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Jeganathan-Udayakumar P, Tochtermann N, Beck T, Wertli MM, Baumgartner C. Haemoglobin thresholds for transfusion: how are we doing in the era of Choosing Wisely? A retrospective cohort study. Swiss Med Wkly 2023; 153:40132. [PMID: 38579320 DOI: 10.57187/smw.2023.40132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION Clinical practice guidelines and the Choosing Wisely initiative launched in 2012 recommend a haemoglobin (Hb) threshold of 70-80 g/lfor red blood cell (RBC) transfusions in stable hospitalised patients. Data on transfusion practices and their trends in medical inpatients are limited. To address this gap, we investigated transfusion practices and their trends in general internal medicine and other clinics. METHODS This retrospective cohort study analysed data from all hospitalisations with RBC transfusions at a Swiss university hospital between 2012 and 2019. We included all first transfusion episodes if pretransfusion Hb was available. The primary endpoint was mean pretransfusion Hb; secondary endpoints included potentially inadequate transfusions (i.e., transfusions at Hb ≥80 g/l) and receipt of a single RBC unit. Trends in mean pretransfusion Hb over time were estimated using generalised estimating equations, and risk factors for potentially inadequate transfusions were identified using multivariable adjusted generalised estimating equations models. RESULTS Of 14,598 hospitalisations with RBC transfusions, 1980 (13.6%) were discharged from general internal medicine. From 2012 to 2019, mean pretransfusion Hb decreased from 74.0 g/l to 68.8 g/l in general internal medicine (mean annual decrease -0.76 g/l, 95% confidence interval [CI] -0.51 to -1.02) and from 78.2 g/l to 72.7 g/l in other clinics (mean annual decrease -0.69, 95% CI -0.62 to -0.77; p for interaction 0.53). The overall proportion of potentially inadequate transfusions was 17.8% in general internal medicine and 24.1% in other clinics (p <0.001) and decreased over the study period from 26.9% to 5.5% in general internal medicine and from 37.0% to 15.2% in other clinics. In contrast, the proportion of cases receiving a single RBC unit increased (39.5% to 81.4% in general internal medicine, 42.7% to 66.1% in other clinics). Older age (adjusted odds ratio [aOR] 1.45, 95% CI 1.32-1.58 for ≥65 vs <65 years), having surgery (aOR 1.24, 95% CI 1.14-1.36), acute haemorrhage (aOR 1.16, 95% CI 1.02-1.33), chronic heart failure (aOR 1.17, 95% CI 1.04-1.32), ischaemic heart diseases (aOR 1.27, 95% CI 1.15-1.41), chronic pulmonary diseases (aOR 1.24, 95% CI 1.08-1.42), malignancy (aOR 1.11, 95% CI 1.01-1.21), and rheumatic disease (aOR 1.27, 95% CI 1.01-1.59) were risk factors for potentially inadequate transfusions. CONCLUSIONS More restrictive transfusion practices were adopted in general internal medicine and other clinics over time, suggesting that guideline recommendations and the Choosing Wisely initiative may have been increasingly followed. Interventions to reduce potentially inadequate transfusions should target providers who care for older patients and those with surgery or chronic cardiac and pulmonary diseases.
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Affiliation(s)
| | - Nicole Tochtermann
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Beck
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maria M Wertli
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Internal Medicine, Kantonsspital Baden, Baden, Switzerland
| | - Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Kelly S, Sharpe S, Culliton M, Higgins MF, Fitzgerald J. The effect of clinician education on blood transfusion practice in obstetrics: completing the audit cycle. Ir J Med Sci 2022; 192:765-771. [PMID: 35665474 DOI: 10.1007/s11845-022-03032-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 05/11/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND With blood products being a limited and expensive resource within the healthcare system, there is an ever-increasing emphasis on judicial and appropriate use. AIMS To evaluate whether implementing contemporary society recommendations on restrictive transfusion policies would reduce inappropriate use of red blood cell transfusions, by evaluating the effect of a staff educational campaign. METHODS An audit of peri-partum red cell concentrate (RCC) transfusion practice within a tertiary obstetric unit was undertaken, covering a 1-year period (2015), examining data related to transfusion prescribing practices. Subsequently, an educational programme was held for clinical and laboratory staff which aimed to bring practice in line with society guidelines. A repeat audit covering another 1-year period (2018) was undertaken. RESULTS The number of RCC units of transfused reduced by 49% between 2015 and 2018 (426 to 218). The number of patients receiving transfusion dropped from 166 in 2018 (1.8% of births) to 119 in 2015 (1.5% of births). Among stable patients who were transfused, the proportion receiving a single unit increased from 6.9 to 53.9%. (p < 0.001). Haematological reassessment between units rose from 13.8 to 80.4% (p < 0.001). Written consent documentation improved (68% in 2018 vs. 38% in 2015) (p < 0.001). CONCLUSIONS The implementation of guidelines has resulted in substantial reduction in RCC transfusions between 2015 and 2018. Fewer women received a blood transfusion, and those who did received fewer units. There is a higher proportion of patients being reassessed between units and receiving single unit transfusions. Recording of consent has improved.
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Affiliation(s)
- Shane Kelly
- University College Dublin School of Medicine, Dublin, Republic of Ireland
| | - Simon Sharpe
- University College Dublin School of Medicine, Dublin, Republic of Ireland
| | - Marie Culliton
- Medical Science, National Maternity Hospital, Dublin, Republic of Ireland
| | - Mary F Higgins
- UCD Peri-Natal Research Centre, University College Dublin Obstetrics and Gynecology, Dublin, Republic of Ireland
| | - Joan Fitzgerald
- Haematology, National Maternity Hospital and Saint Vincent's University Hospital, Holles Street, Dublin 2, Dublin, D02 YH21, Republic of Ireland.
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Delaforce A, Duff J, Munday J, Hardy J. Preoperative Anemia and Iron Deficiency Screening, Evaluation and Management: Barrier Identification and Implementation Strategy Mapping. J Multidiscip Healthc 2020; 13:1759-1770. [PMID: 33293819 PMCID: PMC7718960 DOI: 10.2147/jmdh.s282308] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/04/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction and aims Patients undergoing major surgery risk significant blood loss and transfusion, which increases substantially if they have pre-existing anemia. Preoperative Anemia and Iron Deficiency Screening, Evaluation and Management Pathways (PAIDSEM-P) outline recommended blood tests and treatment to optimize patients before surgery. Documented success using PAIDSEM-P to reduce transfusions and improve patient outcomes exists, but the reporting quality of such studies is suboptimal. It remains unclear what implementation strategies best support the implementation of PAIDSEM-P. Method Maximum variation, purposive sampling was used to recruit a total of 15 participants, including a range of health professionals and patients for semi-structured interviews. Data analysis utilized a deductive approach informed by the Consolidated Framework for Implementation Research (CFIR) for barrier identification and the Expert Recommendations for Implementing Change (ERIC) for reporting recommended implementation strategies. A modified version of the Action, Actor, Context, Target and Time (AACTT) framework assisted with conceptualisation and targeted strategy selection. Results The analysis revealed five barriers: access to knowledge and information, patient needs and resources, knowledge and beliefs about the intervention, available resources, and networks and communications, which had strong ERIC recommendations, including conduct educational meetings, develop educational materials, distribute educational materials, obtain and use patients/consumers family feedback, involve patients/consumers/family members, conduct a local needs assessment, access new funding, promote network weaving, and organize clinician implementation team meetings. Conclusions Mapping the barriers and strategies using the ERIC framework on the basis of individual actor categories proved to be useful in identifying a pragmatic number of implementation strategies that may help in supporting the utilisation of the PAIDSEM-P and other evidence-based healthcare implementation problems more broadly.
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Affiliation(s)
- Alana Delaforce
- School of Nursing and Midwifery, The University of Newcastle, Callaghan, NSW, Australia.,Mater Health Services, South Brisbane, QLD 4101, Australia
| | - Jed Duff
- School of Nursing and Midwifery, The University of Newcastle, Callaghan, NSW, Australia.,School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, QLD, Australia
| | - Judy Munday
- School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, QLD, Australia.,School of Nursing, The University of Agder, Kristiansand, Norway
| | - Janet Hardy
- Mater Health Services, South Brisbane, QLD 4101, Australia
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Delaforce A, Duff J, Munday J, Hardy J. Overcoming barriers to evidence-based patient blood management: a restricted review. Implement Sci 2020; 15:6. [PMID: 31952514 PMCID: PMC6969479 DOI: 10.1186/s13012-020-0965-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 01/06/2020] [Indexed: 01/31/2023] Open
Abstract
Background Blood transfusions are associated with a range of adverse patient outcomes, including coagulopathy, immunomodulation and haemolysis, which increase the risk of morbidity and mortality. Consideration of these risks and potential benefits are necessary when deciding to transfuse. Patient blood management (PBM) guidelines exist to assist in clinical decision-making, but they are underutilised. Exploration of barriers to the implementation and utilisation of the PBM guidelines is required. This study aimed to identify common barriers and implementation strategies used to implement PBM guidelines, with a comparison against current expert opinion. Methods A restricted review approach was used to identify the barriers to PBM guideline implementation as reported by health professionals and to review which implementation strategies have been used. Searches were undertaken in MEDLINE/PubMed, CINAHL, Embase, Scopus and the Cochrane library. The Consolidated Framework for Implementation Research (CFIR) was used to code barriers. The Expert Recommendations for Implementing Change (ERIC) tool was used to code implementation strategies, and subsequently, develop recommendations based on expert opinion. Results We identified 14 studies suitable for inclusion. There was a cluster of barriers commonly reported: access to knowledge and information (n = 7), knowledge and beliefs about the intervention ( = 7) and tension for change (n = 6). Implementation strategies used varied widely (n = 25). Only one study reported the use of an implementation theory, model or framework. Most studies (n = 11) had at least 50% agreement with the ERIC recommendations. Conclusions There are common barriers experienced by health professionals when trying to implement PBM guidelines. There is currently no conclusive evidence to suggest which implementation strategies are most effective. Further research using validated implementation approaches and improved reporting is required.
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Affiliation(s)
- Alana Delaforce
- The University of Newcastle, School of Nursing and Midwifery, University Drive, Callaghan, NSW, 2302, Australia. .,Mater Health Services, Level 6, Duncombe Building, Raymond Terrace, QLD, 4101, Australia.
| | - Jed Duff
- The University of Newcastle, School of Nursing and Midwifery, University Drive, Callaghan, NSW, 2302, Australia
| | - Judy Munday
- School of Nursing/Institute for Health and Biomedical Innovation, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD, 4059, Australia.,Faculty of Health and Sports Sciences, The University of Agder, Grimstad, Norway
| | - Janet Hardy
- Mater Health Services, Level 6, Duncombe Building, Raymond Terrace, QLD, 4101, Australia
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Derzon J, Alford A, Clarke N, Gross I, Shander A, Thurer R. Anemia Management and Audit Feedback Practices for Reducing Overuse of RBC Transfusion: A Laboratory Medicine Best Practice Systematic Review and Meta-Analysis. Am J Clin Pathol 2019; 151:18-28. [PMID: 30357323 DOI: 10.1093/ajcp/aqy123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objectives To evaluate the effectiveness of anemia management and audit with feedback practices in reducing overuse of RBC transfusion. Methods This review follows the Centers for Disease Control and Prevention's Laboratory Medicine Best Practice Systematic Review (A-6) method. We searched the literature and solicited unpublished studies on practices to reduce overuse of RBC transfusions as measured by reductions in units transfused and proportion of patients transfused. Results Thirteen studies on preoperative anemia management and three studies on audit feedback practices met inclusion criteria. Strength of evidence was high to moderate for reducing the number of units and proportion of patients transfused. Conclusions Preoperative anemia management reduces the proportion of patients transfused and units of RBCs transfused. Audit with feedback across cases, physicians, and/or service areas, as part of a continuous quality improvement practice, reduces the proportion of patients and units of RBCs transfused.
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Affiliation(s)
- James Derzon
- RTI International, Social, Statistical, and Environmental Sciences, Washington, DC
| | - Aaron Alford
- National Network of Public Health Institutes, Research and Evaluation, Washington, DC
| | | | | | - Aryeh Shander
- Englewood Hospital and Medical Center, Englewood, NJ
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Soril LJJ, Noseworthy TW, Dowsett LE, Memedovich K, Holitzki HM, Lorenzetti DL, Stelfox HT, Zygun DA, Clement FM. Behaviour modification interventions to optimise red blood cell transfusion practices: a systematic review and meta-analysis. BMJ Open 2018; 8:e019912. [PMID: 29776919 PMCID: PMC5961610 DOI: 10.1136/bmjopen-2017-019912] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To assess the impact of behaviour modification interventions to promote restrictive red blood cell (RBC) transfusion practices. DESIGN Systematic review and meta-analysis. SETTING, PARTICIPANTS, INTERVENTIONS Seven electronic databases were searched to January 2018. Published randomised controlled trials (RCTs) or non-randomised studies examining an intervention to modify healthcare providers' RBC transfusion practice in any healthcare setting were included. PRIMARY AND SECONDARY OUTCOMES The primary outcome was the proportion of patients transfused. Secondary outcomes included the proportion of inappropriate transfusions, RBC units transfused per patient, in-hospital mortality, length of stay (LOS), pretransfusion haemoglobin and healthcare costs. Meta-analysis was conducted using a random-effects model and meta-regression was performed in cases of heterogeneity. Publication bias was assessed by Begg's funnel plot. RESULTS Eighty-four low to moderate quality studies were included: 3 were RCTs and 81 were non-randomised studies. Thirty-one studies evaluated a single intervention, 44 examined a multimodal intervention. The comparator in all studies was standard of care or historical control. In 33 non-randomised studies, use of an intervention was associated with reduced odds of transfusion (OR 0.63 (95% CI 0.56 to 0.71)), odds of inappropriate transfusion (OR 0.46 (95% CI 0.36 to 0.59)), RBC units/patient weighted mean difference (WMD: -0.50 units (95% CI -0.85 to -0.16)), LOS (WMD: -1.14 days (95% CI -2.12 to -0.16)) and pretransfusion haemoglobin (-0.28 g/dL (95% CI -0.48 to -0.08)). There was no difference in odds of mortality (OR 0.90 (95% CI 0.80 to 1.02)). Protocol/algorithm and multimodal interventions were associated with the greatest decreases in the primary outcome. There was high heterogeneity among estimates and evidence for publication bias. CONCLUSIONS The literature examining the impact of interventions on RBC transfusions is extensive, although most studies are non-randomised. Despite this, pooled analysis of 33 studies revealed improvement in the primary outcome. Future work needs to shift from asking, 'does it work?' to 'what works best and at what cost?' PROSPERO REGISTRATION NUMBER CRD42015024757.
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Affiliation(s)
- Lesley J J Soril
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Thomas W Noseworthy
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Laura E Dowsett
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Katherine Memedovich
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Hannah M Holitzki
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Diane L Lorenzetti
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - David A Zygun
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, Alberta Health Services and Faculty of Medicine and Dentistry, University of Alberta, Calgary, Alberta, Canada
| | - Fiona M Clement
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
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Jenkins I, Doucet JJ, Clay B, Kopko P, Fipps D, Hemmen E, Paulson D. Transfusing Wisely: Clinical Decision Support Improves Blood Transfusion Practices. Jt Comm J Qual Patient Saf 2017; 43:389-395. [DOI: 10.1016/j.jcjq.2017.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Camaj A, Zahuranec DB, Paone G, Benedetti BR, Behr WD, Zimmerman MA, Zhang M, Kramer RS, Penn J, Theurer PF, Paugh TA, Engoren M, DeLucia A, Prager RL, Likosky DS. Organizational Contributors to the Variation in Red Blood Cell Transfusion Practices in Cardiac Surgery: Survey Results From the State of Michigan. Anesth Analg 2017; 125:975-980. [PMID: 28719425 DOI: 10.1213/ane.0000000000002277] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND While large volumes of red blood cell transfusions are given to preserve life for cardiac surgical patients, indications for lower volume transfusions (1-2 units) are less well understood. We evaluated the relationship between center-level organizational blood management practices and center-level variability in low volume transfusion rates. METHODS All 33 nonfederal, Michigan cardiac surgical programs were surveyed about their blood management practices for isolated, nonemergent coronary bypass procedures, including: (1) presence and structure of a patient blood management program, (2) policies and procedures, and (3) audit and feedback practices. Practices were compared across low (N = 14, rate: 0.8%-10.1%) and high (N = 18, rate: 11.0%-26.3%) transfusion rate centers. RESULTS Thirty-two (97.0%) of 33 institutions participated in this study. No statistical differences in organizational practices were identified between low- and high-rate groups, including: (1) the membership composition of patient blood management programs among those reporting having a blood management committee (P= .27-1.0), (2) the presence of available red blood cell units within the operating room (4 of 14 low-rate versus 2 of 18 high-rate centers report that they store no units per surgical case, P= .36), and (3) the frequency of internal benchmarking reporting about blood management audit and feedback practices (low rate: 8 of 14 versus high rate: 9 of 18; P= .43). CONCLUSIONS We did not identify meaningful differences in organizational practices between low- and high-rate intraoperative transfusion centers. While a larger sample size may have been able to identify differences in organizational practices, efforts to reduce variation in 1- to 2-unit, intraoperative transfusions may benefit from evaluating other determinants, including organizational culture and provider transfusion practices.
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Affiliation(s)
- Anton Camaj
- From the *Michigan Medicine, Ann Arbor, Michigan; †Department of Neurology, University of Michigan, Ann Arbor, Michigan; ‡Division of Cardiac Surgery, Henry Ford Hospital, Detroit, Michigan; §Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan; ‖Blood Management and Conservation, Bronson Methodist Hospital, Kalamazoo, Michigan; ¶Department of Health Behavior and Health Education, School of Public Health and #Department of Biostatistics, University of Michigan, Ann Arbor, Michigan; **Division of Cardiothoracic Surgery, Maine Medical Center, Portland, Maine; ††Department of Perfusion, Bronson Methodist Hospital, Kalamazoo, Michigan; ‡‡Department of Cardiac Surgery and §§Department of Anesthesiology, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan; and ‖‖Department of Cardiothoracic Surgery, Bronson Methodist Hospital, Bronson, Michigan
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Alizadeh-Ghavidel A, Totonchi Z, Hoseini A, Ziyaeifard M, Azarfarin R. Blood transfusion practice in a referral cardiovascular center in tehran, iran: a critical point of view. Res Cardiovasc Med 2014; 3:e21772. [PMID: 25780781 PMCID: PMC4347724 DOI: 10.5812/cardiovascmed.21772] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 08/25/2014] [Accepted: 09/04/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Unnecessary perioperative transfusions are likely to be related to increased morbidity and additional costs in cardiac surgery. OBJECTIVES The aim of this study was to evaluate the blood transfusion practice during and after adult cardiac surgery in a referral university hospital in Iran. PATIENTS AND METHODS In a descriptive study, we collected data from 153 adult patients underwent cardiac surgery at Rajaie Cardiovascular Medical and Research Center, Tehran, Iran from January to March 2013. The variables were patients' demographic, operative and post-operative data and the numbers of transfused packed red blood cell (PC) units and fresh frozen plasma (FFP) during and after cardiac surgery. Then we evaluated patients' and physicians' related causes of relatively increased transfusion rate in our patients and compared them with literature. RESULTS Of 153 patients, 96.8% received PC and 54.9% transfused FFP during or after surgery. Most of the transfusions were done after operation in intensive care unit (ICU). Also, 20% and 17% of the patients underwent transfusion of more than 6 units of PC and FFP, respectively. The mean left ventricular ejection fraction of the patients was 42.5 ± 10.9%. A significant number of patients had anemia (especially women) or received anticoagulants or antiplatelet agents preoperatively. Thirteen percent of the patients underwent emergency operations and 12.3% had re-exploration. CONCLUSIONS The results of this study demonstrate that the cardiac surgery patients receive a relatively greater number of PC or FFP units during and after the operation in our center. This finding may be explained to some extent by the fact that the sicker and more co-morbid patients referred to our center and such patients are more anemic and undergoing more emergent and complex procedures. Moreover, Transfusion strategy or protocol should be updated, especially after the operation in ICU.
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Affiliation(s)
- Alireza Alizadeh-Ghavidel
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Ziae Totonchi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Abedin Hoseini
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Mohsen Ziyaeifard
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Rasoul Azarfarin
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Rasoul Azarfarin, Rajaie Cardiovascular Medical and Research Center, Vali-Asr St., Niayesh Blvd, Tehran, IR Iran. Tel: +98-2123922017, Fax: +98-2122663293, E-mail:
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Yerrabothala S, Desrosiers KP, Szczepiorkowski ZM, Dunbar NM. Significant reduction in red blood cell transfusions in a general hospital after successful implementation of a restrictive transfusion policy supported by prospective computerized order auditing. Transfusion 2014; 54:2640-5. [PMID: 24673396 DOI: 10.1111/trf.12627] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 01/08/2014] [Accepted: 01/24/2014] [Indexed: 01/09/2023]
Abstract
BACKGROUND Our hospital transfusion policy was recently revised to recommend single-unit red blood cell transfusion (RBC TXN) for nonbleeding inpatients when the hemoglobin (Hb) level is not more than 7 g/dL. Our computerized provider order entry system was reconfigured to provide real-time decision support using prospective computerized order auditing based on the most recent Hb level and to remove the single-click ordering option for 2-unit RBC TXNs to enhance compliance. This study was undertaken to assess the impact of these changes on hospital transfusion practice. STUDY DESIGN AND METHODS This study analyzed the total number of transfusion events, proportion of single and 2-unit transfusions and the Hb transfusion trigger in the preimplementation period (October 2011-March 2012) compared to the postimplementation period (October 2012-March 2013). RESULTS In the postimplementation period the total number of RBC units transfused/1000 patient-days decreased from 60.8 to 44.2 (p < 0.0001). The proportion of 2-unit TXNs decreased from 47% to 15% (p < 0.0001). We also observed significant decreases in pretransfusion Hb triggers. CONCLUSION Implementation of restrictive transfusion policy supported by prospective computerized order auditing has resulted in significantly decreased RBC utilization at our institution.
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Affiliation(s)
- Swaroopa Yerrabothala
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Oliver JC, Griffin RL, Hannon T, Marques MB. The success of our patient blood management program depended on an institution-wide change in transfusion practices. Transfusion 2014; 54:2617-24. [DOI: 10.1111/trf.12536] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 11/08/2013] [Accepted: 11/09/2013] [Indexed: 12/16/2022]
Affiliation(s)
- James C. Oliver
- Department of Medicine; University of Alabama at Birmingham; Birmingham Alabama
| | - Russell L. Griffin
- Department of Epidemiology; University of Alabama at Birmingham; Birmingham Alabama
| | | | - Marisa B. Marques
- Department of Pathology; University of Alabama at Birmingham; Birmingham Alabama
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Sherman CH, Macivor DC. Blood utilization: fostering an effective hospital transfusion culture. J Clin Anesth 2012; 24:155-63. [PMID: 22414711 DOI: 10.1016/j.jclinane.2011.06.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 06/07/2011] [Accepted: 06/09/2011] [Indexed: 11/17/2022]
Abstract
An effective hospital transfusion culture should encourage clinicians to consider the possibility of transfusion in their patients well before the need actually arises, and to plan ahead in an attempt to use blood products most efficiently. Strategies for improved blood utilization include timely and adequate preoperative assessment of risk, optimization of baseline hemoglobin, anticipation of potential transfusion problems, intraoperative techniques to minimize blood loss, blood conservation technologies, transfusion guidelines and targeted therapy, point of care testing, and massive transfusion protocols. Attention to these elements promotes a safe and cost-effective transfusion culture.
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Affiliation(s)
- Carolyn Hyatt Sherman
- Department of Anesthesiology, Chandler Medical Center, University of Kentucky, Lexington, KY 40536, USA.
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A retrospective one-year single-centre survey of obstetric red cell transfusions. Int J Obstet Anesth 2009; 18:309-13. [DOI: 10.1016/j.ijoa.2009.05.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Revised: 03/09/2009] [Accepted: 05/22/2009] [Indexed: 11/19/2022]
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Py JY, Labbe C, Jutant T, Mouchet C, Roubinet F. Évolution de la distribution des produits sanguins labiles en France – analyse détaillée au sein d’un Établissement français du sang interrégional. Transfus Clin Biol 2008; 15:259-65. [DOI: 10.1016/j.tracli.2008.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Accepted: 09/04/2008] [Indexed: 11/17/2022]
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Ohsaka A, Abe K, Ohsawa T, Miyake N, Sugita S, Tojima I. A computer-assisted transfusion management system and changed transfusion practices contribute to appropriate management of blood components. Transfusion 2008; 48:1730-8. [PMID: 18482189 DOI: 10.1111/j.1537-2995.2008.01744.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND ABO-incompatible blood transfusions attributable to inadequate identification (ID) of the patient or the blood unit are among the most serious of transfusion hazards. It has been unclear whether a computer-assisted transfusion management system connected to a bar code ID system could contribute to the appropriate management of blood components, as well as to the prevention of mistransfusions. STUDY DESIGN AND METHODS A transfusion management system has been developed that links the hospital information system, a bar code patient-blood unit ID system, and an automated device for pretransfusion testing. The guidelines for issuing blood components from the transfusion service were also changed. The appropriateness of blood management was evaluated by monitoring the time to initiate transfusion after issuing a blood unit from the transfusion service (time after issuing [TAI]) and by calculating the number of units issued and subsequently returned, as well as the rate of date-expired red cell (RBC) components. RESULTS From July 2002 to December 2006, a total of 49,974 blood components were transfused without a single mistransfusion. The monitoring of TAI and the notice to use the issued blood immediately had the effect of shortening TAI in the inpatient ward. The number of issued and subsequently returned RBC components, as well as the rate of date-expired RBC components, decreased significantly after the introduction of the system. CONCLUSION A computer-assisted transfusion management system and changing transfusion practices appear useful in preventing mistransfusions and in contributing to the appropriate management of blood components.
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Affiliation(s)
- Akimichi Ohsaka
- Department of Transfusion Medicine and Stem Cell Regulation, Juntendo University School of Medicine, Tokyo, Japan.
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Friedman MT, Ebrahim A. Adequacy of physician documentation of red blood cell transfusion and correlation with assessment of transfusion appropriateness. Arch Pathol Lab Med 2006; 130:474-9. [PMID: 16594741 DOI: 10.5858/2006-130-474-aopdor] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT A major function of the hospital transfusion service is to assess the appropriateness of blood transfusion. Inadequate documentation of transfusions may hamper this assessment process. OBJECTIVE To correlate the level of physician documentation of transfusion with the ability to justify transfusion. DESIGN Retrospective review of red blood cell transfusions in adult patients in 2 hospital facilities during 1-week audit periods of each month from April 2001 to March 2003. Assessment forms were used to classify the level of physician documentation of transfusions into 3 groups: adequately, intermediately, and inadequately documented. Transfusions were deemed justified or not via comparison with hospital transfusion guidelines. RESULTS There were 5062 audited red blood cells transfused to 2044 adult (> or = 18 years) patients. Medical records from 154 patients transfused with 257 units of red blood cells during 172 transfusion events were reviewed after initial screenings of hemoglobin/hematocrit values failed to justify the transfusions. Nine percent of adequately documented, 50% of intermediately documented, and 73% of inadequately documented transfusion events could not be justified. Transfusion events with suboptimal (intermediate and inadequate) documentation accounted for 49% of all medical record-reviewed transfusion events and 62% could not be justified. The correlation between inadequate documentation and failure to justify transfusion was significant (P < .001), as was the correlation between suboptimal documentation and failure to justify transfusion (P = .03). CONCLUSIONS There is a significant correlation between suboptimal documentation and failure to justify transfusions. Educating clinicians to improve documentation along with appropriate indications for transfusions may enhance efficiency of blood utilization assessment and lead to reduced rates of unjustifiable transfusions.
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Affiliation(s)
- Mark T Friedman
- Department of Pathology and Laboratory Medicine, St Luke's-Roosevelt Hospital Center, New York, NY 10019, USA.
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Affiliation(s)
- Hyun Ok Kim
- Department of Laboratory Medicine, Yonsei University College of Medicine, Severance Hospital, Korea.
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