Reducing Transfusions in Neuromuscular Spinal Fusion: A NSQIP-P Quality Improvement Project

Pediatric spinal fusion can result in substantial blood loss, particularly in patients with scoliosis related to underlying neuromuscular (NM) disease. Transfusion is frequently required but carries risks including transfusion reactions, alloimmunization, volume overload, and infection. The American College of Surgeons National Surgical Quality Improvement Program - Pediatrics (ACS NSQIP-P) is a nationally validated, risk-adjusted national outcomes registry. At our institution, ACS NSQIP-P data identified our institution as a high outlier in transfusion for neuromuscular scoliosis patients. A multidisciplinary group convened from January 2024 to June 2024 to design and implement a perioperative pathway with the primary goal of reducing transfusion volume to <25 mL/kg, and the secondary goal of reducing overall transfusion volume. The final pathway was formally launched in September 2024. The pathway standardized care across all phases of surgery: preoperative optimization through multidisciplinary review and dedicated clinic visits; intraoperative blood conservation with tranexamic acid, controlled hypotension, cell salvage, standardized lab monitoring, and transfusion thresholds; and postoperative protocols limiting red blood cell transfusion and establishing PICU guidelines. All departments received targeted education, and outcomes were monitored with NSQIP-P data. In the baseline period of July 2023 to December 2023 (n=13), the median transfusion volume was 9.3 mL/kg, with six patients (46%) exceeding 25 mL/kg (median excess transfusion = 25.8 mL/kg). When the team began meeting between January 2024 and June 2024 (n=13), the median transfusion volume was 14.4 mL/kg, with two patients (15%) exceeding 25 mL/kg (median excess transfusion = 11.4 mL/kg). In the subsequent period, July 2024 to December 2024 (n=19), median transfusion volume decreased to 5.1 mL/kg, with two patients (11%) exceeding 25 mL/kg (median excess transfusion = 4.6 mL/kg). In the most recent period of January 2025 to June 2025 (n=13), the median transfusion volume was 7.5 mL/kg with two patients (15%) exceeding 25 mL/kg (median excess transfusion = 3.7 mL/kg). At the end of the study interval, our institution was no longer identified as an NSQIP-P outlier and was performing “As Expected” in this category. Implementation of a multidisciplinary, evidence-based, perioperative pathway that includes patient optimization before surgery, balanced transfusions intra-operatively, correction of coagulopathy, and a lower transfusion target of 7 g/dL in stable patients postoperatively, can safely reduce transfusion exposure after NM spinal fusion. 1) Excessive blood transfusion in neuromuscular spinal fusion is common and associated with adverse outcomes, including infection, transfusion reactions, volume overload, and increased healthcare costs. 2) The American College of Surgeons National Surgical Quality Improvement Program - Pediatrics (ACS NSQIP-P) is a validated outcomes registry that enables institutions to benchmark performance against others. 3) Implementation of a multidisciplinary, perioperative quality improvement pathway spanning preoperative, intraoperative, and postoperative phases, reduced transfusion requirements in neuromuscular patients undergoing spinal fusion at our institution.