From the 2019 HVPAA National Conference
Dr. Andrew W Hwang (Riverside Community Hospital/UC Riverside), Dr. Karla Olmedo (Riverside Community Hospital/UC Riverside), Dr. Michael Whitmore (Riverside Community Hospital/UC Riverside), Dr. Alina S Popa (Riverside Community Hospital/UC Riverside)
Transfusion of packed red blood cells in the US has more than doubled from 1997 to 2011; however, it is thought that greater than 50% of transfusions may be unnecessary. Numerous clinical trials have demonstrated that restrictive transfusion strategies are noninferior or superior to liberal strategies across a variety of clinical scenarios; as a result, restrictive strategies are now recommended by most professional societies.
At our institution, we are working to improve blood utilization and compliance to national transfusion guidelines. Prior to intervention in Q3 2017, transfusion was directed primarily by provider clinical assessment with little-to-no clinical decision support; occurring with hemoglobin greater than 10 g/dL, and 8-10 g/dL without clear indication.
To improve utilization of RBCs by increasing provider compliance to clinical guidelines. We expected reduction of unindicated RBC transfusions in our facility by at least 25% as well as an overall reduction in blood use of at least 10% within 12 months of initial intervention.
This quality improvement initiative was completed over 15 months (Q3 2017-Q3 2018). Baseline data collected in Q1-Q2 2017 revealed that 53% of transfusions occurred with hemoglobin greater than 7g/dL; details are shown in Table 1.
During this baseline-period, a blood utilization committee comprised of representatives from medicine, surgery, nursing, blood bank, quality and safety, and pharmacy was established. The plan-do-study-act (PDSA) methodology for quality improvement was utilized for this initiative over two phases.
In the first phase, the committee generated decision support tools that were implemented to our electronic ordering system in Q3 2017; it asked that an indication be entered for each transfusion from a pre-populated list of evidence-based indications. In addition, providers were asked to complete an education module highlighting data in support of restrictive strategies. Following a 5-month run-in period, all transfusions over a 30-day period were evaluated for appropriateness and compliance to clinical guidelines.
In the second phase implemented in Q1 2018, a targeted program was initiated to address unindicated transfusions directly: blood bank staff selectively contact providers prior to the release of RBCs if the transfusion-indication is not readily apparent. Following a 6-month run-in period, transfusions were reassessed.
Our overall rate of transfusion decreased from 58.94 to 45.29 units per 1000 patient-days (r = -0.71, Figure 1). This represents an overall reduction of 24.2% or 129.2 units per month. There was no effect on transfusion-related adverse events.
Following the first PDSA cycle, 34.2% of transfusions did not meet guideline-directed indications for transfusion (Table 2). Upon close review, 79% of these were potentially compliant, but lacked clear documentation of transfusion indication.
To address this deficiency, blood bank staff were directed to clarify transfusion indication in these situations with providers. Following a second wash-in period, transfusions that did not meet guideline-standards fell to 23.4%, representing an overall 10.8% improvement in guideline-compliance.
Utilizing a PDSA approach, we have decreased our overall RBC utilization by 24.2%, and improved guideline-compliance by 10.8%. We plan to further optimize our blood management program by implementing a revised order set leveraging feedback elicited from blood bank staff during our second PDSA cycle.
Unnecessary blood transfusion is associated with significant morbidity and mortality. Therefore, programs to decrease blood utilization and improve compliance with society guidelines will improve value and patient safety.