Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
Implementing a perioperative anaemia service improved early anaemia detection and optimisation, with associated reduction in transfusion rates, postoperative complications in elective patients at a regional hospital.
Dates: December 2024 - ongoing
Implementation sites: Toowoomba Hospital
This project was presented as a Poster at CEQ Showcase 2026 (PDF 12MB).
Aim
To evaluate a structured perioperative anaemia management service on improving preoperative anaemia detection and optimisation in elective surgical patients.
Outcomes
Between January and June 2025, 276 elective surgical patients were screened, with 38 (13.8%) diagnosed with anaemia and 37 (13.4%) requiring active optimisation prior to surgery.
- Compared to 2023 audit cohort (n=82), implementation of PAOS (n=225) was associated with:
- Reduced blood transfusion rates: 3.6%, (8/225, 2025) vs. 9.8%, (8/82, 2023),
- Lower postoperative infection rates: 1.8%, (4/225, 2025) vs. 3.7% (3/82, 2023),
- Shorter hospital stays among anaemic patients (length of stay > 2 days): 69%, (22/32, 2025) vs. 85% (11/13, 2023)
The service was delivered without dedicated funding or additional staffing. It received highly positive informal feedback from patients and surgical teams, particularly regarding earlier optimisation and reduced last-minute surgical delays.
Background
Preoperative anaemia is a common and modifiable risk factor associated with increased perioperative morbidity, transfusion requirements, length of stay, and mortality. Patient Blood Management (PBM) guidelines recommend early identification and treatment of anaemia prior to elective surgery; however, implementation in regional health services remains variable due to workforce limitations, fragmented care pathways, and limited access to specialist services.
At our regional Australian hospital, 2 previous audits in 2019 and 2023 showed that preoperative anaemia screening and optimisation were inconsistently performed, with many patients presenting for elective surgery without appropriate investigation or treatment, leading to cancellation on day of surgery. Anaemia management was often reactive rather than proactive, leading to delayed surgery, avoidable transfusion, or suboptimal perioperative outcomes. There was no formalised pathway outlining responsibility for anaemia screening, investigation, treatment or escalation.
Our project sought to address these gaps by implementing a structured perioperative anaemia management service, embedded within existing pre-admission clinic workflows and supported by anaesthetic services. The central problem addressed was how to deliver evidence-based perioperative anaemia care in a resource-limited regional setting while maintaining sustainability and clinician engagement.
The project aimed to improve patient safety, optimise surgical readiness, and reduce avoidable transfusion.
Methods
A clinician-led Perioperative Anaemia Optimisation Service (PAOS) was established at Toowoomba Hospital in January 2025 as a quality improvement initiative. The service was implemented without dedicated staffing or funding and relied on voluntary contributions from anaesthesia, perioperative nursing staff, allied health and haematology, supported by multidisciplinary collaboration.
PAOS was embedded within our existing pre-admission clinic workflows. All adult patients scheduled for in-scope Category 1 and 2 elective surgical procedures were screened preoperatively for anaemia using standard laboratory testing. Locally designed digital tools were developed to identify, track and monitor anaemic patients throughout the perioperative pathway. A secure REDCap database was utilised to support structured data capture, patient tracking, and prospective service evaluation.
Patients identified with anaemia underwent structured assessment to determine aetiology and suitability for optimisation. Management was based on Patient Blood Management (PBM) guidelines by National Blood Authority and Queensland Health PBM protocol, including oral iron therapy, intravenous iron infusion, and vitamin B12 or folate replacement where indicated. Escalation pathways to anaesthesia and haematology services were defined for complex cases. Intravenous iron infusions were coordinated with support of existing day infusion services across the Darling Downs region to ensure equitable access. Infusions were arranged not only at Toowoomba Hospital but also throughout rural and regional facilities including Taroom, Mungindi, Stanthorpe, Chinchilla, and so on, minimising travel burden for patients.
To enhance continuity of care, a nurse-led follow-up clinic was setup to monitor treatment response, reinforce adherence, and ensure appropriate ongoing management. Standardised communication templates were developed to provide structured GP follow-up letters, supporting community-based continuity of care across the Darling Downs region. The introduction of nurse-led anaemia follow-up clinics also enabled generation of activity-based revenue within existing service frameworks, contributing to sustainability.
Data were collected prospectively between January and June 2025, including screening rates, anaemia prevalence, interventions delivered, perioperative blood transfusion rates, postoperative infection rates, and length of hospital stay. Outcomes were compared with historical audit data from 2023 to assess early service impact.
Discussion
This project demonstrates that despite significant resource constraints, a structured perioperative anaemia optimisation service can be successfully implemented in a regional referral hospital, with strong clinician leadership and multidisciplinary commitment. Implementation of PAOS was associated with early improvements in perioperative outcomes, including reduced blood transfusion rates, lower postoperative infection rates, and shorter hospital length of stay among anaemic patients, consistent with established patient blood management evidence.
Success was driven by strong clinician leadership, particularly from anaesthesia and the Nursing Manager for embedding the service within existing pre-admission clinic workflows. Multidisciplinary collaboration across nursing and allied health, enabled delivery of care without dedicated funding or staffing, supporting sustainability in a resource-limited setting.
Key challenges included reliance on voluntary clinician and nursing effort, limited access to timely intravenous iron transfusion service and specialist review, and dependence on locally developed digital tools requiring ongoing refinement. These factors constrained scalability and required prioritisation of higher-risk patients.
Strengths of this project include its pragmatic design, real-world implementation, and relevance to regional healthcare contexts serving a diverse and large geographical area.
Limitations include the observational nature of the evaluation, use of historical comparators, small sample size, and short follow-up period, which limit causal inference.
Despite these limitations, Perioperative Anaemia Optimisation Service represents a feasible and transferable model for perioperative anaemia optimisation across other regional Queensland Health facilities. Future work will focus on strengthening governance, improving digital integration, and evaluating longer-term clinical and cost-effectiveness outcomes.
References
1. Parr J. Perioperative management of anaemia in patients undergoing major elective orthopaedic surgery. Poster presented at: Australian & New Zealand College of Anaesthetists Annual Scientific Meeting; 2021 Apr; Australia.
2. Fowler AJ, Ahmad T, Phull MK, Allard S, Gillies MA, Pearse RM. Meta-analysis of the association between preoperative anaemia and mortality after surgery. Br J Surg. 2015;102(11):1314-24.
3. Cata JP et al. The Association Between Perioperative Red Blood Cell Transfusions and 1-Year Mortality After Major Cancer Surgery: An International Multicenter Observational Study. Anesth Analg. 2025;140:782-794.
4. Kotze A, Harris A, Baker C, Iqbal T, Lavies N, Richards T, et al. British Committee for Standards in Haematology Guidelines on the Identification and Management of Pre-Operative Anaemia. Br J Haematol. 2015;171(3):322-31.
5. Authority NB. Patient Blood Management Guidelines - Module 2 - Perioperative: National Blood Authority; 2012.
6. Ng O, Keeler BD, Mishra A, Simpson JA, Neal K, Al-Hassi HO, et al. Iron therapy for preoperative anaemia. Cochrane Database Syst Rev. 2019;12:CD011588.
7. Richards T, Baikady RR, Clevenger B, Butcher A, Abeysiri S, Chau M, et al. Preoperative intravenous iron to treat anaemia before major abdominal surgery (PREVENTT): a randomised, double-blind, controlled trial. Lancet. 2020.
8. Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, et al. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. European Journal of Anaesthesiology | EJA. 2023;40(4):226-304.
9. National Blood Authority. (n.d.) Three Pillar Approach. Retrieved from pbm-3-pillars.pdf (blood.gov.au)
10. PA Harris, R Taylor, R Thielke, J Payne, N Gonzalez, JG. Conde, Research electronic data capture (REDCap) – A metadata-driven methodology and workflow process for providing translational research informatics support, J Biomed Inform. 2009 Apr;42(2):377-81.
Key contact
Dr Yigang Liu
Principal House Officer
Darling Downs Hospital and Health Service
Email: yigang.liu@health.qld.gov.au