From the 2022 HVPA National Conference
Adelaide Kwon MD (UT Southwestern Medical Center), Vidushi Golla MD
Transfusion of packed red blood cells (pRBC) is one of the most common hospital procedures performed in the United States. The Association for the Advancement of Blood & Biotherapies transfusion guidelines recommends hemoglobin of 7-8 g/dL as the transfusion threshold, but there is variation in clinical practice in both this threshold as well as the number of pRBCs transfused at a time. Inappropriate or unnecessary transfusion of blood products can lead to overuse of healthcare resources and increased adverse outcomes.
During the COVID-19 pandemic, blood became a particularly scarce resource, underscoring the importance of appropriate transfusion practices and high-value care to circumvent drastic shortages in pRBC supplies. In response to this shortage, the Dallas County Hospital implemented new protocols, including screening of each pRBC order, to ensure appropriate use of these limited supplies.
To compare transfusion practices in hemodynamically stable patients needing routine transfusions for Hb 6-7 g/dL in the Hospital Medicine and teaching wards of the Dallas County Hospital before and during the COVID-19 pandemic.
Transfusion records were pulled from August to December in each year for pre-pandemic (2019) and mid-pandemic periods (2020 and 2021). Entries that were not of “routine” priority and were not of a Hospital Medicine or teaching ward were omitted. Entries with Hb not between 6-7 g/dL were also omitted. The data was then sorted by number of units transfused for analysis.
730 of 784 transfusion events involved 1 pRBC unit in 2019, compared to 939 of 986 in 2020 and 909 of 939 in 2021. However, the average daily patient census pre-pandemic was approximately 340, whereas the daily patient census mid-pandemic was approximately 420. Considering censuses, there is a statistically significant difference in transfusion practices between pre- (2019) and mid- (2020 and 2021) pandemic groups. We noted that more patients mid-pandemic received a lower number of units when needing a transfusion for a Hb value between 6-7 g/dL (p-value: 0.001).
Because of the blood supply shortage and higher censuses with the onset of the COVID-19 pandemic, stricter transfusion guidelines were enacted. The usual pre-pandemic practice did not include screening every pRBC unit for appropriateness; this was deferred to the discretion of the ordering provider. This changed during the pandemic, and rethinking our transfusion practices due to pandemic-related shortages led to more efficient and appropriate use of transfusion services.
These findings suggest that there is room for improvement and scrutiny of transfusion practices, especially in hemodynamically stable patients in Hospital Medicine and teaching services. A focus on high-value care and close assessment of transfusion appropriateness is needed. Additionally, these findings emphasize the importance of training faculty, house staff, and medical students in transfusion appropriateness and in considering alternate therapies like iron infusions, which can be a cost-effective and safe alternative. In this regard, our hospital now has a Patient Blood Management committee-driven Hospital Wide Campaign of “ONE”: order One unit at a time in stable patients, consider iroN, and Eliminate unnecessary pRBC transfusions.