Abstract
Introduction:
A restrictive approach to blood transfusion was shown to be safe and effective over a decade ago, but liberal transfusion practices prevail in many institutions. In 2012, the American Association of Blood Banks published its guidelines encouraging a restrictive approach to transfusions (Carson, B J. et al. Ann Intern Med. 2012;157(1):49-58). In 2013, the American Society of Hematology, along with the American Board of Internal Medicine began a "Choosing Wisely" campaign to educate physicians to limit unnecessary blood transfusions (L K Hicks, et al. Blood. 2013 Dec 5;122(24):3879-83). These guidelines were based on over a decade of published research demonstrating the non-inferiority (and occasionally superiority) of the restrictive approach. Hemodynamically stable patients do not benefit from transfusions to a Hb >9 g/dl. (Bush, R et al. Am J Surg. 1997; 174: 143-148; Hebert, P et al. N Engl J Med 1999; 340:409-417; Barkun A N et al. Ann Intern Med. 2010; 152: 101-113; Carson, J L N Engl J Med 2011; Carson JL et al. Am Heart J. 2013; 165: 365: 2453-2462; Holst, L et al. N Engl J Med 2014;371:1381-91;).
Our hospital started an active patient blood management (PBM) program in January 2013 with intensive educational lectures for all departments, addressing physician trainees as well as senior physicians. This led to a modest drop in blood utilization, but many patients continued to receive liberal transfusions. In July 2013, our institution hired a transfusion safety officer (TSO) to review all orders for blood transfusion that fell outside of the medical board approved guidelines (a restrictive policy). This report details the results of our activities and highlights the importance of one-on-one education to change practices that are ingrained over time.
Methods:
In January 2013, educational lectures along with pocket cards containing restrictive indications were given to the Internal Medicine, ICU, Surgical, and Ob/Gyn house staff to promote a restrictive transfusion approach. In July 2013, a TSO was hired to supplement educational efforts regarding PBM. The TSO underwent training and then trained the blood bank staff. By January 2014, the entire technical staff was trained to screen all packed red blood cell (pRBC) requests prospectively for compliance with the medical board guidelines (transfuse for Hb <7 g/dl). Previously, all pRBC transfusions were audited in a retrospective fashion. In both cases, the results of the audits were forwarded to the transfusion committee and department chairperson.
If the Hb <7 g/dl: 2 units issued
If the Hb 7-9 g/dl: 1 unit issued, repeat CBC requested
If the Hb >9 g/dl with hemodynamic stability: question the justification
If the patient was actively bleeding or hemodynamically unstable, release pRBC as requested
If the MD insisted on pRBC outside guidelines, issue the units and refer to Medical Director for retrospective audit of medical necessity
If no medical necessity found, refer to transfusion committee for review
If final review did not meet guidelines, letter sent to MD and to department chairperson.
Data including the number of pRBC transfusions, the number of patients transfused, the adjusted discharges and financials were reviewed from 2012 to 2014.
Results:
Table. 2012 2013 2014 pRBC (units 10,449 10,185 7,980 Patients transfused (#) 2698 2606 2167 Adjusted discharges 40,555 40,225 39,705 RBC units/adjusted discharge 0.258 0.253 0.20 Blood product expense ($) 2,901,069 2,973,863 2,406,370
Conclusion:
Traditional approaches to education with grand rounds, case presentations and lectures had only a modest effect on the practice of liberal pRBC transfusions at our institution. However, one-on-one intervention with education was successful in reducing inappropriate pRBC transfusions. The above 22% decrease in RBC utilization was greater than could be accounted for by a fall in adjusted discharges, as demonstrated by the RBC/adjusted discharge ratio. In addition, there was an overall savings of $495,000 from 2012-2014 without any change in vendor or any decrease in the price of the blood products. Experience in many different medical fields has shown that influencing established medical practices is challenging. This PBM process demonstrates how patient safety and quality improvements can also lead to financial savings.
Disclosures
No relevant conflicts of interest to declare.
Evaluating the Importance of Patient Blood Management During COVID-19 Pandemic
