Implementing a program to improve compliance with neonatal intensive care unit transfusion guidelines was accompanied by a reduction in transfusion rate: a pre-post analysis within a multihospital health care system

Implementation of a Standardized Red Blood Cell Transfusion Policy in a Level IV Neonatal Intensive Care Unit: A Quality Improvement Project

BACKGROUND

Within the neonatal intensive care unit (NICU), infants frequently receive packed red blood cell (PRBC) transfusions. Although medically necessary, potential negative long- and short-term outcomes exist following PRBC transfusions in very low birth-weight (VLBW) infants (<1500 g). Synthesis of the literature demonstrates that the use of a restrictive PRBC transfusion policy can lead to a decreased number of transfusions administered with no increase in long-term neurodevelopmental outcomes. Blood transfusions have also been linked to the diagnosis of necrotizing enterocolitis (NEC) or intraventricular hemorrhage (IVH) in VLBW infants.

PURPOSE

For this quality improvement project, a restrictive PRBC transfusion policy was implemented in a level IV NICU to promote consistent care and evaluate changes in PRBC administration.

METHODS

The data were collected both pre- and post-policy implementation including: the number of blood transfusions, diagnosis of NEC, and diagnosis of IVH among infants <1500 g.

RESULTS

The data showed no significant change in the number of PRBC transfusions administered. Likewise, few infants were diagnosed with NEC or IVH during this same time period with minimal change between pre- and post-policy implementation data.

IMPLICATIONS FOR PRACTICE AND RESEARCH

Following policy implementation, there was a significant improvement in communication among providers regarding transfusion ordering and the inclusion of hematocrit thresholds in daily progress notes. This unintended outcome has helped to promote sustainability and enhance patient care within the NICU where this policy was implemented. Continued data collection may be beneficial in indicating whether a standardized PRBC transfusion policy will impact the administration of transfusions and diagnosis of NEC or IVH.

Impact of Delayed Cord Clamping on Red Blood Cell Transfusion and Related Outcomes in Very Low Birth Weight Infants

OBJECTIVE

Delayed cord clamping (DCC) for 30 to 60 seconds after birth facilitates placental transfusion, increases blood volume, and decreases red blood cell (RBC) transfusion in preterm infants. Study objective was to determine (1) RBC transfusion burden over a 5-year period, (2) impact of DCC practice on RBC transfusions, and (3) association of RBC transfusion on outcomes in very low birthweight (VLBW) preterm infants.

STUDY DESIGN

A retrospective medical chart review was performed in 787 VLBW infants between 2016 and 2020. Demographic factors, DCC status, number of RBC transfusions, and neonatal outcomes were determined in eligible infants. Adjusted association between DCC, RBC transfusion, and outcomes were determined using logistic and linear regression methods.

RESULTS

Of the 538 eligible VLBW infants, 62% (N = 332) received RBC transfusions. Proportion receiving RBC transfusion were significantly higher for infants <1,000 g (N = 217, 65.4%) and gestational age (GA) <29 weeks (N = 256, 77.1%) than larger (1,001-1,250 g, N = 77, 23.2% and 1,251-1,500 g, N = 38, 11.4%) and older GA ≥ 29 weeks' infants (N = 76, 22.9%, p < 0.05). Of the 81/538 (15.1%) who received DCC, 48 (59.2%) received no RBC transfusion (p < 0.001). In multivariable logistic regression analysis, preterm infants with DCC were 55% less likely to receive RBC transfusions as compared with infants with no DCC. At any given GA, the number of RBC transfusions in preterm infants with DCC was 25% lower as compared with infants without DCC (p < 0.05). Transfusion was associated with 8-fold increased odds for bronchopulmonary dysplasia and 4-fold increased odds for medical and surgically treated patent ductus arteriosus compared with no transfusion. There was no significant association of transfusion with neonatal sepsis, laser treated retinopathy of prematurity, necrotizing enterocolitis, and intraventricular hemorrhage.

CONCLUSION

DCC was significantly associated with reduced RBC transfusion, but fewer preterm infants received DCC. Further research is needed to explore the feasibility of providing neonatal resuscitation during DCC in preterm infants.

KEY POINTS

· Delayed cord clamping significantly reduced the need for RBC transfusions.. · Fewer very preterm infants received DCC.. · Future research is needed to explore feasibility of neonatal resuscitation during DCC..

Patient Blood Management in Neonates

Patient blood management (PBM) is an evidence-based care package to improve patient outcomes by optimizing a patient's blood, minimizing blood loss, and the effective management and, when appropriate, the tolerance of anemia. It is relatively well-developed in adult medicine and remains in its infancy in neonatology. This review explores why evidence-based guidelines are insufficient, discusses the variations in neonatal transfusion practice and why this matters, and provides the key updates in neonatal transfusion practice. The authors give examples of a successful neonatal PBM program and single-center projects.

Paediatric clinical decision support: Evaluation of a best practice alert for red blood cell transfusion

BACKGROUND AND OBJECTIVES

Providing red blood cell (RBC) transfusion to paediatric patients with a haemoglobin (Hb) level of <7 g/dL is the current best practice, but it is often difficult to ensure appropriateness of RBC transfusion on a health system level. Electronic health record (EHR) clinical decision support systems have been shown to be effective in encouraging providers to transfuse at appropriate Hb thresholds. We present our experience with an interruptive best practice alert (BPA) at a paediatric healthcare system.

MATERIALS AND METHODS

An interruptive BPA requiring physician response was implemented in our EHR (Epic Systems Corp., Verona, WI, USA) in 2018 based on Hb thresholds for inpatients. The threshold was initially <8 g/dL and later changed to <7 g/dL in 2019. We assessed total activations, number of RBC transfusions and hospital metrics through 2022 compared to the 2 years prior to implementation.

RESULTS

The BPA activated 6956 times over 4 years, slightly less than 5/day, and the success rate, with no RBC transfusions within 24 h of order attempt, was 14.5% (1012/6956). There was a downward trend in the number of total RBC transfusions and RBC transfusions per admission after implementation, non-significant (p = 0.41 and p = >0.99). The annual case mix index was similar over the years evaluated. The estimated cost savings based on acquisition costs for RBC units were 213,822 USD or about $51,891 per year.

CONCLUSION

BPA implementation led to sustained change in RBC transfusion towards best practice, and there were long-term savings in RBC expenditure.

Red Blood Cell Transfusion Thresholds for Anemia of Prematurity

Anemia of prematurity affects the majority of preterm infants, particularly extremely low birthweight infants. Anemia of prematurity arises from both innate and iatrogenic causes and results in more than 80% of extremely preterm infants receiving red blood cell transfusions during the first month after birth. Multiple randomized controlled trials were conducted to evaluate the effect of using lower versus higher transfusion thresholds based on hemoglobin levels. These trials showed no difference in the primary outcome of neurodevelopmental impairment at 2 years of age between lower and higher thresholds. However, some uncertainties about transfusion thresholds remain. This review elaborates the following: 1) the etiology, prevention, and treatment of anemia of prematurity with a focus on red blood cell transfusions, 2) the history of randomized controlled trials on the treatment of anemia of prematurity, and 3) limitations of the evidence and remaining questions about thresholds for red blood cell transfusions in preterm infants.

Is Low-value Testing Before Low-risk Hand Surgery Associated With Increased Downstream Healthcare Use and Reimbursements? A National Claims Database Analysis

BACKGROUND

Minor hand procedures can often be completed in the office without any laboratory testing. Preoperative screening tests before minor hand procedures are unnecessary and considered low value because they can lead to preventable invasive confirmatory tests and/or procedures. Prior studies have shown that low-value testing before low-risk hand surgery is still common, yet little is known about their downstream effects and associated costs. Assessing these downstream events can elucidate the consequences of obtaining a low-value test and inform context-specific interventions to reduce their use.

QUESTIONS/PURPOSES

(1) Among healthy adults undergoing low-risk hand surgery, are patients who receive a preoperative low-value test more likely to have subsequent diagnostic tests and procedures than those who do not receive a low-value test? (2) What is the increased 90-day reimbursement associated with subsequent diagnostic tests and procedures in patients who received a low-value test compared with those who did not?

METHODS

In this retrospective, comparative study using a large national database, we queried a large health insurance provider's administrative claims data to identify adult patients undergoing low-risk hand surgery (carpal tunnel release, trigger finger release, Dupuytren fasciectomy, de Quervain release, thumb carpometacarpal arthroplasty, wrist ganglion cyst, or mass excision) between 2011 and 2017. This database was selected for its ability to track patient claims longitudinally with direct provision of reimbursement data in a large, geographically diverse patient population. Patients who received at least one preoperative low-value test, including complete blood count, basic metabolic panel, electrocardiogram, chest radiography, pulmonary function test, and urinalysis within the 30-day preoperative period, were matched with propensity scores to those who did not. Among the 73,112 patients who met our inclusion criteria (mean age 57 ± 14 years; 68% [49,847] were women), 27% (19,453) received at least one preoperative low-value test and were propensity score-matched to those who did not. Multivariable regression analyses were performed to assess the frequency and reimbursements of subsequent diagnostic tests and procedures in the 90 days after surgery while controlling for potentially confounding variables such as age, sex, comorbidities, and baseline healthcare use.

RESULTS

When controlling for covariates such as age, sex, comorbidities, and baseline healthcare use, patients in the low-value test cohort had an adjusted odds ratio of 1.57 (95% confidence interval [CI] 1.50 to 1.64; p < 0.001) for a postoperative use event (a downstream diagnostic test or procedure) compared with those who did not have a low-value test. The median (IQR) per-patient reimbursements associated with downstream utilization events in patients who received a low-value test was USD 231.97 (64.37 to 1138.84), and those who did not receive a low-value test had a median of USD 191.52 (57.1 to 899.42) (adjusted difference when controlling for covariates: USD 217.27 per patient [95% CI 59.51 to 375.03]; p = 0.007). After adjusting for inflation, total additional reimbursements for patients in the low-value test cohort increased annually.

CONCLUSION

Low-value tests generate downstream tests and procedures that are known to provide minimal benefit to healthy patients and may expose patients to potential harms associated with subsequent, unnecessary invasive tests and procedures in response to false positives. Nevertheless, low-value testing remains common and the rising trend in low-value test-associated spending demonstrates the need for multicomponent interventions that target change at both the payer and health system level. Such interventions should disincentivize the initial low-value test and the cascade that may follow. Future work to identify the barriers and facilitators to reduce low-value testing in hand surgery can inform the development and revision of deimplementation strategies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Severe Anemia at Birth-Incidence and Implications

OBJECTIVE

To identify neonates with severe anemia at birth, defined by a hemoglobin or hematocrit value within the first 6 hours after birth that plotted below the 1st percentile according to gestational age. For each patient, we retrospectively determined whether caregivers recognized the anemia within the first 24 hours after birth and the probable cause and outcome of anemia.

STUDY DESIGN

This was a retrospective cohort analysis of Intermountain Healthcare population-based data from neonates born between January 2011 and December 2020 who had a hemoglobin or hematocrit value measured within the first 6 hours after birth below the 1st percentile lower reference interval (hematocrit ∼35% in near-term/term neonates).

RESULT

Among 299 927 live births, we identified 344 neonates with severe anemia at birth. In 191 of these neonates (55.5%), the anemia was recognized by caregivers during the first 24 hours. Anemia was more likely to be recorded as a problem (85%) if the hemoglobin was ≥2 g/dL below the 1st percentile (P < .001). The lowest hemoglobin values occurred in those in whom hemorrhage was the probable cause (P < .013 vs hemolysis and P < .001 vs hypoproduction, mixed cause, or indeterminant.) Treatment was provided to 39.5%. A retrospective review suggested that mixed mechanisms, particularly hemorrhagic plus hemolytic, occurred more commonly than was recognized at the time of occurrence.

CONCLUSIONS

Severe anemia at birth often went unrecognized on the first day of life. Algorithm-directed retrospective reviews commonly identified causes that were not listed in the medical record. We postulate that earlier recognition and more accurate diagnoses would be facilitated by an electronic medical record-associated hemoglobin/hematocrit gestational age nomogram.

Recommendations for transfusion of blood products in neonatology

The scant evidence on the use of transfusions in neonatal care explains the limitations of current clinical guidelines. Despite this, in this document we explore the most recent evidence to make recommendations for the clinical practice. The prevention of anaemia of prematurity, the use of protocols and restrictive transfusion strategies constitute the best approach for clinicians in this field. In the case of platelet transfusions, the risk of bleeding must be assessed, combining clinical and laboratory features. Lastly, fresh frozen plasma is recommended in neonates with coagulopathy and active bleeding, with congenital factor deficiencies for which there is no specific treatment or with disseminated intravascular coagulation. All blood products have adverse effects that warrant a personalised and thorough assessment of the need for transfusion.

Red cell transfusion thresholds for preterm infants: finally some answers

Extremely low birthweight infants become anaemic during their care in the neonatal intensive care unit because of the physiological anaemia experienced by all newborn infants compounded by early umbilical cord clamping, blood loss by phlebotomy for laboratory monitoring and delayed erythropoiesis. The majority of these infants receive transfusions of packed red blood cells, usually based on haemoglobin values below a certain threshold. The haemoglobin or haematocrit thresholds used to guide transfusion practices vary with infant status and among institutions and practitioners. Previous smaller studies have not given clear guidance with respect to the haemoglobin thresholds that should trigger transfusions or even if this is the best way to decide when to transfuse an infant. Two large clinical trials of similar design comparing higher and lower haemoglobin thresholds for transfusing extremely low birthweight infants were recently published, the ETTNO and TOP trials. These trials found reassuringly conclusive and concordant results. Within the range of haemoglobin transfusion thresholds studied, there was no difference in the primary outcome (which was the same in both studies), neurodevelopmental impairment at 2 years' corrected age or death before assessment, in either study. In addition, there was no difference in either study in either of the components of the primary outcome. In conclusion, haemoglobin transfusion thresholds within the ranges used in these trials, 11-13 g/dL for young critically ill or ventilated infants and 7-10 g/dL for stable infants not requiring significant respiratory support, can be safely used without expecting adverse consequences on survival or neurodevelopment.

Knowledge translation strategies for policy and action focused on sexual, reproductive, maternal, newborn, child and adolescent health and well-being: a rapid scoping review

OBJECTIVE

The aim of this study was to identify knowledge translation (KT) strategies aimed at improving sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) and well-being.

DESIGN

Rapid scoping review.

SEARCH STRATEGY

A comprehensive and peer-reviewed search strategy was developed and applied to four electronic databases: MEDLINE ALL, Embase, CINAHL and Web of Science. Additional searches of grey literature were conducted to identify KT strategies aimed at supporting SRMNCAH. KT strategies and policies published in English from January 2000 to May 2020 onwards were eligible for inclusion.

RESULTS

Only 4% of included 90 studies were conducted in low-income countries with the majority (52%) conducted in high-income countries. Studies primarily focused on maternal newborn or child health and well-being. Education (81%), including staff workshops and education modules, was the most commonly identified intervention component from the KT interventions. Low-income and middle-income countries were more likely to include civil society organisations, government and policymakers as stakeholders compared with high-income countries. Reported barriers to KT strategies included limited resources and time constraints, while enablers included stakeholder involvement throughout the KT process.

CONCLUSION

We identified a number of gaps among KT strategies for SRMNCAH policy and action, including limited focus on adolescent, sexual and reproductive health and rights and SRMNCAH financing strategies. There is a need to support stakeholder engagement in KT interventions across the continuum of SRMNCAH services. Researchers and policymakers should consider enhancing efforts to work with multisectoral stakeholders to implement future KT strategies and policies to address SRMNCAH priorities.

REGISTRATION

The rapid scoping review protocol was registered on Open Science Framework on 16 June 2020 (https://osf.io/xpf2k).

Thresholds for blood transfusion in extremely preterm infants: A review of the latest evidence from two large clinical trials

There are two recently completed large randomized clinical trials of blood transfusions in the preterm infants most at risk of requiring them. Liberal and restrictive strategies were compared with composite primary outcome measures of death and neurodevelopmental impairment. Infants managed under restrictive guidelines fared no worse in regard to mortality and neurodevelopment in early life. The studies had remarkably similar demographics and used similar transfusion guidelines. In both, there were fewer transfusions in the restrictive arm. Nevertheless, there were large differences between the studies in regard to transfusion exposure with almost 3 times the number of transfusions per participant in the transfusion of prematures (TOP) study. Associated with this, there were differences between the studies in various outcomes. For example, the combined primary outcome of death or neurodevelopmental impairment was more likely to occur in the TOP study and the mortality rate itself was considerably higher. Whilst the reasons for these differences are likely multifactorial, it does raise the question as to whether they could be related to the transfusions themselves? Clearly, every effort should be made to reduce exposure to transfusions and this was more successful in the Effects of Transfusion Thresholds on Neurocognitive Outcomes (ETTNO) study. In this review, we look at factors which may explain these transfusion differences and the differences in outcomes, in particular neurodevelopment at age 2 years. In choosing which guidelines to follow, centers using liberal guidelines should be encouraged to adopt more restrictive ones. However, should centers with more restrictive guidelines change to ones similar to those in the studies? The evidence for this is less compelling, particularly given the wide range of transfusion exposure between studies. Individual centers already using restrictive guidelines should assess the validity of the findings in light of their own transfusion experience. In addition, it should be remembered that the study guidelines were pragmatic and acceptable to a large number of centers. The major focus in these guidelines was on hemoglobin levels which do not necessarily reflect tissue oxygenation. Other factors such as the level of erythropoiesis should also be taken into account before deciding whether to transfuse.

Plasma and Platelet Transfusion Strategies in Critically Ill Children Following Severe Trauma, Traumatic Brain Injury, and/or Intracranial Hemorrhage: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding

OBJECTIVES

To present consensus statements and supporting literature for plasma and platelet transfusions in critically ill children with severe trauma, traumatic brain injury, and/or intracranial hemorrhage from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding.

DESIGN

Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children.

SETTING

Not applicable.

PATIENTS

Critically ill neonates and children with severe trauma, traumatic brain injury, and/or intracranial hemorrhage.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A panel of eight experts developed expert-based statements for plasma and platelet transfusions in critically ill neonates and children with severe trauma, traumatic brain injury, and/or intracranial hemorrhage. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed one good practice statement and six expert consensus statements.

CONCLUSIONS

The lack of evidence precludes proposing recommendations on monitoring of the coagulation system and on plasma and platelets transfusion in critically ill pediatric patients with severe trauma, severe traumatic brain injury, or nontraumatic intracranial hemorrhage.

Variation in Neonatal Transfusion Practice

OBJECTIVE

To estimate the incidence of blood product transfusion, including red blood cells, platelets, and plasma, and characterize pretransfusion hematologic values for infants during their initial hospitalization after birth.

STUDY DESIGN

Retrospective cohort study using data from 7 geographically diverse US academic and community hospitals that participated in the National Heart Lung and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) from 2013 to 2016. Pretransfusion hematologic values were evaluated closest to each transfusion and no more than 24 hours beforehand.

RESULTS

Data from 60 243 infants were evaluated. The incidence of any transfusion differed by gestational age (P < .0001), with 80% (95% CI 76%-84%) transfused at <27 weeks of gestation (n = 329) and 0.5% (95% CI 0.5%-0.6%) transfused at ≥37 weeks of gestation (n = 53 919). The median pretransfusion hemoglobin was 11.2 g/dL (10th-90th percentile 8.8-14.1) for the entire cohort, ranging from 10.5 g/dL (8.8-12.3) for infants born extremely preterm at <27 weeks of gestation to 13.0 g/dL (10.5-15.5) for infants born at term. The median pretransfusion platelet count (×10⁹/L) was 71 (10th-90th percentile 26-135) for the entire cohort, and was >45 for all gestational age groups examined. The median pretransfusion international normalized ratio for the entire cohort was 1.7 (10th-90th percentile 1.2-2.8).

CONCLUSIONS

There is wide variability in pretransfusion hemoglobin, platelet count, and international normalized ratio values for neonatal transfusions. Our findings suggest that a large proportion of neonatal transfusions in the US are administered at thresholds greater than supported by the best-available evidence and highlight an opportunity for improved patient blood management.

Role of platelets in neonatal necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is an inflammatory bowel necrosis of premature infants and is a leading cause of morbidity and mortality in infants born between 23 and 28 weeks of gestation. Fifty to 95% of all infants with NEC develop thrombocytopenia (platelet counts <150 × 109/L) within 24-72 h of receiving this diagnosis. In many patients, thrombocytopenia is severe and is treated with one or more platelet transfusions. However, the underlying mechanism(s) and biological implications of NEC-related thrombocytopenia remain unclear. This review presents current evidence from human and animal studies on the clinical features and mechanisms of platelet depletion in NEC. Anecdotal clinical experience is combined with evidence from laboratory studies and from an extensive literature search in databases PubMed, EMBASE, and Scopus and the electronic archives of abstracts presented at the annual meetings of the Pediatric Academic Societies. To avoid bias in identification of existing studies, key words were short-listed prior to the actual search both from anecdotal experience and from PubMed's Medical Subject Heading (MeSH) thesaurus. IMPACT: Fifty to 95% of infants with necrotizing enterocolitis (NEC) develop idiopathic thrombocytopenia (platelet counts <150 × 109/L) within 24-72 h of disease onset. Early clinical trials suggest that moderate thrombocytopenia may be protective in human NEC, although further work is needed to fully understand this relationship. We have developed a neonatal murine model of NEC-related thrombocytopenia, where enteral administration of an immunological stimulant, trinitrobenzene sulfonate, on postnatal day 10 induces an acute necrotizing ileocolitis resembling human NEC. In this murine model, thrombocytopenia is seen at 15-18 h due to platelet consumption and mild-moderate thrombocytopenia is protective.

Closing the evidence to practice gap in neonatal transfusion medicine

Significant resources are directed towards world-class research projects, but the findings are not necessarily translated into better healthcare outcomes, either at all or in a sustained way. There is a clear need to dedicate further resources to understanding how to promote the uptake of evidence and effectively change neonatal transfusion practice to improve outcomes. Approaching blood transfusion behaviour change more systematically, and working across disciplines and involving families, holds the potential to increase the rate of uptake of emerging evidence in clinical practice. This approach holds the potential to save costs, conserve resources, and improve clinical outcomes. Our paper focuses on the use of quality improvement to bridge the gap between evidence-based knowledge and transfusion practice in neonatal units around the world.

Transfusions and neurodevelopmental outcomes in extremely low gestation neonates enrolled in the PENUT Trial: a randomized clinical trial

BACKGROUND

Outcomes of extremely low gestational age neonates (ELGANs) may be adversely impacted by packed red blood cell (pRBC) transfusions. We investigated the impact of transfusions on neurodevelopmental outcome in the Preterm Erythropoietin (Epo) Neuroprotection (PENUT) Trial population.

METHODS

This is a post hoc analysis of 936 infants 24-0/6 to 27-6/7 weeks' gestation enrolled in the PENUT Trial. Epo 1000 U/kg or placebo was given every 48 h × 6 doses, followed by 400 U/kg or sham injections 3 times a week through 32 weeks postmenstrual age. Six hundred and twenty-eight (315 placebo, 313 Epo) survived and were assessed at 2 years of age. We evaluated associations between BSID-III scores and the number and volume of pRBC transfusions.

RESULTS

Each transfusion was associated with a decrease in mean cognitive score of 0.96 (95% CI of [-1.34, -0.57]), a decrease in mean motor score of 1.51 (-1.91, -1.12), and a decrease in mean language score of 1.10 (-1.54, -0.66). Significant negative associations between BSID-III score and transfusion volume and donor exposure were observed in the placebo group but not in the Epo group.

CONCLUSIONS

Transfusions in ELGANs were associated with worse outcomes. We speculate that strategies to minimize the need for transfusions may improve outcomes.

IMPACT

Transfusion number, volume, and donor exposure in the neonatal period are associated with worse neurodevelopmental (ND) outcome at 2 years of age, as assessed by the Bayley Infant Scales of Development, Third Edition (BSID-III). The impact of neonatal packed red blood cell transfusions on the neurodevelopmental outcome of preterm infants is unknown. We speculate that strategies to minimize the need for transfusions may improve neurodevelopmental outcomes.

Reducing two-unit red cell transfusions on the oncology ward: a choosing wisely initiative

Background/context

Despite Choosing Wisely recommendations for single unit red blood cell transfusion orders, ~50% of orders on the oncology ward at London Health Sciences Centre (LHSC) were for two units. The oncology ward at LHSC is a 60 bed tertiary care unit. In mid 2016, LHSC was 18 months into its implementation of computerised provider order entry (CPOE).

Aim/objectives

By December 2017, increase the proportion of one-unit red cell transfusion orders on the oncology ward from 50% to 80%

Measures

Outcome: % one-unit red cell transfusion orders (aggregated monthly).

Improvement/innovation/change ideas

Our initial theory was that unawareness of the guidelines (established in 2014) and subscription to the obsolete doctrine of two-unit transfusions were the primary behavioural drivers. Initial change ideas included an educational/awareness blitz including rounds presentations, memos and posters. Failure led us to revisit our hypothesis and carry out a real-time audit, where our team was notified on each two-unit transfusion. This revealed the true root cause: the overwhelming majority of two-unit transfusions could be traced back to standing orders that were entered on an admission order set. After provider engagement, we proceeded to remove all admission order sets containing two-unit transfusions.

Impact/lessons learned/results

After order set removal, our one-unit transfusion rate rose to 86% and was sustained for 17 months. We learnt two primary lessons. First that CPOE and poor order set design combined to perpetuate poor ordering practices. Second that revisiting our hypothesis and engaging in thoughtful root cause analysis that included direct observation ultimately led to an effective, sustainable solution.

Discussion/spread

Our study underscores the importance of executing root cause analysis on a microsystem level. We would expect the factors driving poor performance to be completely different on a service such as general internal medicine. Our study also highlights the potential pitfalls of CPOE and the importance of regular order set review to ensure adherence to current evidence.

Standardized Implementation of Evidence-based Guidelines to Decrease Blood Transfusions in Pediatric Intensive Care Units

Introduction

Despite evidence that red blood cell (RBC) transfusions may be associated with more harm than benefit, current transfusion practices vary significantly. This multicenter, quality improvement study aimed to sustainably decrease the rate of RBC transfusions in pediatric intensive care units (PICUs).

Methods

This 16-month prospective study included 5 PICUs. We implemented a standardized project plan including education, bedside tools, real-time reminders, and email feedback. We collected data from consecutive transfusions during pre-implementation (Phase I), postimplementation (Phase II), and post-stabilization phases (Phase III).

Results

Of the 2,064 RBC transfusions, we excluded 35% (N = 729) from analysis in patients undergoing extracorporeal membrane oxygenation. Transfusion/1,000 admissions improved throughout the study periods from a baseline 209.6 -199.8 in Phase II and 195.8 in Phase III (P value < 0.05). There were fewer transfusions outside of the hemoglobin threshold guideline, decreasing from 81% of transfusions outside of guidelines in Phase I to 74% in Phases II and III, P < 0.05. Study phase, site, co-management status, service of requesting provider, admit reason, previous transfusion status, and age were associated with transfusion above guideline threshold.

Conclusions

Multicenter collaboration can successfully deploy a standardized plan that adheres to implementation science principles to sustainably decrease the rate of RBC transfusion outside of guideline thresholds. However, we did not decrease the total number of transfusions in our study. The complexity of multiple specialties co-managing patients is common in the contemporary PICU. Educational initiatives aimed at one specialty may have limited effectiveness in a multifaceted system of care.

Recommendations on RBC Transfusion in General Critically Ill Children Based on Hemoglobin and/or Physiologic Thresholds From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative

OBJECTIVES

To present the consensus recommendations and supporting literature for RBC transfusions in general critically ill children from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

DESIGN

Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children.

METHODS

The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based recommendations and research priorities regarding RBC transfusions in critically ill children. The subgroup on RBC transfusion in general critically ill children included six experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 30, 2017, using a combination of keywords to define concepts of RBC transfusion and critically ill children. Recommendation consensus was obtained using the Research and Development/UCLA Appropriateness Method. The results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method.

RESULTS

Three adjudicators reviewed 4,399 abstracts; 71 papers were read, and 17 were retained. Three papers were added manually. The general Transfusion and Anemia Expertise Initiative subgroup developed, and all Transfusion and Anemia Expertise Initiative members voted on two good practice statements, six recommendations, and 11 research questions; in all instances, agreement was reached (> 80%). The good practice statements suggest a framework for RBC transfusion in PICU patients. The good practice statements and recommendations focus on hemoglobin as a threshold and/or target. The research questions focus on hemoglobin and physiologic thresholds for RBC transfusion, alternatives, and risk/benefit ratio of transfusion.

CONCLUSIONS

Transfusion and Anemia Expertise Initiative developed pediatric-specific good practice statements and recommendations regarding RBC transfusion management in the general PICU population, as well as recommendations to guide future research priorities. Clinical recommendations emphasized relevant hemoglobin thresholds, and research recommendations emphasized a need for further understanding of physiologic thresholds, alternatives to RBC transfusion, and hemoglobin thresholds in populations with limited pediatric literature.

Behaviour modification interventions to optimise red blood cell transfusion practices: a systematic review and meta-analysis

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.

Changes in plasma unit distributions to hospitals over a 10-year period

BACKGROUND

There are many influences on a hospital's demand for plasma. Pharmaceuticals are now being administered for many indications instead of plasma, although trauma resuscitation now emphasizes increased and early intervention with plasma. This multinational study evaluated changes in blood center plasma unit distributions over a 10-year period.

STUDY DESIGN AND METHODS

Data on the total number and the ABO groups of plasma unit distributions were obtained from nine American blood collectors (ABCs) and nine national or provincial blood services (NPBS) from 2007 through 2016. Plasma distributions to trauma hospitals by five ABCs and four NPBS were also analyzed.

RESULTS

The overall number of plasma unit distributions from ABCs decreased by 23.1% from 2007 to 2016, but the relative proportion of distributed AB plasma units increased during the same period. The NPBS (excluding the Japanese Red Cross [JRC]) also had a 35.4% decrease in the overall number of plasma unit distributions with an increase in the relative proportion of AB plasma distributions between 2007 and 2016. The JRC, however, reported an increase in the overall number of plasma distributions by 13.5% in 2016 compared to 2007. The proportion of low-titer A plasma distributions increased to 1.6% of total plasma distributions by ABCs in 2016. There was a trend of distributing increasing proportions of group AB plasma units to trauma hospitals over the 10-year period.

CONCLUSION

Although the number of plasma unit distributions has decreased at many blood collectors over time, the proportion of AB units has increased at both ABCs and NPBS.

Evaluation of RBC Transfusion Practice in Adult ICUs and the Effect of Restrictive Transfusion Protocols on Routine Care

OBJECTIVE

Research supports the efficacy and safety of restrictive transfusion protocols to reduce avoidable RBC transfusions, but evidence of their effectiveness in practice is limited. This study assessed whether admission to an ICU with an restrictive transfusion protocol reduces the likelihood of transfusion for adult patients.

DESIGN

Observational study using data from the multicenter, cohort Critical Illness Outcomes Study. Patient-level analyses were conducted with RBC transfusion on day of enrollment as the outcome and admission to an ICU with a restrictive transfusion protocol as the exposure of interest. Covariates included demographics, hospital course (e.g., lowest hematocrit, blood loss), severity of illness (e.g., Sequential Organ Failure Assessment score), interventions (e.g., sedation/analgesia), and ICU characteristics (e.g., size). Multivariable logistic regression modeling assessed the independent effects of restrictive transfusion protocols on transfusions.

SETTING

Fifty-nine U.S. ICUs.

PATIENTS

A total of 6,027 adult ICU patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of the 59 study ICUs, 24 had an restrictive transfusion protocol; 2,510 patients (41.6%) were in an ICU with an restrictive transfusion protocol. The frequency of RBC transfusion among patients with severe (hematocrit, < 21%), moderate (hematocrit, 21-30%), and mild (hematocrit, > 30%) anemia in restrictive transfusion protocol ICUs was 67%, 19%, and 4%, respectively, compared with 60%, 14%, and 2% for those in ICUs without an restrictive transfusion protocol. Only 27% of transfusions were associated with a hematocrit less than 21%. Adjusting for confounding factors, restrictive transfusion protocols independently reduced the odds of transfusion in moderate anemia with an odds ratio of 0.59 (95% CI, 0.36-0.96) while demonstrating no effect in mild (p = 0.93) or severe (p = 0.52) anemia.

CONCLUSIONS

In this sample of ICU patients, transfusions often occurred outside evidence-based guidelines, but admission to an ICU with an restrictive transfusion protocol did reduce the risk of transfusion in moderately anemic patients controlling for patient and ICU factors. This study supports the effectiveness of restrictive transfusion protocols for influencing transfusions in clinical practice.

Evaluation and Treatment of Anemia in Premature Infants

Introduction:

Anemia in preterm infants is the pathophysiological process with greater and more rapid decline in hemoglobin compared to the physiological anemia in infants. There is a need for transfusions and administration of human recombinant erythropoietin.

Aim:

To determine the frequency of anemia in premature infants at the Pediatric Clinic, University Clinical Center Sarajevo, as well as parameter values in the blood count of premature infants and to explore a relationship between blood transfusions with the advent of intraventricular hemorrhage (determine treatment outcome in preterm infants).

Patients and methods:

Research is retrospective study and it included the period of six months in year 2014. Research included 100 patients, gestational age < 37 weeks (premature infants). Data were collected by examining the medical records of patients at the Pediatric Clinic, UCCS.

Results:

The first group of patients were premature infants of gestational age ≤ 32 weeks (62/100) and the second group were premature infants of gestational age 33-37 weeks (38/100). Among the patients, 5% were boys and 46% girls. There was significant difference in birth weight and APGAR score among the groups. In the first group, there were 27.42% of deaths, while in the second group, there were only 10.53% of deaths. There was a significant difference in the length of treatment. There was a statistically significant difference in the need for transfusion among the groups. 18 patients in the first group required a transfusion, while in the second group only 3 patients.

Conclusions:

Preterm infants of gestational age ≤ 32 weeks are likely candidates for blood transfusion during treatment. Preterm infants of gestational age ≤ 32 weeks have the risk of intracranial bleeding associated with the application of blood transfusion in the first week of life.

Computerised decision support systems to promote appropriate use of blood products

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effect of computerised decision support systems (DSSs) on transfusion practice.

Interhospital Variability in Perioperative Red Blood Cell Ordering Patterns in United States Pediatric Surgical Patients

OBJECTIVE

To evaluate perioperative red blood cell (RBC) ordering and interhospital variability patterns in pediatric patients undergoing surgical interventions at US children's hospitals.

STUDY DESIGN

This is a multicenter cross-sectional study of children aged <19 years admitted to 38 pediatric tertiary care hospitals participating in the Pediatric Health Information System in 2009-2014. Only cases performed at all represented hospitals were included in the study, to limit case mix variability. Orders for blood type and crossmatch were included when done on the day before or the day of the surgical procedure. The RBC transfusions included were those given on the day of or the day after surgery. The type and crossmatch-to-transfusion ratio (TCTR) was calculated for each surgical procedure. An adjusted model for interhospital variability was created to account for variation in patient population by age, sex, race/ethnicity, payer type, and presence/number of complex chronic conditions (CCCs) per patient.

RESULTS

A total of 357 007 surgical interventions were identified across all participating hospitals. Blood type and crossmatch was performed 55 632 times, and 13 736 transfusions were provided, for a TCTR of 4:1. There was an association between increasing age and TCTR (R(2) = 0.43). Patients with multiple CCCs had lower TCTRs, with a stronger relationship (R(2) = 0.77). There was broad variability in adjusted TCTRs among hospitals (range, 2.5-25).

CONCLUSIONS

The average TCTR in US children's hospitals was double that of adult surgical data, and was associated with wide interhospital variability. Age and the presence of CCCs markedly influenced this ratio. Studies to evaluate optimal preoperative RBC ordering and standardization of practices could potentially decrease unnecessary costs and wasted blood.

Bilirubin levels and phototherapy use before and after neonatal red blood cell transfusions

BACKGROUND

Our previous retrospective study suggested that red blood cell (RBC) transfusion of preterm neonates can be associated with an increase in bilirubin, but this has not been tested prospectively.

STUDY DESIGN AND METHODS

We studied neonates before and after RBC transfusions, recording serial bilirubin levels and whether they qualified for phototherapy. Because lysed RBCs release plasma-free hemoglobin (Hb), a precursor to bilirubin, we also measured plasma free Hb and bilirubin from the donor blood.

RESULTS

We studied 50 transfusions given to 39 neonates. Gestation ages of transfused neonates, at birth, were 26 (24-29) weeks (median [interquartile range]); birthweights were 750 (620-1070) g. The study transfusion was given on Day of Life 9.9 (3.4-19.2). In 20% (10/50) phototherapy was being administered at the beginning of and during the transfusion. In these patients neither the 4- to 6- nor the 24- to 36-hour-posttransfusion bilirubin levels were significantly higher than before transfusion. However, in 30% of the others (12/40) phototherapy was started (or restarted) after the transfusion and 15% had a posttransfusion bilirubin increase of at least 2.5 mg/dL. These neonates received donor blood with a higher plasma-free Hb (p < 0.05).

CONCLUSIONS

Neonates commonly qualify for phototherapy after transfusion. A minority (15% in this series) have a posttransfusion bilirubin increase of at least 2.5 mg/dL. We speculate that neonates qualifying for a RBC transfusion, who are judged to be at high risk for bilirubin-induced neurotoxicity, might benefit from checking their serum bilirubin level after the transfusion and providing donor blood with low plasma-free Hb levels.

Clinical Decision Support for Pediatric Blood Product Prescriptions

Since the beginning of the 20th century, blood products have been used to effectively treat life-threatening conditions. Over time, we have come to appreciate the many benefits along with significant risks inherent to blood product transfusions. As such, recommendations for the safe and effective use of blood products have evolved over time. Current evidence supports the use of restrictive transfusion strategies that can avoid the risks of unnecessary transfusions. In spite of good evidence, there is a considerable amount of variability in transfusion practices across providers. Clinical decision support (CDS) is an effective tool capable of increasing adherence to evidence-based practices. CDS has been used successfully to improve adherence to transfusion guidelines. Pediatric literature demonstrates strong evidence for the use of CDS to improve appropriateness of red blood cell and plasma transfusion utilization. Further studies in more diverse settings with more standardized reporting are needed to provide more clarity around the effectiveness of CDS in blood product prescriptions.

Interventions Aimed at Reducing Use of Low-Value Health Services: A Systematic Review

The effectiveness of different types of interventions to reduce low-value care has been insufficiently summarized to allow for translation to practice. This article systematically reviews the literature on the effectiveness of interventions to reduce low-value care and the quality of those studies. We found that multicomponent interventions addressing both patient and clinician roles in overuse have the greatest potential to reduce low-value care. Clinical decision support and performance feedback are promising strategies with a solid evidence base, and provider education yields changes by itself and when paired with other strategies. Further research is needed on the effectiveness of pay-for-performance, insurer restrictions, and risk-sharing contracts to reduce use of low-value care. While the literature reveals important evidence on strategies used to reduce low-value care, meaningful gaps persist. More experimentation, paired with rigorous evaluation and publication, is needed.

Assessing productive efficiency and operating scale of community blood centers

BACKGROUND

In recent years demand for blood products has decreased, and as a result, the blood product marketplace has become much more competitive. Reducing inefficiency in the procurement and processing of blood products at blood centers can reduce costs while assuring that demand for blood products is met.

STUDY DESIGN AND METHODS

This study uses data envelopment analysis to compare the productive efficiency of 65 community blood centers to determine to what extent efficiency can be improved, what cost savings and increases in platelet (PLT) production may be obtained by eliminating inefficiency, and what scales of operation are the most efficient from a budgetary and staffing standpoint. Data were collected from the 2012 to 2013 AABB Directory of Community Blood Centers and Hospital Blood Banks.

RESULTS

The study found that 27 of 65 blood centers are efficient. The remaining 38 blood centers can reduce budget and staff levels and may be able to expand output. If inefficient centers were to eliminate all inefficiency, the total savings would be $671 million, approximately 20% of the aggregated budget ($3.45 billion) of all centers in the study. In addition, the centers would also see a 36% increase in PLT production. Inefficiency of some large blood centers stems from operating at too large a scale, while inefficiency of most small blood centers is scale independent.

CONCLUSION

The results suggest that reducing inefficiency in blood procurement may be a good strategy to maximize competitiveness in the blood product marketplace. These findings further suggest that the trend of blood center consolidation may be ill advised from a cost containment perspective.

Fresh Frozen Plasma Administration in the Neonatal Intensive Care Unit: Evidence-Based Guidelines

Neonates receiving fresh frozen plasma (FFP) should do so according to evidence-based guidelines so as to reduce inappropriate use of this life-saving and costly blood product and to minimize associated adverse effects. The consensus-based uses of FFP in neonatology involve neonates with active bleeding and associated coagulopathy. However, because of limited and poor-quality evidence, considerable FFP utilization occurs outside these recommendations. In this review, we describe what we conclude are currently the best practices for the use of FFP in neonates, including interpreting neonatal coagulation tests and strategies for reducing unnecessary FFP transfusions.

Red cell and platelet transfusions in neonates: a population-based study

OBJECTIVES

This study aimed to describe the use of red cells, platelets and exchange transfusions among all neonates in a population cohort, to examine trends in transfusion over time and to determine transfusion rates in at-risk neonates.

DESIGN

Linked population-based birth and hospital data from New South Wales (NSW), Australia, were used to determine rates of blood product transfusion in the first 28 days of life. The study included all live births ≥23 weeks' gestation in NSW between 2001 and 2011.

RESULTS

Between 2001 and 2011, 5326 of 989 491 live born neonates received a red cell, platelet or exchange transfusion (5.4/1000 births). Transfusion rates were 4.8 per 1000 for red cells, 1.3 per 1000 for platelets and 0.3 per 1000 for exchange transfusion. Overall transfusion rate remained constant from 2001 to 2011 (p=0.27). Among transfused neonates, 60% were <32 weeks' gestation (n=3210, 331/1000 births), 40% were ≥32 weeks' gestation (n= 2116, 2/1000 births) and 7% received transfusions in a hospital without a neonatal intensive care unit (NICU). Factors other than prematurity associated with higher transfusion rates were prior in utero transfusion (631/1000), congenital anomaly requiring surgery (440/1000) and haemolytic disorder (106/1000).

CONCLUSIONS

In this population-based study, preterm neonates had a higher rate of transfusion than term neonates; however, 40% of those who received a transfusion were born ≥32 weeks' gestation and 7% were transfused in hospitals without an NICU. These findings need to be considered by transfusion services and personnel developing neonatal transfusion guidelines.

Thrombocytopenia in Small-for-Gestational-Age Infants

BACKGROUND

Thrombocytopenia is common among small-for-gestational-age (SGA) neonates (birth weight <10th percentile reference range), but several aspects of this thrombocytopenia are unclear, including the incidence, typical nadir, duration, association with preeclampsia, mechanism, and risk of death.

METHODS

Using 9 years of multihospital records, we studied SGA neonates with ≥2 platelet counts <150,000/μL in their first week.

RESULTS

We found first-week thrombocytopenia in 31% (905 of 2891) of SGA neonates versus 10% of non-SGA matched controls (P < .0001). Of the 905, 102 had a recognized cause of thrombocytopenia (disseminated intravascular coagulation, early-onset sepsis, or extracorporeal membrane oxygenation). This group had a 65% mortality rate. The remaining 803 did not have an obvious cause for their thrombocytopenia, and we called this "thrombocytopenia of SGA." They had a mortality rate of 2% (P < .0001) and a mean nadir count on day 4 of 93,000/μL (SD 51,580/μL, 10th percentile 50,000/μL, 90th percentile 175,000/μL). By day 14, platelet counts were ≥150,000/μL in more than half of the patients. Severely SGA neonates (<1st percentile) had lower counts and longer thrombocytopenia duration (P < .001). High nucleated red cell counts at birth correlated with low platelets (P < .0001). Platelet transfusions were given to 23%, and counts typically more than tripled. Thrombocytopenia was more associated with SGA status than with the diagnosis of maternal preeclampsia.

CONCLUSIONS

SGA neonates with clearly recognized varieties of thrombocytopenia have a high mortality rate. In contrast, thrombocytopenia of SGA is a hyporegenerative condition of moderate severity and 2 weeks' duration and is associated with evidence of intrauterine hypoxia and a low mortality rate.

Temporal changes in blood product usage in preterm neonates born at less than 30 weeks' gestation in Canada

BACKGROUND

Knowledge of neonatal transfusion practices remains limited to local cohorts or survey-based studies. This study evaluated the pattern and temporal changes in the types and frequency of blood product use among preterm neonates born at less than 30 weeks' gestation in Canada.

STUDY DESIGN AND METHODS

A retrospective cohort study of preterm neonates born at less than 30 weeks' gestation and admitted to participating neonatal intensive care units in the Canadian Neonatal Network from 2004 to 2012 was conducted to evaluate blood product usage. The temporal change in red blood cell (RBC) use was evaluated by dividing the study period into three epochs: 2004 to 2006, 2007 to 2009, and 2010 to 2012.

RESULTS

Of 14,868 eligible neonates admitted to participating units in Canada during the overall study period, 8252 (56%) received RBCs, 2151 (15%) platelets, 1556 (11%) fresh-frozen plasma, 915 (6%) albumin, and 302 (2%) cryoprecipitate. Temporal evaluation over three epochs revealed a trend toward fewer RBC transfusions among neonates born at 26 to 29 weeks' gestation (p = <0.01-0.04) but use remained unchanged or increased for neonates born at 23 to 25 weeks' gestation (p = 0.02-0.54).

CONCLUSION

Blood product use remains at a very high frequency in preterm neonates born at less than 30 weeks' gestation. Evolutionary practice changes and relative high tolerance for anemia may be associated with a reduction in RBC usage in recent years in neonates born at at least 26 weeks' gestation. This contrasts with the ongoing higher usage of blood products observed at extremely low gestational ages.

Why do four NICUs using identical RBC transfusion guidelines have different gestational age-adjusted RBC transfusion rates?

OBJECTIVE

To compare neonatal red blood cell (RBC) transfusion rates in four large Intermountain Healthcare NICUs, all of which adhere to the same RBC transfusion guidelines.

STUDY DESIGN

This retrospective analysis was part of a transfusion-management quality-improvement project. De-identified data included RBC transfusions, clinical and laboratory findings, the anemia-prevention strategies in place in each NICU, and specific costs and outcomes.

RESULT

Of 2389 NICU RBC transfusions given during the 4-year period studied, 98.9 ± 2.1% (mean ± S.D.) were compliant with our transfusion guidelines, with no difference in compliance between any of the four NICUs. However, RBC transfusion rates varied widely between the four, with averages ranging from 4.6 transfusions/1000 NICU days to 21.7/1000 NICU days (P < 0.00001). Gestational age-adjusted transfusion rates were correspondingly discordant (P < 0.00001). The lower-transfusing NICUs had written anemia-preventing guidelines, such as umbilical cord milking at very low birth weight delivery, use of cord blood for admission laboratory studies, and darbepoetin dosing for selected neonates. Rates of Bell stage ⩾ 2 necrotizing enterocolitis and grade ⩾ 3 intraventricular hemorrhage were lowest in the two lower-transfusing NICUs (P < 0.0002 and P < 0.0016). Average pharmacy costs for darbepoetin were $84/dose, with an average pharmacy cost of $269 per transfusion averted. With a cost of $900/RBC transfusion, the anemia-preventing strategies resulted in an estimated cost savings to Intermountain Healthcare of about $6970 per 1000 NICU days, or about $282,300 annually.

CONCLUSION

Using transfusion guidelines has been shown previously to reduce practice variability, lower transfusion rates and diminish transfusion costs. Based on our present findings, we maintain that even when transfusion guidelines are in place and adhered to rigorously, RBC transfusion rates are reduced further if anemia-preventing strategies are also in place.

Trends in RBC ordering and use after implementing adaptive alerts in the electronic computerized physician order entry system

OBJECTIVES

To reduce unnecessary RBC transfusions, the computerized physician order entry (CPOE) system was programmed to require prescribers to select an indication for transfusion. An alert appeared if the patient's hemoglobin (Hb) level was above the threshold determined by the selected indication (adaptive alerts).

METHODS

Data on RBC orders from the 4 months before the adaptive alerts were implemented were compared with the 10 months after implementation.

RESULTS

Significantly fewer alerts were generated after the implementation, and the rate at which the alerts were heeded also increased. There was a trend toward fewer RBC units transfused after adaptive alert implementation. A large number of RBCs were ordered using a nonspecific transfusion indication, although many of these patients had antecedent Hb values close to the threshold.

CONCLUSIONS

Electronically generated alerts can reduce but are insufficient to eliminate non-evidence-based transfusions. Analysis of the alerts suggests areas for CPOE improvement.

Evaluation of real-time clinical decision support systems for platelet and cryoprecipitate orders

OBJECTIVES

To evaluate cryoprecipitate and platelet ordering practices after the implementation of real-time clinical decision support systems (CDSSs) in a computerized physician order entry (CPOE) system.

METHODS

Uniform platelet and cryoprecipitate transfusion thresholds were implemented at 11 hospitals in a regional health care system with a common CPOE system. Over 6 months, a variety of information was collected on the ordering physicians and the number of alerts generated by the CDSSs when these products were ordered outside of the institutional guidelines.

RESULTS

There were 1,889 orders for platelets and 152 orders for cryoprecipitate placed in 6 months. Of these, 1,102 (58.3%) platelet and 74 (48.7%) cryoprecipitate orders triggered an alert. The proportion of orders canceled after an alert was generated ranged from 13.5% to 17.9% for platelets and 0% to 50.0% for cryoprecipitate orders.

CONCLUSIONS

CDSS alerts reduce, but do not eliminate, platelet and cryoprecipitate transfusions that do not meet institutional guidelines.

Quality improvement initiatives in neonatal intensive care unit networks: achievements and challenges

Neonatal intensive care unit networks that encompass regions, states, and even entire countries offer the perfect platform for implementing continuous quality improvement initiatives to advance the health care provided to vulnerable neonates. Through cycles of identification and implementation of best available evidence, benchmarking, and feedback of outcomes, combined with mutual collaborative learning through a network of providers, the performance of health care systems and neonatal outcomes can be improved. We use examples of successful neonatal networks from across North America to explore continuous quality improvement in the neonatal intensive care unit, including the rationale for the formation of neonatal networks, the role of networks in continuous quality improvement, quality improvement methods and outcomes, and barriers to and facilitators of quality improvement.

Recent advances toward defining the benefits and risks of erythrocyte transfusions in neonates

Like many treatments available to small or ill neonates, erythrocyte transfusions carry both benefits and risks. This review examines recent publications aimed at better defining those benefits and those risks, as means of advancing evidence-based neonatal intensive care unit transfusion practices. Since decisions regarding whether to not to order an erythrocyte transfusion are based, in part, on the neonate's blood haemoglobin concentration, the authors also review recent studies aimed at preventing the haemoglobin from falling to a point where a transfusion is considered.

A randomized, masked, placebo-controlled study of darbepoetin alfa in preterm infants

BACKGROUND

A novel erythropoiesis stimulating agent (ESA), darbepoetin alfa (Darbe), increases hematocrit in anemic adults when administered every 1 to 3 weeks. Weekly Darbe dosing has not been evaluated in preterm infants. We hypothesized that infants would respond to Darbe by decreasing transfusion needs compared with placebo, with less-frequent dosing than erythropoietin (Epo).

METHODS

Preterm infants 500 to 1250 g birth weight and ≤48 hours of age were randomized to Darbe (10 μg/kg, 1 time per week subcutaneously), Epo (400 U/kg, 3 times per week subcutaneously) or placebo (sham dosing) through 35 weeks' gestation. All received supplemental iron, folate, and vitamin E, and were transfused according to protocol. Transfusions (primary outcome), complete blood counts, absolute reticulocyte counts (ARCs), phlebotomy losses, and adverse events were recorded.

RESULTS

A total of 102 infants (946 ± 196 g, 27.7 ± 1.8 weeks' gestation, 51 ± 25 hours of age at first dose) were enrolled. Infants in the Darbe and Epo groups received significantly fewer transfusions (P = .015) and were exposed to fewer donors (P = .044) than the placebo group (Darbe: 1.2 ± 2.4 transfusions and 0.7 ± 1.2 donors per infant; Epo: 1.2 ± 1.6 transfusions and 0.8 ± 1.0 donors per infant; placebo: 2.4 ± 2.9 transfusions and 1.2 ± 1.3 donors per infant). Hematocrit and ARC were higher in the Darbe and Epo groups compared with placebo (P = .001, Darbe and Epo versus placebo for both hematocrit and ARCs). Morbidities were similar among groups, including the incidence of retinopathy of prematurity.

CONCLUSIONS

Infants receiving Darbe or Epo received fewer transfusions and fewer donor exposures, and fewer injections were given to Darbe recipients. Darbepoetin and Epo successfully serve as adjuncts to transfusions in maintaining red cell mass in preterm infants.