Provider Feedback Reduces Unindicated Transfusions In Orthopaedic Surgery

From the 2018 HVPAA National Conference

Raj Amin (Johns Hopkins Hospital), Robert Sterling (Johns Hopkins Hospital), Steven Frank (Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland), James Ficke (Johns Hopkins Hospital), Adam Levin (Johns Hopkins Hospital)

Background

Multifaceted blood-management programs are a well described means of reducing out of guideline transfusions. Sustained education and feedback measures are a common component of these programs, but are time intensive. Moreover, the efficacy of this feedback in altering surgical provider transfusion practices is not well defined.

Objectives

To evaluate the effect of individual provider education and feedback on the appropriateness of allogenic red blood cell transfusion use in a tertiary care academic orthopaedic surgery department.

Methods

In February 2016, our department began giving providers individualized monthly feedback regarding their transfusion utilization and adherence to recommended guidelines. We conducted a retrospective chart review to compare the adherence to recommended guidelines for transfusions in the pre-feedback (2/2015-1/2016) and post-feedback (3/2016-2/2017) cohorts. Appropriateness of transfusions was based upon our institutional guidelines of transfusion for Hb <7 g/dl in asymptomatic patients or Hb <8 g/dl in those with active cardiac disease or symptomatic anemia. Any transfusion in response to a hemoglobin <7 was considered appropriate, as were transfusions between 7-8 with appropriate clinical indication.  Out of guideline transfusions were defined as lack of medical record documentation for transfusion necessity in patients with a Hb >7 g/dl, or multiple-unit transfusions without a Hb recheck after the first unit. Statistical comparison was done with t-tests, Mann-Whitney, and Chi squared analyses, with P < 0.05 defining significance.

Results

There were 34.5 transfusions per month in the pre-feedback cohort and 22.0 in the post-feedback cohort (p = 0.003). There was no significant difference in the case volume, or complexity, between the two cohorts. Following the implementation of provider feedback, there were significantly fewer Hb 7-8 g/dl transfusions (14.2% pre v. 8.6% post, p=0.004) and transfusions above Hb >8 (5.2% pre v 2.5% post, p=0.02). Compared to the pre-feedback cohort, the number of indicated transfused increased by 33% in the post-feedback cohort (p=0.005), largely due to a decrease in 2-unit transfusion orders following the intervention. The number of unindicated transfusions decreased by 73% (p<0.001) following the intervention.

Conclusion

Our findings suggest that repeated direct provider feedback and education can be a strong component of the overall success of a comprehensive patient blood management program. We demonstrate that this program intervention was associated with a 73% reduction in out of guideline blood product transfusion orders by surgical providers.

Implications for the Patient

Unnecessary blood transfusions in orthoapedic surgery are associated with substantial patient level morbidity, including surgical site infection, increased length of stay and mortality. Therefore, measures which decrease out of guideline transfusion orders by providers

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