whether a patient will need a transfusion is their preoperative hemoglobin level. The Holland Centre at Sunnybrook performs over 3,000 orthopaedic surgical procedures annually. In 2011, it introduced routine CBC (complete blood count) preoperative screening of all surgical candidates to identify anemic patients, manage potential anemia and refer high risk patients to the Blood Conservation Clinic for anemia optimization before surgery. All preoperative patients are given oral iron for one month. If patients are anemic, they are referred to the Blood Conservation Clinic (BCC) four to six weeks preoperatively for consideration of IV iron or Eprex. The project involved an interprofessional team that included Anesthesia, Hematology, Nursing, and Orthopaedic Surgeons. A preoperative blood conservation algorithm was designed and broad staff education was conducted. Patient education materials were also developed. Transfusion rates during the study period were 3.6% compared to 5.1% previously. The estimated cost-savings associated with fewer transfusions in this patient population was $75,000.
(Ottawa Hospital Research Institute, 2006)
Dr. Paul Hébert treats the sickest patients in The Ottawa Hospital – three of every 10 patients who arrive in the intensive care unit will never recover….While Dr. Hébert spends about half of his time trying to heal these patients one-by-one, the other half is spent on critical care research that is helping hundreds of thousands of patients in Ottawa and around the world….he found that patients treated aggressively with transfused blood had a higher death rate than patients whose doctors waited to order a transfusion.
References
Clevenger B, Mallett SV, Klein AA, Richards T. Patient blood management to reduce surgical risk. Br J Surg. 2015;102(11):1325-1337. doi:10.1002/bjs.9898
Ferraris VA, Davenport DL, Saha SP, Austin PC, Zwischenberger JB. Surgical Outcomes and Transfusion of Minimal Amounts of Blood in the Operating Room. Arch Surg. 2012;147(1):49-55. doi:10.1001/archsurg.2011.790
Gombotz H. Patient Blood Management: A Patient-Orientated Approach to Blood Replacement with the Goal of Reducing Anemia, Blood Loss and the Need for Blood Transfusion in Elective Surgery. Transfus Med Hemother. 2012;39(2):67-72. doi:10.1159/000337183
Institute for Healthcare Improvement (IHI). How-to Guide: Prevent Harm from High-Alert Medications. Cambridge, MA: IHI; 2012. http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventHarmfromHighAlertMedications.aspx.
Mazer CD. Blood conservation in cardiac surgery: Guidelines and controversies. Transfus Apher Sci. 2014;50(1):20-25. doi:10.1016/j.transci.2013.12.008
Muñoz M, Gómez-Ramírez S, Kozek-Langeneker S. Pre-operative haematological assessment in patients scheduled for major surgery. Anaesthesia. 2016;71(S1):19-28. doi:10.1111/anae.13304
Musallam KM, Tamim HM, Richards T, et al. Preoperative anaemia and postoperative outcomes in non-cardiac surgery: A retrospective cohort study. Lancet. 2011;378(9800):1396-1407. doi:10.1016/S0140-6736(11)61381-0
National Institute for Health and Care Excellence (NICE). NICE Publishes Draft Guidance on Tests for Bleeding Problems during and after Cardiac Surgery. London, UK: NICE; 2014. https://www.nice.org.uk/news/press-and-media/nice-publishes-draft-guidance-on-tests-for-bleeding-problems-during-and-after-cardiac-surgery.
National Patient Safety Agency (NPSA), National Reporting and Learning Service (NRLS). Haemorrhage after Liver Biopsy. London, UK: National Health Service; 2009. https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Pages/AlertDetail.aspx?AlertID=NPSA013.
National Patient Safety Agency (NPSA), National Reporting and Learning Service (NRLS). Early Detection of Complications after Gastrostomy. London, UK: National Health Service; 2010a. https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Pages/AlertDetail.aspx?AlertID=NPSA089.
National Patient Safety Agency (NPSA), National Reporting and Learning Service (NRLS). Haemorrhage Following Removal of Femoral Catheters. London, UK: National Health Service; 2010b. https://www.patientsafetyinstitute.ca/en/NewsAlerts/Alerts/Pages/AlertDetail.aspx?AlertID=NPSA014.
National Patient Safety Agency (NPSA), National Reporting and Learning Service (NRLS). Haemorrhages from Arteriovenous Fistula. London, UK: National Health Service; 2011. https://webarchive.nationalarchives.gov.uk/20120506001436/http://www.nrls.npsa.nhs.uk/resources/type/signals/?entryid45=94847&cord=ASC&p=1.
Oregon Patient Safety Commission. Patient Safety Alert: Colonoscopies and Red Dot Alerts for Anticoagulants. Portland, OR: Oregon Patient Safety Commission; 2015. https://oregonpatientsafety.org/news-information/news-information/action-alert-colonoscopies-and-red-dot-alerts-for-anticoagulants/553/.
Ottawa Hospital Research Institute (OHRI). From blood transfusions, to heart surgery, to lung infections, Dr. Paul Hébert is doing research to improve the way we care for the sickest patients in the hospital. OHRI Newsroom. http://www.ohri.ca/newsroom/story/view/751?l=en. Published June 1, 2006.
Spahn D. Anemia and Patient Blood Management in Hip and Knee Surgery: A Systematic Review of the Literature. Anesthesiology. 2010;113(2):482-495. doi:10.1097/ALN.0b013e3181e08e97
Sunnybrook Health Sciences Centre. Leading Practices: Best Practice in Patient Blood Management in a Surgical Patient Population. Ottawa, ON: Health Standards Organization; 2013. https://healthstandards.org/leading-practice/best-practice-in-patient-blood-management-in-a-surgical-patient-population/.
Theusinger OM, Kind SL, Seifert B, Borgeat L, Gerber C, Spahn DR. Patient blood management in orthopaedic surgery: A four-year follow-up of transfusion requirements and blood loss from 2008 to 2011 at the Balgrist University Hospital in Zurich, Switzerland. Blood Transfus. 2014;12(2):195-203. doi:10.2450/2014.0306-13
Theusinger OM MD, Leyvraz P-F MD, Schanz U MD, Seifert B PhD, Spahn DR MD,FRCA. Treatment of Iron Deficiency Anemia in Orthopedic Surgery with Intravenous Iron: Efficacy and Limits: A Prospective Study. Anesthesiology. 2007;107(6):923-927. doi:10.1097/01.anes.0000291441.10704.82
Veterans Affairs Central Office, National Center for Patient Safety. Bleeding Episodes During Dialysis. Washington, DC: Veterans Affairs Central Office; 2008. https://www.patientsafety.va.gov/docs/alerts/BleedingEpisodesDuringDialysisAD09-02.pdf
Add the listing of resources here.
:quality(80))
:quality(80))
:quality(80))