Interventions make headway in changing the 'culture' of blood transfusions

At an urban, academic medical center, interventions to decrease the need for red blood cell (RBC) transfusions—the most frequently performed hospital procedure in the United States—resulted in a reduction of 67.1% in multiunit transfusions and an annual cost savings of over $1 million, according to a recent study published in The Joint Commission Journal on Quality and Patient Safety.

Researchers were led by Ian Jenkins, MD, SFHM, clinical professor, Department of Medicine, and chair, Patient Safety Committee, Hospital Medicine, University of California San Diego Health, San Diego, CA.

The study aimed to test their hypothesis that using a revised CPOE transfusion protocol and a BestPractice Advisory (BPA) for transfusions above the hemoglobin (Hb) threshold, combined with an educational campaign and provider feedback, would serve to reduce inappropriate transfusions. The BPA they used was an adaptation of the best practice alert from Goodnough et al,¹ with exceptions for perioperative patients and active bleeding.

A multidisciplinary team reviewed all transfusion literature in clinical trials, meta-analyses, guidelines, and improvement efforts, and implemented several interventions, including a BPA to reduce unnecessary blood products and costs using real-time clinical decision support, a process for providing information at point of care to help inform decisions about patient care, and enhancements to the health system’s computerized provider order entry system.

They included all non-infant inpatients without gastrointestinal bleeding who were not within 12 hours of surgical procedures. In all, there were 65,861 inpatient discharges, 464,424 patient-days, and 36,386 administered RBC units during the study period.

The percentage of RBC transfusions in which ≥ 2 units were used decreased from baseline to post-intervention, from 59.9% at baseline to 41.7% during the intervention to 19.7% post-intervention (P < 0.001). The percentage of inpatient RBC transfusion units administered for Hb ≥ 7 g/dL declined from 72.3% to 57.8% to 38.0%, respectively (P < 0.0001). The overall rate of RBC transfusions without exclusions per 1,000 patient-days decreased as well, from 89.8% to 78.1% to 72.8% (P < 0.0001).

The estimated annual costs savings was $1,050,750.

Thus, multiunit transfusions were reduced by 67.1%, and transfusions for Hb ≥ 7 g/dL by 47.4%. Improvements in the overall transfusion rate were 19.0%, and researchers noted that this less significant improvement was caused by better baseline performance compared with other centers.

“Our results are noteworthy because they represent a meaningful improvement in a system already using relatively little blood—our baseline transfusion rate was 18% lower than the national average of Vizient-participating academic medical centers. It is difficult to make a direct comparison with the study conducted by Goodnough et al, which examined system-wide RBC transfusions per 1,000 inpatient discharges, but our pre-project transfusion rate was about 75% of their post-project rate (679 vs about 900 units transfused per 1,000 inpatient discharges),” wrote Jenkins et al.

“Hospital systems can improve patient outcomes while enjoying cost savings with similar efforts; the savings, however, likely depend on the baseline performance, with high-performing institutions saving less than low-performing institutions,” they concluded.

According to an accompanying editorial by Aryeh Shander, MD, executive medical director, Institute for Patient Blood Management and Bloodless Medicine and Surgery, and director, TeamHealth Research Institute, Englewood Hospital and Medical Center, Englewood, NJ:

“The efforts to make transfusion of RBCs ‘appropriate’ is laudable, as the current culture needs significant overhaul. In their article, Jenkins et al have demonstrated that a project of this magnitude can change the culture of transfusion for the better by reducing unnecessary use of RBCs and conserving resources. In the background, the patient who has been spared a transfusion still remains anemic. It is time to change that culture.”

References

1. Goodnough, T.L. et al. Improved blood utilization using real-time clinical decision support. Transfusion. 2014; 54: 1358–1365.