Strategies for increasing the use of tranexamic acid in patients undergoing major surgery

Tranexamic acid reduces major bleeding events in patients undergoing major surgery without increasing thromboembolic events. In October 2022, the Joint Royal Colleges Tranexamic Acid in Surgery Implementation Group issued recommendations for consideration of tranexamic acid use in all patients having inpatient surgery. National and local audit data shows that a significant portion of eligible patients do not receive tranexamic acid. We designed and implemented a quality improvement project to increase the use of tranexamic acid in patients undergoing major surgery (surgery with the potential for estimated blood loss > 500 ml). Data were collected on baseline tranexamic acid use and stakeholder-reported barriers to tranexamic acid use. This was used to design and implement a sequence of quality improvement interventions. We disseminated Joint Royal Colleges guidance and delivered education sessions to increase understanding of tranexamic acid use. The local World Health Organisation (WHO) surgical checklist was updated to prompt clinical staff to consider the use of tranexamic acid. At baseline tranexamic acid was used in 50 of 100 (50%) major surgical cases. In the third audit cycle, tranexamic acid use had improved to 65 of 96 (68%) cases, with a shift in practice noted on continuous monitoring data indicating sustained improvement. Key factors in successful implementation of this project included stakeholder engagement, widespread dissemination of education and guidance and change of the local WHO surgical checklist.