Efficacy of education followed by computerized provider order entry with clinician decision support to reduce red blood cell utilization

Evaluation of the Factors Influencing Blood Transfusion during Minimally Invasive Direct Coronary Artery Bypass Surgery

INTRODUCTION

The objective of this study was to analyze the blood transfusion factors of minimally invasive direct coronary artery bypass (MIDCAB) surgery using artificial intelligence.

METHODS

A retrospective analysis was performed for patients undergoing MIDCAB operations and no heart-lung machine was used from January 2017 to September 2022 in our hospital. The influencing factors of blood transfusion were used to build the artificial intelligence model. Eighty percent of the database was used as the training set, and twenty percent database was used as the testing set. To predict whether to use red blood cells during operation, we compared 104 artificial intelligence models. We aimed to assess whether which factors influence allogeneic transfusion in MIDCAB operations.

RESULTS

Of the 104 machine learning algorithms, the XGBoost model delivered the best performance, with an AUC of 0.726 in the testing set and an accuracy of 0.854 in the testing set. The artificial intelligence model showed preoperative hemoglobin less than 120 g/L, prothrombin time greater than 13.75, body mass index less than 22.7 kg/m2, coronary heart disease with additional comorbidities, a history of percutaneous coronary intervention, weight lower than 67 kg were the six major risk factors of allogeneic transfusion.

CONCLUSION

The XGBoost model can predict transfusion or not transfusion in MIDCBA surgery with high accuracy.

A simple program to improve the appropriateness of red blood cell transfusions in non-bleeding hospital patients: a before-and-after study

Introduction

Transfusion of red blood cells (RBCs) is not devoid of risks; nor is anemia. The aim of the study was to assess the usefulness of a program designed to improve the appropriateness of RBC transfusions in hospital patients.Methods: We retrospectively analyzed time periods before and after program implementation.

Results

Before program implementation 415 out of 23492 (1.8%) patients received at least 1 RBC, whereas after implementation 162 out of 25062 (0.6%) did so. The percentage of appropriate RBC transfusions increased from 23.6 to 37.1%.

Conclusions

A simple program may lead to a 3-fold decrease in transfusion rate and a significant increase in the percentage of appropriate RBC transfusions.

Clinical decision support versus a paper-based protocol for massive transfusion: Impact on decision outcomes in a simulation study

BACKGROUND

Management of major hemorrhage frequently requires massive transfusion (MT) support, which should be delivered effectively and efficiently. We have previously developed a clinical decision support system (CDS) for MT using a multicenter multidisciplinary user-centered design study. Here we examine its impact when administering a MT.

STUDY DESIGN AND METHODS

We conducted a randomized simulation trial to compare a CDS for MT with a paper-based MT protocol for the management of simulated hemorrhage. A total of 44 specialist physicians, trainees (residents), and nurses were recruited across critical care to participate in two 20-min simulated bleeding scenarios. The primary outcome was the decision velocity (correct decisions per hour) and overall task completion. Secondary outcomes included cognitive workload and System Usability Scale (SUS).

RESULTS

There was a statistically significant increase in decision velocity for CDS-based management (mean 8.5 decisions per hour) compared to paper based (mean 6.9 decisions per hour; p .003, 95% CI 0.6-2.6). There was no significant difference in the overall task completion using CDS-based management (mean 13.3) compared to paper-based (mean 13.2; p .92, 95% CI -1.2-1.3). Cognitive workload was statistically significantly lower using the CDS compared to the paper protocol (mean 57.1 vs. mean 64.5, p .005, 95% CI 2.4-12.5). CDS usability was assessed as a SUS score of 82.5 (IQR 75-87.5).

DISCUSSION

Compared to paper-based management, CDS-based MT supports more time-efficient decision-making by users with limited CDS training and achieves similar overall task completion while reducing cognitive load. Clinical implementation will determine whether the benefits demonstrated translate to improved patient outcomes.

Haemoglobin thresholds for transfusion: how are we doing in the era of Choosing Wisely? A retrospective cohort study

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.

Data and Metrics for Patient Blood Management: A Narrative Review and Practical Guide

Data collection, analysis, and reporting are fundamental for a successful hospital-based patient blood management program; however, very little has been published on the topic. Our aim was to synthesize evidence from a literature review to provide a detailed, practical list of outcome metrics, and the required data collection(s) to inform implementation. Ovid MEDLINE and PubMed were searched for any full-text original research articles published from inception to the year 2020. We included any studies reporting the implementation of interventions or programs study authors defined as "patient blood management" and extracted information on data collected and metrics reported. We included 45 studies describing the implementation of a patient blood management program and/or strategies. The outcomes reported by these studies were grouped into 1 of 36 metrics. We compiled a list of 65 relevant data elements to collect, and their potential source hospital information systems: patient administration, laboratory, transfusion/blood bank, operating room, pharmacy, emergency department, and intensive care unit. We further categorized patient blood management data systems into basic, intermediate, and advanced based on the combination of different information systems sourced. The results of this review can be used to inform patient blood management programs in planning what data collection(s) are needed, where these data can be sourced from, and how they can be analyzed.

Evaluating the costs and consequences of computerized clinical decision support systems in hospitals: a scoping review and recommendations for future practice

OBJECTIVE

Sustainable investment in computerized decision support systems (CDSS) requires robust evaluation of their economic impacts compared with current clinical workflows. We reviewed current approaches used to evaluate the costs and consequences of CDSS in hospital settings and presented recommendations to improve the generalizability of future evaluations.

MATERIALS AND METHODS

A scoping review of peer-reviewed research articles published since 2010. Searches were completed in the PubMed, Ovid Medline, Embase, and Scopus databases (last searched February 14, 2023). All studies reported the costs and consequences of a CDSS-based intervention compared with current hospital workflows. Findings were summarized using narrative synthesis. Individual studies were further appraised against the Consolidated Health Economic Evaluation and Reporting (CHEERS) 2022 checklist.

RESULTS

Twenty-nine studies published since 2010 were included. Studies evaluated CDSS for adverse event surveillance (5 studies), antimicrobial stewardship (4 studies), blood product management (8 studies), laboratory testing (7 studies), and medication safety (5 studies). All studies evaluated costs from a hospital perspective but varied based on the valuation of resources affected by CDSS implementation, and the measurement of consequences. We recommend future studies follow guidance from the CHEERS checklist; use study designs that adjust for confounders; consider both the costs of CDSS implementation and adherence; evaluate consequences that are directly or indirectly affected by CDSS-initiated behavior change; examine the impacts of uncertainty and differences in outcomes across patient subgroups.

DISCUSSION AND CONCLUSION

Improving consistency in the conduct and reporting of evaluations will enable detailed comparisons between promising initiatives, and their subsequent uptake by decision-makers.

Comparison of computerized provider order entry specific transfusion indications versus the use of "Other"

BACKGROUND

Computerized physician order entry (CPOE) systems are one way to reinforce evidence-based transfusion indications for blood products. The new CPOE system that was implemented at our institution allowed healthcare providers to select "Other" as an indication and provide reasons for transfusion outside of accepted guidelines.

STUDY DESIGN AND METHODS

Transfusion order records for packed red blood cells (RBCs), platelets, and fresh frozen plasma (FFP) from high product-ordering areas of Long Island Jewish Medical Center and Cohen's Children's Medical Center from April 2021, when the new CPOE system was implemented, to November 2021 were reviewed. The percentage of "Other" orders was determined and the reason for each "Other" order was reviewed to identify possible areas for education or valid indications not included in the institutionally recognized indications.

RESULTS

9.7% of RBC orders, 1.9% of platelet orders, and 18.2% of FFP orders were placed with "Other" as the indication for transfusion (χ² ₂  = 88.5; p < .001). Reasons for "Other" orders were varied, but notable reasons included indications already institutionally accepted such as, bleeding (15.7% of pediatric "Other" RBC orders), hold for OR (14.3% of pediatric and 15.8% of adult "Other" RBC orders), and novel reasons such as FFP for ACE-inhibitor associated angioedema (84.6% of adult "Other" FFP orders).

DISCUSSION

The findings from our study provide examples of potential difficulties hospitals may encounter when they implement a new computerized physician order entry system. Provider education may play an important role to reduce the number of "Other" orders placed for already recognized indications.

Information technology improves the quality of transfusion practice in China

BACKGROUND AND OBJECTIVES

Transfusion services in China must establish a quality management system, and regular inspection of quality indicators is an important component of quality management. Although the positive role of information technology in reducing human errors has been widely reported, its role in improving transfusion quality indicators still requires further study. This study explores the role of information technology in improving the quality of transfusion practice.

MATERIALS AND METHODS

We developed an optimized blood transfusion management information system and then analysed the changes in four quality indicators before and after using the system to clarify the role of information technology in improving the quality of transfusion practice.

RESULTS

After using the optimized system, the completeness rate for transfusion request forms increased from 81.5% to 99.3%; an unqualified doctor's signature was the most common incomplete content (0.45%). The appropriate transfusion rate increased from 87% to 99.4%, and red blood cell and frozen plasma utilization in most surgical departments decreased. Although the reporting rate for adverse transfusion reactions increased from 0.22% to 0.49%, these increases might be partly due to changes in transfusion regulations. The adequacy rate of transfusion medical records increased from 74.8% to 90.4%. Overall, the inadequacy of informed consent for transfusion, pre-transfusion laboratory tests and documentation of the transfusion process were reduced from 6.4%, 6.2% and 12.6% to 1.7%, 2.0% and 5.9%, respectively.

CONCLUSION

Information technology can play an important role in improving the quality of transfusion practice, as part of a programme of medical education, regular audit and other measures.

Determination of Unnecessary Blood Transfusion by Comprehensive 15-Hospital Record Review

BACKGROUND

Although unnecessary blood component transfusions are costly and pose substantial patient risks, the extent of unnecessary blood use in a community hospital setting has not been systematically measured.

METHODS

A 15-hospital observational analysis was performed using comprehensive retrospective review. Approximately 100 encounters (x¯ = 103.9, standard deviation [SD] ± 7.6) per hospital (6,696 total component transfusion events) were reviewed between 2012 and 2018. Review was performed by two medical directors. Findings were supported by blind intra- and inter-reviewer double review and blind external review by 10 independent reviewers.

RESULTS

Patients received an average of 4.3 (± 1.3) units. Only 8.2% (± 6.7) of patient encounters did not receive unnecessary units. Fifty-five percent (54.6% ± 13.5) could have been managed without at least one component type, while 44.6% (± 14.9) could have been managed completely without transfusion. Forty-five percent (45.4% ± 17.0) of red blood cell, 54.9% (± 19.3) of plasma-cryoprecipitate, and 38.0% (± 15.6) of plateletpheresis encounters could likely have been managed without transfusion. Between 2,713 units (40.5%) and 3,306 units (49.4%) were likely unnecessary. In patients who could have been managed without transfusion of at least one component type, unnecessary blood use was associated with a 0.38 (± 0.11)-day increase in length of hospital stay for each additional unnecessary unit received (p < 0.001).

CONCLUSION

Substantial unnecessary blood use was identified, all of which was unrecognized by hospitals prior to review. Unnecessary blood use was attributed to overreliance on laboratory transfusion criteria and failure to follow common blood management principles, which resulted in potential harm to patients and avoidable cost.

Racial differences in red blood cell transfusion in hospitalized patients with anemia

BACKGROUND

Guidelines recommend transfusion of red blood cells (RBC's) when a hospitalized patient's hemoglobin (Hb) drops below a restrictive transfusion threshold, either at 7 or 8 g. Hospitals have implemented transfusion policies to encourage compliance with guidelines and reduce variation in transfusion practice. However, variation in transfusion practice remains. The purpose of this study was to examine whether there is variation in the receipt of transfusion by patient race.

METHODS

Hospitalized general medicine patients with anemia (Hb < 10 g/dL) were eligible. Chi-squared tests were used to compare the percent of patients receiving a transfusion by race overall and within strata of their nadir Hb. Linear regression was used to test the association between a patient's race, their nadir Hb, receipt of an RBC transfusion, and the number of units transfused.

RESULTS

Four thousand nine hundred and fifty-one patients consented, including 1363 (28%) who received a transfusion. 71% of patients were African American, 25% were White, and 4% were Other Race. Overall African Americans were less likely to be transfused compared to Whites (25% vs. 30%, p < .01), and within Hb strata below a Nadir Hb of 9 g/dL (Hb 8.0-8.9 g/dL 1% vs. 7%, p < .01; 7.0-7.9 g/dL 15% vs. 28%, p < .01; <7 g/dL 80% vs. 86%, p < .01). African Americans also received fewer units of RBC's (β = -.17, p < .01) overall and at lower Hb levels (β = .14, p < .01) compared to Whites.

DISCUSSION

The Hb level at which patients are transfused at and the total number of RBC units received during hospitalization differ by patient race.

Transfusion Medicine Informatics: A Review of Current Practice and a Glimpse into the Future

Clinical informatics has been described as the "relentless pursuit of assisting people" by using data and information technology to improve health care. A core principle is that a person supported by information technology is superior to either a person or machine alone. Striving toward this harmonization, the transfusion medicine field has had a significant number of accomplishments. Clinical informatics interventions have helped achieve better quality, efficiency, and safety in nearly all aspects of transfusion medicine. This review summarizes these accomplishments and provides a preview of novel ideas that could transform transfusion medicine into a proactive, data-driven, and patient-centered discipline.

Physician's Subjective Increase in Awareness towards Perioperative Anaemia, Patient's Blood Resource, and Transfusion after the Implementation of Patient Blood Management: A Nationwide Multicentre Survey

INTRODUCTION

Patient blood management (PBM) is a clinical and multidisciplinary, 3-pillar concept. The aim of this study was to detect the subjective increase in physician's awareness towards perioperative anaemia, patient's blood resource, and transfusion after the implementation of PBM in German hospitals.

MATERIAL AND METHODS

A survey among 56 hospitals from the German PBM Network group was conducted from October 27 to December 19, 2020. An electronic questionnaire with 28 questions was sent to the local PBM coordinator for the distribution at the hospital level. For assessment of the physician's subjective increase in awareness, numeric rating scales (0 [no increase] - 10 [maximum increase]) were used.

RESULTS

In total, 404 clinicians from 56 hospitals completed the survey. The mean (±standard deviation) time of an existing PBM program was 4.8 (±2.2) years. The physician's subjective increase in awareness towards anaemia (8.2 [±2.0]), patient's blood resource (7.6 [±2.5]), and transfusion (8.1 [±1.9]) was the highest in physicians from hospitals with ≥21 implemented PBM measures. In addition, a subjective increase in awareness towards anaemia (6.6 [±3.3]), patient's blood resource (7.0 [±3.3]), and transfusion (6.6 [±3.4]) was the highest in physicians with daily PBM contact.

CONCLUSION

Results suggest that physician's awareness towards perioperative anaemia, patient's blood resource, and transfusion has increased, depending on the hospital's number of implemented PBM measures and physician's PBM contact in everyday clinical practice.

A Theoretically Informed Approach to Support the Implementation of Pre-Operative Anemia and Iron Deficiency Screening, Evaluation, and Management Pathways: Protocol for a Type Two Hybrid-Effectiveness Study

Introduction

Blood transfusions are a risk factor for increased morbidity, mortality, and length of hospital stay. Patient blood management guidelines provide guidance to reduce risk and improve patient outcomes. They outline steps to help prevent transfusions and considerations for when deciding to transfuse. One recommendation to prevent unnecessary transfusion is to optimize patients using Pre-operative Anemia and Iron Deficiency Screening, Evaluation and Management Pathways (PAIDSEM-P). The uptake of these recommendations is highly variable, and an effective approach to implementing them in a tailored and context-specific manner remains elusive.

Method and Design

A mixed-methods, interventional study, using a type two-hybrid effectiveness-implementation design, will evaluate the impact of a change package to improve the uptake of PAIDSEM-P. The change package consists of the intervention (PAIDSEM-P) supported by theoretically informed implementation strategies. Pre- and post-implementation, retrospective health record reviews will determine the effect of the change package on provider outcomes, including compliance with guideline recommendations as measured by the proportion of patients who have the appropriate tests performed, and, if required, appropriate treatment and/or referrals. Patient outcomes will be measured by checking for any difference in the proportion of patients with anemia on the day of surgery and the proportion of patients who receive a blood transfusion during the peri-operative period. An economic evaluation will be conducted to compare health outcomes and costs. The feasibility, acceptability and appropriateness of the PAIDSEM-P will be assessed using a quantitative, validated survey to measure implementation outcomes.

Discussion

Testing of implementation theory is required to advance understanding of what works, in what context, and the impact on implementation success. This study aims to evaluate the impact of a theoretically informed change package on improving the uptake of PAIDSEM-P. If successful, it will also provide a framework for health care facilities to follow when addressing other evidence-practice gaps.

Adherence to blood product transfusion guidelines-An observational study of the current transfusion practice in a medical intensive care unit

BACKGROUND

Blood transfusions though life-saving are not entirely benign. They are the most overused procedure in the hospital and have been under scrutiny by the 'Choosing Wisely campaign'. The strict adoption of restrictive transfusion guidelines could improve patient outcomes while reducing cost.

OBJECTIVES

In this study, we evaluate adherence to restrictive transfusion guidelines, along with hospital mortality and length of stay (LOS) in transfusion events with a pre-transfusion haemoglobin (Hb) ≥7 g/dl. Additionally, we evaluated associated costs accrued due to unnecessary transfusions.

METHODS

We conducted a retrospective observational study in a 64-bed medical intensive care unit (MICU) of an academic medical centre involving all adult patients (N = 957) requiring packed red blood cell transfusion between January 2015 and December 2015.

RESULTS

In total, 3140 units were transfused with a mean pre-transfusion Hb of 6.75 ± 0.86 g/dl. Nine hundred forty-four (30%) transfusion events occurred with a pre-transfusion Hb ≥7 g/dl, and 385 (12.3%) of these occurred in patients without hypotension, tachycardia, use of vasopressors, or coronary artery disease. Forgoing them could have led to a savings of approximately 0.3 million dollars. Transfusion events with pre-transfusion Hb ≥7 g/dl were associated with an increased mortality in patients with acute blood loss (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.11-3.88; p = 0.02) and LOS in patients with chronic blood loss (β₁ .8.26, 95% CI 4.09-12.43; p < 0.01).

CONCLUSION

A subset of anaemic patients in the MICU still receive red blood cell transfusions against restrictive guidelines offering hospitals the potential for effective intervention that has both economic and clinical implications.

Overcoming barriers to evidence-based patient blood management: a restricted review

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.

Extended Follow-up of an Educational Intervention Encouraging Appropriate Use of Blood Transfusions

INTRODUCTION

A restrictive transfusion strategy of packed red blood cells (PRBCs) has been associated with at least non-inferior patient outcomes in a variety of clinical settings. In December 2014, we conducted an educational intervention which consisted of an oral presentation and computerized notifications at a single tertiary medical center.

OBJECTIVE

The aim of this study was to examine the long-term effects of a simple and low-cost educational intervention aimed to promote awareness to transfusion guidelines.

METHODS

We retrospectively analyzed all PRBC transfusions ordered between 2014 and 2017. The primary end point was defined as the percentage of PRBC transfused to patients with hemoglobin (Hb) ≥8 g/dL.

RESULTS

Between 2014 and 2017, a total of 27,475 PRBCs were transfused in our medical center. There was a continuous reduction in the percentage of PRBCs transfused at a Hb level ≥8 g/dL between 2014 and 2017, with a matching increase in the PRBC percentage trans-fused at Hb <7 g/dL (OR reduction of 42%, 95% CI 0.54-0.62 and OR increase of 68% [95% CI 1.56-1.81], respec-tively).

CONCLUSION

A simple educational intervention likely contributed to sustained improvement in the appropriateness of PRBC transfusions.

Implementation of a patient blood management program in hematopoietic stem cell transplantation (Editorial, p. 2763)

BACKGROUND

Recipients of hematopoietic stem cell transplantation (HSCT) are among the highest consumers of allogeneic red blood cell (RBC) and platelet (PLT) components. The impact of patient blood management (PBM) efforts on HSCT recipients is poorly understood.

STUDY DESIGN AND METHODS

This observational study assessed changes in blood product use and patient-centered outcomes before and after implementing a multidisciplinary PBM program for patients undergoing HSCT at a large academic medical center. The pre-PBM cohort was treated from January 1 through September 31, 2013; the post-PBM cohort was treated from January 1 through September 31, 2015.

RESULTS

We identified 708 patients; 284 of 352 (80.7%) in the pre-PBM group and 225 of 356 (63.2%) in the post-PBM group received allogeneic RBCs (p < 0.001). Median (interquartile range [IQR]) RBC volumes were higher before PBM than after PBM (3 [2-4] units vs. 2 [1-4] units; p = 0.004). A total of 259 of 284 pre-PBM patients (91.2%) and 57 of 225 (25.3%) post-PBM patients received RBC transfusions when hemoglobin levels were more than 7 g/dL (p < 0.001). The median (IQR) PLT transfusion quantities was 3 (2-5) units for pre-PBM patients and 2 (1-4) units for post-PBM patients (p < 0.001). For patients with PLT counts of more than 10 × 10⁹ /L, a total of 1219 PLT units (73.4%) were transfused before PBM and 691 units (48.8%) were transfused after PBM (p < 0.001). Estimated transfusion expenditures were reduced by $617,152 (18.3%). We noted no differences in clinical outcomes or transfusion-related adverse events.

CONCLUSION

Patient blood management implementation for HSCT recipients was associated with marked reductions in allogeneic RBC and PLT transfusions and decreased transfusion-related costs with no detrimental impact on clinical outcomes.

Choosing Wisely: Decreasing the incidence of perioperative blood transfusions in gynecologic oncology

OBJECTIVE

To evaluate the efficacy and economic impact of a transfusion reduction initiative for patients undergoing gynecologic surgery.

METHODS

We conducted a prospective healthcare improvement study to align transfusion practices with the American Society of Hematology's Choosing Wisely® campaign. Baseline transfusion rates were determined retrospectively for all major gynecologic surgical cases from 3/1/14 to 6/30/14. Data for the post-intervention period from 5/15/15 to 5/16/16 were captured prospectively. The primary outcome was transfusion within 72 h of surgery. Secondary outcomes included perioperative morbidity, mortality, number of units ordered per transfusion episode and cost.

RESULTS

We identified 1281 surgical cases, 334 in the baseline and 947 in the post-implementation cohort. The baseline cohort was noted to have a higher median estimated blood loss (100 v. 75 mL, P < 0.01). Otherwise, there were no differences in clinical or perioperative characteristics between the two cohorts. The perioperative transfusion rate decreased from 24% to 11% (adjusted OR 0.27, 95% CI 0.16 to 0.45; P < 0.001). The perioperative laparotomy transfusion rate decreased from 48% to 23% (adjusted OR 0.21, 95% CI 0.12, 0.37; P < 0.001). The number of occurrences in which more than one unit of blood was ordered at a time decreased from 65% to 23%, P < 0.001. The incidence of surgical site infections declined in the post-intervention group, otherwise there were no differences in 30-day mortality, cardiac, venous thromboembolism or readmission rates between the groups. The projected cost savings was $161,112 over the 12-month intervention period.

CONCLUSIONS

Implementation of an educational based transfusion reduction program was associated with substantial reductions in perioperative transfusions and cost without significant changes in morbidity or mortality.

Assessment of the knowledge and perceptions of Brazilian medical residents on transfusion medicine

Background

Medical education has a major social impact because it ultimately influences the quality and safety of the health service offered to the population. Several studies have acknowledged the relationship between medical knowledge on transfusion medicine and the proper use of this therapy. The rational use of blood has become a worldwide concern. In this context, the aim of the present study was to evaluate medical residents' knowledge on transfusion medicine in hospitals located in Rio de Janeiro, Brazil, and their training during their medical education.

Methods

One hundred and six residents from eight medical specialties of four hospitals participated. A questionnaire developed by the Biomedical Excellence for Safer Transfusion (BEST) group was applied to evaluate the participants' medical knowledge. Another questionnaire was also applied to evaluate participant profiles regarding frequency of transfusion prescriptions, self-perceived knowledge and relevance of the subject.

Results

The mean number of correct answers to the questionnaire on knowledge about transfusion practices was 43.5% (range: 15-80%). A relationship between training during medical residency and the obtained result was observed (p-value = 0.0007). Most residents (73%) did not receive training in transfusion medicine during their graduation or residency and 93% would like to receive additional training.

Conclusion

A clear deficit in the knowledge of transfusion medicine was verified, indicating the need for change in the teaching of this specialty. This result is similar to some developed countries.

Transitioning to a High-Value Health Care Model: Academic Accountability

Health care spending in the United States has increased to unprecedented levels, and these costs have broken medical providers' promise to do no harm. Medical debt is the leading contributor to U.S. personal bankruptcy, more than 50% of household foreclosures are secondary to medical debt and illness, and patients are choosing to avoid necessary care because of its cost. Evidence that the health care delivery model is contributing to patient hardship is a call to action for the profession to transition to a high-value model, one that delivers the highest health care quality and safety at the lowest personal and financial cost to patients. As such, value improvement work is being done at academic medical centers across the country. To promote measurable improvements in practice on a national scale, academic institutions need to align efforts and create a new model for collaboration, one that transcends cross-institutional competition, specialty divisions, and geographical constraints. Academic institutions are particularly accountable because of the importance of research and education in driving this transition. Investigations that elucidate effective implementation methodologies and evaluate safety outcomes data can facilitate transformation. Engaging trainees in quality improvement initiatives will instill high-value care into their practice. This article charges academic institutions to go beyond dissemination of best practice guidelines and demonstrate accountability for high-value quality improvement implementation. By effectively transitioning to a high-value health care system, medical providers will convincingly demonstrate that patients are their most important priority.

Impact of organizational interventions on reducing inappropriate intravenous immunoglobulin (IVIG) usage: A systematic review and meta-analysis

BACKGROUND

With increasing global use of intravenous immunoglobulin (IVIG), there is interest in its appropriate usage. Efforts to regulate IVIG usage have primarily taken the form of organizational interventions implemented in hospitals to monitor and improve physician prescribing. Similar interventions have proven effective in reducing the inappropriate and total hospital usage of other blood products, but their efficacy on IVIG use is less understood. Thus, we performed a systematic review of studies reporting the change in inappropriate IVIG use following such interventions in hospitals or regions.

METHODS

A systematic search was carried out using MEDLINE and EMBASE (1966-June 2016) for English language studies if they 1) were primary research, 2) described an organizational intervention to target plasma, IVIG, or albumin, and 3) reported appropriateness of usage and total usage preand post-intervention. Review Manager v5.0 was utilized to perform a random-effects meta-analysis on eligible IVIG studies, where the risk ratio (RR) of inappropriate IVIG transfusion comparing pre- and postintervention periods was calculated with 95% confidence intervals (CI).

RESULTS

Our search retrieved three retrospective cohort studies, where metaanalysis encompassing 2100 episodes of IVIG transfusion demonstrated no decrease in inappropriate IVIG use (RR 1.55, 95% CI 0.78-3.07). Heterogeneity between studies was considerable (I2 = 89%).

CONCLUSION

Organizational interventions were ineffective at changing inappropriate IVIG use, but more high-quality studies describing the effects of these interventions are required before any conclusions can be drawn. Futureresearch efforts should also be directed at evolving evidence-based IVIGguidelines to improve patient safety and burdens on healthcare systems.

Implementing a Health System-wide Patient Blood Management Program with a Clinical Community Approach

BACKGROUND

Patient blood management programs are gaining popularity as quality improvement and patient safety initiatives, but methods for implementing such programs across multihospital health systems are not well understood. Having recently incorporated a patient blood management program across our health system using a clinical community approach, we describe our methods and results.

METHODS

We formed the Johns Hopkins Health System blood management clinical community to reduce transfusion overuse across five hospitals. This physician-led, multidisciplinary, collaborative, quality-improvement team (the clinical community) worked to implement best practices for patient blood management, which we describe in detail. Changes in blood utilization and blood acquisition costs were compared for the pre- and post-patient blood management time periods.

RESULTS

Across the health system, multiunit erythrocyte transfusion orders decreased from 39.7 to 20.2% (by 49%; P < 0.0001). The percentage of patients transfused decreased for erythrocytes from 11.3 to 10.4%, for plasma from 2.9 to 2.2%, and for platelets from 3.1 to 2.7%, (P < 0.0001 for all three). The number of units transfused per 1,000 patients decreased for erythrocytes from 455 to 365 (by 19.8%; P < 0.0001), for plasma from 175 to 107 (by 38.9%; P = 0.0002), and for platelets from 167 to 141 (by 15.6%; P = 0.04). Blood acquisition cost savings were $2,120,273/yr, an approximate 400% return on investment for our patient blood management efforts.

CONCLUSIONS

Implementing a health system-wide patient blood management program by using a clinical community approach substantially reduced blood utilization and blood acquisition costs.

Reducing liberal red blood cell transfusions at an academic medical center

BACKGROUND

Educational and computerized interventions have been shown to reduce red blood cell (RBC) transfusion rates, yet controversy remains surrounding the optimal strategy needed to achieve sustained reductions in liberal transfusions.

STUDY DESIGN AND METHODS

The purpose of this study was to assess the impact of clinician decision support (CDS) along with targeted education on liberal RBC utilization to four high-utilizing service lines compared with no education to control service lines across an academic medical center. Clinical data along with associated hemoglobin levels at the time of all transfusion orders between April 2014 and December 2015 were obtained via retrospective chart review. The primary outcome was the change in the rate of liberal RBC transfusion orders (defined as any RBC transfusion when the hemoglobin level is >7.0 g/dL). Secondary outcomes included the annual projected reduction in the number of transfusions and the associated decrease in cost due to these changes as well as length of stay (LOS) and death index. These measures were compared between the 12 months prior to the initiative and the 9-month postintervention period.

RESULTS

Liberal RBC utilization decreased from 13.4 to 10.0 units per 100 patient discharges (p = 0.002) across the institution, resulting in a projected 12-month savings of $720,360. The mean LOS and the death index did not differ significantly in the postintervention period.

CONCLUSION

Targeted education combined with the incorporation of CDS at the time of order entry resulted in significant reductions in the incidence of liberal RBC utilization without adversely impacting inpatient care, whereas control service lines exposed only to CDS had no change in transfusion habits.

Effectiveness of Provider Education Followed by Computerized Provider Order Entry Alerts in Reducing Inappropriate Red Blood Cell Transfusion

To reduce the rate of inappropriate red blood cell transfusion, a provider education program, followed by alerts in the computerized provider order entry system (CPOE), was established to encourage AABB transfusion guidelines. Metrics were established for nonemergent inpatient transfusions. Service lines with high order volume were targeted with formal education regarding AABB 2012 transfusion guidelines. Transfusion orders were reviewed in real time with email communications sent to ordering providers falling outside of AABB recommendations. After 12 months of provider education, alerts were activated in CPOE. With provider education alone, the incidence of pretransfusion hemoglobin levels greater than 8 g/dL decreased from 16.64% to 6.36%, posttransfusion hemoglobin levels greater than 10 g/dL from 14.03% to 3.78%, and number of nonemergent two-unit red blood cell orders from 45.26% to 22.66%. Red blood cell utilization decreased by 13%. No additional significant reduction in nonemergent two-unit orders was observed with CPOE alerts. Provider education, an effective and low-cost method, should be considered as a first-line method for reducing inappropriate red blood cell transfusion rates in stable adult inpatients. Alerts in the computerized order entry system did not significantly lower the percentage of two-unit red blood cells orders but may help to maintain educational efforts.

A multicenter study of blood component transfusion in patients with liver cirrhosis in China: Patient characteristics, transfusion practice, and outcomes

BACKGROUND

Cirrhosis is a complex acquired disorder of hemostasis and patients frequently receive blood transfusions. But there is very limited data on patterns of blood use at a patient level.

AIMS

To characterize blood use in cirrhotic patients in China and compare with recommendations to help identify areas where quality improvement strategies can be targeted. We also compared findings to a similar study undertaken in UK.

METHODS

A cross-sectional study was conducted in 11 hospitals over a 2-month period. Data were collected prospectively on each hospitalized cirrhotic patient to day 28.

RESULTS

1595 cirrhotic patients were included and 20.6% were transfused. 48.2% of transfused patients received transfusion for bleeding, most commonly gastrointestinal bleeding (65.8%). The remaining 51.8% were transfused for non-bleeding indications. 32.5% of patients transfused for gastrointestinal bleeding with red blood cells had a pre-transfusion haemoglobin >7g/dL. 89.1% of patients transfused frozen plasma for non-bleeding indications received them in the absence of a planned procedure. The patterns of blood transfusion in cirrhosis were different between China and UK. Of note, empirical prophylactic use of frozen plasma was more common in the Chinese study (89%) than in the UK (24%).

CONCLUSION

Education and research should be implemented to improve patient blood management, especially in prophylactic frozen plasma use area.

Implementing a blood utilization program to optimize transfusion practice

Blood utilization review programs educate clinicians on guidelines for appropriate transfusion, review local transfusion practice, and provide feedback on transfusion trends. To gather data on transfusion practice, modern blood utilization programs leverage electronic medical records and computerized physician order entry with automated decision support. Data may be collected and feedback may be given in real-time for individual transfusions or retrospectively with aggregated data. Important elements for a successful program include a multidisciplinary group that can champion the effort, adequate documentation and data capture for transfusions, and regular discussions about trends with ordering clinicians. Blood utilization programs are popular because they can lower transfusion risk, improve quality outcomes, and lower costs.

Hemoglobin thresholds for transfusion in pediatric patients at a large academic health center

BACKGROUND

Although prior studies support the use of a hemoglobin (Hb) transfusion trigger of 7 to 8 g/dL for most hospitalized adults, there are few studies in pediatric populations. We therefore investigated transfusion practices and Hb triggers in hospitalized children.

STUDY DESIGN AND METHODS

We performed a historical cohort study comparing transfusion practices in hospitalized children by service within a single academic institution. Blood utilization data from transfused patients (n = 3370) were obtained from electronic records over 4 years. Hb triggers and posttransfusion Hb levels were defined as the lowest and last Hb measured during hospital stay, respectively, in transfused patients. The mean and percentile distribution for Hb triggers were compared to the evidence-based restrictive transfusion threshold of 7 g/dL.

RESULTS

Mean Hb triggers were above the restrictive trigger (7 g/dL) for eight of 12 pediatric services. Among all of the services, there were significant differences between the mean Hb triggers (>2.5 g/dL, p<0.0001) and between the posttransfusion Hb levels (>3 g/dL, p < 0.0001). The variation between the 10th and 90th percentiles for triggers (up to 4 g/dL, p < 0.0001) and posttransfusion Hb levels (up to 6 g/dL, p < 0.0001) were significant. Depending on the service, between 25 and 90% of transfused patients had Hb triggers higher than the restrictive range.

CONCLUSIONS

Red blood cell (RBC) transfusion therapy varies significantly in hospitalized children with mean Hb triggers above a restrictive threshold for most services. Our findings suggest that transfusions may be overused and that implementing a restrictive transfusion strategy could decrease the use of RBC transfusions, thereby reducing the associated risks and costs.