Leading Hospital Improvement

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Transfusing Wisely

07/21/2017

By Ian Jenkins, MD, SFHM, Clinical Professor, Department of Medicine Chair, Patient Safety Committee, Hospital Medicine
University of California San Diego Health

Red blood cell (RBC) transfusions are the most frequently performed hospital procedure in the United States, increasing 134 percent from 1997 to 2011. But, did you know that 50 percent or more of RBC transfusions may be unnecessary?

Each patient who undergoes an unnecessary transfusion is put at risk for:

  • infection
  • volume overload, an adverse effect of rapid, large-volume blood transfusions
  • transfusion-related lung injury
  • hemolysis
  • rupture or destruction of red blood cells

Other complications are possible as well. This is not to mention the millions of dollars in costs.

In 2014, a team at Stanford published the results of a quality initiative that used a best practice alert in the electronic medical record to reduce unnecessary RBC transfusions. The team reduced blood use by about a quarter and saved the hospital $1.6 million annually. However, it was not known if this best practice alert could work in other hospitals, especially ones that were already using less blood.

Improving Blood Transfusion Practices
In an effort to find out, I, along with my colleagues at the University of California San Diego (UCSD) Health, began to research how we too could leverage the electronic medical record. Our efforts are detailed in the study, “Transfusing Wisely: Clinical Decision Support Improves Blood Transfusion Practices, from the August 2017 issue of The Joint Commission Journal on Quality and Patient Safety.

For the study, we established a multidisciplinary team to review transfusion literature on clinical trials, meta-analyses, guidelines and improvement efforts. Our team then implemented several interventions at UCSD Health, including:

  • educational tools
  • a Best Practice Advisory to reduce unnecessary blood products and costs by using real-time clinical decision support, a process for providing information at point of care to help inform decisions about a patient’s care
  • enhancements to the computerized provider order entry system

Significant Results
Over the course of the 32-month study, these significant results were achieved for a subset of patients (those who were not within 12 hours of surgery and not admitted for gastrointestinal bleeding):

  • 47 percent reduction in transfusions for hemoglobin
  • 67 percent reduction in multi-unit transfusions

The overall rate of RBC transfusions without exclusions per 1,000 patient-days had a 19 percent reduction and savings of over $1 million.

“4S” Approach to Transfusions
As a result of our initiative, we used education and order set redesign to now promote a simple “4S” approach to transfusions throughout the medical center. This approach encourages health care professionals to transfuse:

  • For Serious symptoms
  • If a patient is unStable from bleeding
  • For a hemoglobin less than Seven g/dL (if a number is used)
  • Using Single units (in most cases)

The Future of Transfusions
As a physician committed to patient safety, I often discover that one of the greatest challenges in quality improvement is the dissemination of work across diverse medical centers. To help facilitate broad implementation, we are sharing our educational tools—fliers, posters, badge cards and a PowerPoint presentation—that can be customized with your own hospital’s local transfusion data. These tools may be accessed online or requested by email.

Reducing unnecessary RBC transfusions offers a great opportunity to improve patient safety and quality, as well as value in the American health care system. Together, we can help transfuse wisely in hospitals across the country. 

Note: The article is “Transfusing Wisely: Clinical Decision Support Improves Blood Transfusion Practices,” by Ian Jenkins, MD, SFHM; Jay J. Doucet, MD; Brian Clay, MD; Patricia Kopko, MD; Donald Dipps, MS, MT (ASCP), DBB; Eema Hemmen, MPH; and Debra Paulson, MS.