Promoting High-Value Transfusion Practice Through Clinical Decision Support with Best Practice Advisories

From the 2019 HVPAA National Conference

Mr. Kevin Merkel (Johns Hopkins School of Medicine), Mr. Tymoteusz Kajstura (Johns Hopkins School of Medicine), Ms. Mereze Visagie (Johns Hopkins School of Medicine), Ms. Caroline Qin (Johns Hopkins School of Medicine), Mr. Vince DeMario (Johns Hopkins School of Medicine), Dr. Brian Cho (Johns Hopkins School of Medicine), Dr. Eric Gehrie (Johns Hopkins School of Medicine), Dr. Steven Frank (Johns Hopkins School of Medicine)


Blood transfusion is the most common procedure performed in United States hospitals and is one of the top five overused procedures according to the American Medical Association and The Joint Commission. Transfusion of red blood cells (RBCs), plasma (FFP), and platelets (PLT) is not without risk and comes with substantial cost, making the judicious use of products prudent. Transfusion guidelines are available for RBCs (based on 9 randomized clinical trials [RCT]), PLTs (based on 2 RCTs) and FFP (based on best available evidence), which can be used to reduce risks and costs, while improving outcomes. Clinical decision support with a best practice advisory (BPA) can encourage guideline compliance, and in this study we report effectiveness of the BPA for all three major blood components.


Across five hospitals in the Johns Hopkins Health System, an electronic BPA was developed to alert providers when they placed a transfusion order outside of guidelines. The BPA was triggered: for RBCs, by the most recent hemoglobin (Hb) value ≥ 7 g/dL or no Hb measured in the past 24 hrs; for FFP, a most recent international normalized ratio (INR) < 1.5, or no INR ordered in the past 24 hrs; for PLTs, a most recent available platelet count ≥ 50,000 or no platelet count ordered in the past 24 hrs. The BPA was educational by providing hyperlinks to citations backing up the evidence-based guidelines and requested the provider either select a reason for transfusing outside of guidelines or discontinue the order. The BPAs were launched in September 2015, and guideline compliance for transfusion orders as well as blood utilization (units transfused per 1,000 patients) and cost, were compared between the first and last years of the study period (2014 vs. 2017).


The overall blood utilization for inpatients was reduced by 19.8% for RBCs, 38.9% for FFP, and 15.6% for PLTs (Figure). Out-of-guideline transfusions for RBCs (Hb ≥ 8) were reduced by 34.8%, for FFP (INR < 1.5) were reduced by 9.1%, and for PLTs (platelet count > 50k) were reduced by 3.4%. RBC multi-unit orders were reduced by 49.1% which we attribute to our “Why Give 2 When 1 Will Do?” single unit transfusion campaign. The corresponding annual decrease in blood acquisition cost, comparing 2017 to 2014, was $1.7 million for RBCs, $650,000 for FFP, and $383,000 for PLTs; for a total savings of $2.73 million/year.


Compliance to guidelines for RBC, FFP and PLT transfusions increased, while unnecessary transfusions for all three blood components decreased after implementation of a simple BPA intervention as part of a health-system wide patient blood management program. Success of the BPA was bolstered by an educational campaign spreading awareness of hospital transfusion guidelines, with emphasis on evidence from randomized trials where possible. These results highlight how clinical decision support can be leveraged to promote high-value practice within a patient blood management program.


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