Impact of implementing a nurse-led intraoperative cell saver service in reducing allogeneic red blood cell transfusions in Singapore General Hospital

Abstract

Introduction: Major perioperative blood loss often necessitates allogeneic blood transfusions, leading to adverse outcomes and straining healthcare resources. Intraoperative cell salvage (ICS) offers benefits like reduced adverse reactions, optimised blood resource allocation, and cost-effectiveness. Yet, ICS adoption remains limited. Our aim is to formalise and expand ICS as a routine service to promote wider adoption and improve patient outcomes.

Methods: The model for improvement was adopted for an ICS quality improvement initiative across two Plan-Do-Study-Act cycles. Interventions followed the '4E' framework: education, empowerment, enforcement and embedding reminders. The primary outcome was the number of allogeneic red blood cell (RBC) units transfused per surgery with predicted blood loss >500 mL; the secondary outcome was the percentage of indicated surgeries using ICS. Process measure was percentage of anaesthetic unit nurses trained in ICS. Balancing measures included the number of ICS activations with no blood return and complications during and after ICS.

Results: A total of 152 surgeries used ICS postintervention (January 2023 to April 2024), marking an increase from preintervention levels. The median number of monthly mean allogeneic RBC units transfused per patient demonstrated a significant reduction from 3.10 (preintervention) to 2.44 (postintervention). The percentage of indicated surgeries utilising ICS increased from 1.4% to 12.3%. Cost savings were observed, with potential annual savings close to SGD 500 000. No complications related to the use of ICS were recorded.

Conclusion: The formalisation and expansion of the ICS service within our institution resulted in notable improvements, including increased ICS adoption rates, reduced reliance on allogeneic blood transfusions and potential cost savings. Future quality improvement efforts should concentrate on further promoting ICS adoption, particularly for surgeries with clinical indications.

Keywords: Health policy; Healthcare quality improvement; Quality improvement.

Figure 1. Driver diagram with aligned outcome and process metrics. AU, anaesthetic unit; ICS, intraoperative cell salvage; OT, operating theatre; PDSA, Plan-Do-Study-Act; RBC, red blood cell; SGH, Singapore General Hospital.

Figure 2. Run chart of the monthly mean number of RBC units transfused per patient for surgery in MOT with blood loss ≥500 mL. MOT, major operating theatre; PDSA, Plan-Do-Study-Act; RBC, red blood cell.