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Transfusing Wisely: Clinical Decision Support Improves Blood Transfusion Practices
ARTICLE IN PRESS The Joint Commission Journal on Quality and Patient Safety 2017; ■■:■■–■■
Transfusing Wisely: Clinical Decision Support Improves Blood Transfusion Practices Ian Jenkins, MD, SFHM; Jay J. Doucet, MD; Brian Clay, MD; Patricia Kopko, MD; Donald Fipps, MS, MT (ASCP), DBB; Eema Hemmen, MPH; Debra Paulson, MS
Background: The cost and risks of red blood cell (RBC) transfusions, along with evidence of overuse, suggest that improving transfusion practices is a key opportunity for health systems to improve both the quality and value of patient care. Previous work, which included a BestPractice Advisory (BPA), was adapted in a quality improvement project designed to reduce both exposure to unnecessary blood products and costs. Methods: A prospective, pre-post study was conducted at an academic medical center with a diverse patient population. All noninfant inpatients without gastrointestinal bleeding who were not within 12 hours of surgical procedures were included. The interventions were education, a BPA, and other enhancements to the computerized provider order entry system. Results: The percentage of multiunit (≥ 2 units) RBC transfusions decreased from 59.9% to 41.7% during the intervention period and to 19.7% postintervention (p < 0.0001). The percentage of inpatient RBC transfusion units administered for hemoglobin (Hb) ≥ 7 g/dL declined from 72.3% to 57.8% during the intervention period and to 38.0% for the postintervention period (p < 0.0001). The overall rate of inpatient RBC transfusion (units administered per 1,000 patientdays without exclusions) decreased from 89.8 to 78.1 during the intervention period and to 72.7 during the postintervention period (p < 0.0001). The estimated annual cost savings was $1,050,750. Conclusion: The interventions reduced multiunit transfusions (by 67.1%) and transfusions for Hb ≥ 7 g/dL (by 47.4%). The improvement in the overall transfusion rate (19.0%) was less marked, limited by better baseline performance relative to other centers.
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ed blood cell (RBC) transfusion, which has been identified as the most frequently performed hospital procedure in the United States, increased by 134% from 1997 to 2011.1 However, 50% or more of RBC transfusions may be unnecessary,2–5 and the rate of RBC transfusion of RBCs in other developed countries, including Canada, the United Kingdom, and the Netherlands, is more than 25% lower than in the United States.6 A number of clinical trials have shown that restrictive RBC transfusion strategies are either noninferior to or have advantages compared with liberal transfusion strategies in patients with critical illness,7 septic shock,8 closed head injury,9 cardiac surgery,10,11 orthopedic surgery,12 and gastrointestinal bleeding.13 Meta-analyses have suggested in-hospital or overall mortality advantages with restrictive transfusion strategies, as well as superior or equal outcomes with regard to heart failure, rebleeding, infections, and myocardial infarction.14–16 These benefits likely relate to the known risks of blood transfusion, which include hemolytic reactions, circulatory overload, acute lung injury, transmission of infection,17 and a predisposition to hospital-acquired infections of disparate types.18 The cost and risks of RBC transfusions, along with evidence of overuse, suggest that improving transfusion practices 1553-7250/$-see front matter © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjq.2017.04.003
is a key opportunity for health systems to improve both the quality and value of patient care. Excessive transfusions have been identified as an improvement priority in the Choosing Wisely lists of wasteful practices by six professional organizations, including obstetric, hematology, critical care, and anesthesiology societies, and the Society of Hospital Medicine (SHM),19 and reducing excessive transfusion is the subject of an SHM–Society for the Advancement of Blood Management improvement guide.20 The Joint Commission, the AABB, and the US Department of Health and Human Services have recognized the importance of improving blood management.21–23 Previous transfusion improvement efforts have shown both benefits and limitations. Some used labor-intensive interventions24–26 or were limited to the critical care setting.27–29 One effort that focused on education plus audit was associated with a 25% reduction in blood utilization but required intensive chart review and provider contacts.24 Another site achieved a 19% reduction in blood utilization with extensive education, but the mean posttransfusion hemoglobin (Hb) was still > 10 g/dL, indicating high baseline use and insufficient improvement. 26 By requiring approval for nonemergency blood transfusion by a transfusion safety officer, one hospital reduced RBC transfusions by 38%; the hospital also reduced transfusion of plasma and platelets, saving more than $2 million.25 However, this method requires additional staff and may be politically unfeasible. More improvement efforts have focused on computerized provider order entry (CPOE) enhancements, which have
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varied from requiring rationales for transfusions, to providing alerts or recommendations tied to lab values or even vital signs, all of which are less labor intensive. In the ICU setting, CPOE interventions reduced transfusions by 13%–20%.27,28 One study achieved a larger impact in a pediatric ICU.29 In a randomized study, education reduced inappropriate transfusions, and computer decision support reduced it further, but only slightly: from 72% to 60% inappropriate.30 In perhaps the best example of a simple intervention with hospitalwide impact, Goodnough et al. used a BestPractice Advisory (BPA) to achieve 24% fewer transfusions, with an estimated annual savings of $1.6 million.31 They later showed that the effort was associated with improved inpatient mortality,32 but the work has not been duplicated. University of California San Diego (UCSD) Health’s transfusion rates for the first three quarters of 2014 were lower than mean rates at Vizient-participating academic medical centers (64.9 per 1,000 discharges vs. 92.1 for California centers and 79.2 nationally). We hypothesized that the use of a revised CPOE transfusion protocol and a BPA for transfusions above the Hb threshold, supported by an educational campaign and provider feedback, would further reduce inappropriate transfusions. We adapted the BPA used by Goodnough et al.,31 with exceptions for perioperative patients and active bleeding, and studied the effects in a quality improvement project with a pre-post design. METHODS Setting and Overview
UCSD Health is a 563-bed urban, academic medical center with active oncology, bone marrow transplant (BMT), trauma, orthopedic, and cardiothoracic surgery services, which transfuse significant volumes of blood, and a 49-bed neonatal ICU. From January 1, 2014, through September 30, 2014, our baseline total inpatient RBC transfusion rate was 89.8 units per 1,000 patient-days. This figure excludes neonatal transfusions, which are small fractions of units of blood, but includes rare pediatric patients. A multidisciplinary team was formed in January 2014 with representatives from transfusion medicine, surgery, critical care, nursing, hematology-oncology, hospital medicine, performance improvement, and information technology. The team reviewed the transfusion literature, focusing on clinical trials, meta-analyses, guidelines, and improvement efforts, and developed a list of evidence-based indications for RBC transfusion (Table 1) as well as educational tools. The tools included a quick reference ID badge card (Appendix 1, available in online article), handouts (Appendix 2, available in online article), and posters (Appendix 3, available in online article) reviewing the transfusion indications and reminders about the risks of transfusion; subtle differences among them reflected formatting constraints. We also prepared a video featuring hospital leaders33 and Microsoft PowerPoint presentations to be used in teaching sessions for trainee and
Table 1. The “4 S” Indications for Blood Transfusion Severe Symptoms due to Anemia (In)Stability: unstable blood volume due to bleeding Seven g/dL, if an Hb threshold is used And Single Unit transfusions are preferred unless the patient is unstable. For patients with active cardiac or brain ischemia, an Hb target of 8 g/dL is advised. Hb, hemoglobin.
faculty physicians, which covered current performance, clinical trials, guidelines, and the work-flow changes (available from the authors, prepared for adoption by other facilities). CPOE Enhancements
We revised the existing RBC transfusion order set in our hospital’s electronic medical record (EMR) system (Epic Systems Corporation, Verona, Wisconsin) by adapting the BPA of Goodnough et al.31 Minor changes included permitting transfusion for perioperative patients rather than only cardiothoracic surgery patients, as cardiac disease and anemia risk are not limited to cardiothoracic procedures. The transfusion protocol default RBC dose was changed from two units to one unit. Pre-transfusion options for acetaminophen and diphenhydramine, which were previously ordered automatically, were reconfigured such that they would not be given unless actively ordered; links to evidence-based literature on premedication were provided. Providers were already required to select an indication for transfusion from a dropdown list of options. These indications were revised to comply with the new transfusion guideline. The BPA (Figure 1) was designed to appear when the patient’s last known Hb value exceeded 7 g/dL. The BPA displayed the most recent Hb and required a reason for deviation from protocol (active blood loss, anticipated surgery, Hb < 8 g/dL and either acute myocardial or cerebral ischemia, or “other,” with space to explain off-protocol transfusion). We allowed transfusions for other reasons because we knew that there would be valid explanations (for example, clinical trials and certain specialty treatments requiring higher Hb values) and because providers who wanted to transfuse might otherwise falsify the indication as a workaround. In addition, admission order sets for the BMT service were revised. Existing standing orders for transfusion, which allowed the selection of Hb targets of 8, 9, or 10 g/dL, were replaced with a single option with the institutionwide 7 g/ dL threshold. Implementation
Educational presentations; e-mail notifications, including links to the video; and distribution of badge cards and handouts began in September 2014. The CPOE order set revisions and the BPA were launched on October 4, 2014. The
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BestPractice Advisory (BPA)
Figure 1: The BPA, adapted from the BPA developed by Goodnough et al. (Improved blood utilization using real-time clinical decision support. Transfusion. 2014;54:1358–1365), was designed to appear when the patient’s last known Hb value exceeded 7 g/dL. It advises providers that they are ordering blood for a patient whose most recent Hb value is >7 g/dL and requires them to remove the orders or specify a valid reason for deviating from the 7 g/dL transfusion threshold. HGB [Hb], hemoglobin; PRBC, packed red blood cells; UCSD, University of California San Diego.
revisions to the BMT order set went live on February 2, 2015. Because it was initially possible to bypass the BPA alert without documenting the indication why RBCs were being ordered at an Hb > 7 g/dL, the BPA was reconfigured on March 4, 2015, to require documentation of the indication for off-protocol transfusion of RBCs. After several months, the charts of patients who received multiunit (≥ 2 units) transfusions or RBCs for Hb values ≥ 8 g/dL were reviewed for the necessity of transfusion (8 g/dL was chosen as a threshold to focus attention on more serious outliers and because of the role of clinical judgment for Hb values between 7 and 8 g/dL). Ordering physicians were contacted by e-mail with the results of chart review and a reminder of the new transfusion indications.
tered for Hb ≥ 7 g/dL, and the percentage of multiunit RBC transfusions. RBC transfusions were divided into three periods: • Baseline (January 1, 2014–September 30, 2014) • Intervention (October 1, 2014–April 30, 2015) • Postintervention (May 1, 2015–September 30, 2016) The chi-square test was used to analyze and compare data between the three periods. Finally, our Medicare case mix index (CMI) for all inpatients receiving blood transfusion was monitored to identify any external drivers of changing transfusion rates. UCSD’s Institutional Review Board identified the project as a quality improvement effort and waived the requirement for formal review.
Data Collection and Analysis
RESULTS
All noninfant inpatient RBC transfusions given at UCSD Health between January 1, 2014, and September 30, 2016, were included in our analysis, with two exceptions: units given to patients with ICD-9-CM or ICD-10-CM (International Classification of Diseases, Ninth [or Tenth] Revision) codes for gastrointestinal bleeding, or within 12 hours of a surgical procedure. These transfusions were excluded because of the higher probability of unstable blood volume or special circumstances that might justify off-protocol transfusion. Inpatient discharges with RBC transfusion were identified using transfusion services information system (SoftBank; SCC Soft Computer, Clearwater, Florida). These data were joined with EPIC data to determine the rate of inpatient RBC units transfused per 1,000 patient-days (without exclusions), the percentage of inpatient RBC transfusion units adminis-
There were 65,861 inpatient discharges, 464,424 patientdays, and 36,386 administered RBC units during the study period. The percentage of multiunit transfusion orders are shown in Figure 2a, and the percentage of transfusions given to patients with pretransfusion Hb values ≥ 7 g/dL are shown in Figure 2b. Multiunit transfusions decreased by 67.1%—from 59.9% at baseline to 41.7% during the intervention period and 19.7% during the postintervention period (p < 0.0001). Transfusions for Hb values ≥ 7 g/dL decreased by 47.4%, from 72.3% at baseline to 57.8% during the intervention period and 38.0% during the postintervention period (p < 0.0001). Both measures improved with the launch of the new protocol but showed greater improvement after the BMT order sets and the reconfigured BPA were put in place. A histogram displaying the characteristics of transfusions
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Percentage of Red Blood Cells Transfusion Orders for (a) ≥ 2 Units and (b) Hb ≥ 7 g/dL During the Baseline, Intervention, and Postintervention Periods a
b
Figure 2: As shown in Figure 2a, the interventions were associated with reductions in multiunit transfusions by 67.1%—from 59.9% at baseline (January 1, 2014–September 30, 2014) to 41.7% during the intervention period (October 1, 2014–April 30, 2015) and 19.7% during the postintervention period (May 1, 2015–September 30, 2016) (p < 0.0001). As shown in Figure 2b, transfusions for Hb values ≥ 7 g/dL decreased by 47.4%—from 72.3% at baseline to 57.8% during the intervention period and 38.0% during the postintervention period (p < 0.0001). Hb, hemoglobin; LCL, lower control limit; UCL, upper control limit; Q, quarter.
given to patients on the BMT service is shown in Figure 3. Monthly data points are graphed with the percentage of transfusions for Hb ≥ 7 g/dL on the x-axis and the percentage of multiunit transfusions on the y-axis. Dramatic improvement is evident by the shift to the left and down (arrow). The total RBC transfusion rate (units administered per 1,000 patient-days) decreased from 89.8 at baseline to 78.1 during the intervention period and 72.7 during the postintervention period (p < 0.0001). This reduction translates into approximately 4,203 RBC units during the postintervention period. The estimated savings based on an acquisition cost of $250 per unit was about $1,050,750 per year. Our Medicare CMI increased from 3.57 at baseline to 3.96 during the intervention period, and 4.03 during the postintervention period. DISCUSSION
Our BPA led to a prompt and meaningful improvement in compliance with our transfusion standards. Our project used methods that should be relatively easy to adapt to other hospitals: a CPOE protocol, a BPA, and educational initiatives and tools. Hospitals using paper charts could create similar
written protocols. In addition, the effort was sustainable: Continued use of the BPA required no effort or modification, and ongoing data gathering burden was minimal. Our results are noteworthy because they represent a meaningful improvement in a system already using relatively little blood—our baseline transfusion rate was 18% lower than the national average of Vizient-participating academic medical centers. It is difficult to make a direct comparison with the study conducted by Goodnough et al., which examined systemwide RBC transfusions per 1,000 inpatient discharges, but our preproject transfusion rate was about 75% of their postproject rate (679 vs. about 900 units transfused per 1,000 inpatient discharges). At the same time, our prestudy performance limited the impact of our project. Goodnough et al. limited transfusions for Hb ≥ 8 g/dL to 24% of total transfusions, saving $1.6 million annually; 31 we limited transfusions for Hb ≥ 7 g/dL to 38.0% of the total (and transfusions for Hb ≥ 8 g/dL to less than 8.5% of the total), but our cost savings (at our acquisition cost of $250 per unit; theirs was $225) was only 58.5% of theirs. Like Rana et al.,27 we were more successful at reducing off-protocol transfusions than
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Distribution of Transfusion Orders on the Bone Marrow Transplant (BMT) Service with Hb ≥ 7 g/dL, January 1, 2014–September 30, 2016
Figure 3: Monthly data points are graphed, with the percentage of transfusions for Hb ≥ 7 g/dL on the x-axis and the percentage of multiunit (≥ 2 units) transfusions on the y-axis. Dramatic improvement, as evident by the shift to the left and down (arrow) from the baseline (January 1, 2014–September 30, 2014), intervention (October 1, 2014–April 30, 2015), and postintervention periods (May 1, 2015–September 30, 2016), is shown. Hb, hemoglobin.
total transfusions. We suspect that many transfusions were delayed, rather than prevented, causing the discrepancy between marked improvement in processes and lesser improvement in total utilization. In addition, substantial contributions to month-to-month RBC use occur with massive transfusion and bleeding. Our hospital provides Level 1 trauma care, transplantation services, extracorporeal membrane oxygenation, and ventricular assist device therapies, and treats many cirrhotic patients. This high bleeding risk population might have attenuated the impact of a protocol aimed at restricting transfusions in stable patients. Our study has limitations. We focused on blood management, which is only one way to manage anemia and does nothing to prevent it. We have programs to discourage excessive phlebotomy (educating clinicians about the discomfort, anemia, vein exhaustion, sleep disruption, and other harms and costs of phlebotomy; discouraging “daily labs” and recurring lab orders) and to identify and treat anemia in highrisk patients before admission (for example, elective surgery patients), and to optimize use of platelets and plasma. These measures are partially implemented and are the subject of ongoing improvement efforts. For our protocol compliance measures, we excluded transfusions in patients with acute gastrointestinal bleeding, although such patients also benefit from restrictive transfusion strategies,13 because of the difficulties of assessing clinical stability from hospital charts alone. Future efforts to address this population could include a BPA triggered by normal vital
signs, or targeted education for emergency physicians and gastroenterology consultants who would be involved in most of these cases. We also excluded transfusions given within 12 hours pre- or postsurgery. We know of evidence for restrictive transfusion practices in surgical patients7,10,12 but not in the immediate perioperative period. Such transfusions could be targeted by providing feedback to surgeons and anesthesiologists regarding their patients’ postoperative Hb values, to encourage self-assessment. Also, we did not address outpatient transfusions, which are sometimes made for higher Hb values so patients are not inconvenienced by repeated trips to the infusion center. Also, outpatient transfusions may have been given more often because of our intervention; the combination of outpatient and inpatient transfusions costs yielded 15% less savings than did inpatient transfusions alone. The greatest limitation of our study is a pre-post design, which is somewhat mitigated by the use of run charts to demonstrate trends. Other trends in blood management besides our interventions may have influenced blood utilization, such as the knowledge of trainee physicians beginning to work in July 2014, increased awareness of cost issues or clinical trial results, or other factors. However, the Medicare CMI at UCSD Health increased during the study, which may actually have attenuated our improvement. Data from the latest American Red Cross and the National Blood collection and utilization survey showed an 8.2% decrease in RBC transfusion from 2008 to 2011;23 if that trend continued locally, it could have explained some of our improvement. However,
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the abrupt changes in blood utilization associated with our CPOE enhancements suggest a causal relationship.
8.
CONCLUSION
A restrictive transfusion strategy implemented using a typical quality improvement framework and based on education and CPOE enhancements significantly reduced off-protocol and total blood transfusions. Our success, the success of others,26–28,31 and the availability of resources to support blood management projects19 demonstrate the feasibility of the strategy. Hospital systems can improve patient outcomes while enjoying cost savings with similar efforts; the savings, however, likely depend on the baseline performance, with high-performing institutions saving less than low-performing institutions. Funding. The work was supported by University of California, San Diego Health’s Performance Improvement and Patient Safety Department. Conflicts of Interest. All authors report no conflicts of interest.
Ian Jenkins, MD, SFHM, is Clinical Professor, Department of Medicine, and Chair, Patient Safety Committee, Hospital Medicine, University of California San Diego Health. Jay J. Doucet, MD, is Professor of Surgery, Department of Surgery. Brian Clay, MD, is Clinical Professor, Department of Medicine. Patricia Kopko, MD, is Clinical Professor, Department of Pathology. Donald Fipps, MS, MT(ASCP), SBB, is Director, Clinical Laboratory. Eema Hemmen, MPH, is Director of Analytics; and Debra Paulson, MS, is Analyst, Performance Improvement and Patient Safety. Please address correspondence to Ian Jenkins, [email protected].
ONLINE-ONLY CONTENT See the online version of this article for Appendix 1. Quick Reference Badge Card. Appendix 2. Educational Handout. Appendix 3. Educational Poster.
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REFERENCES 1. Agency for Healthcare Research and Quality. HCUP Statistical Brief 165. Most Frequent Procedures Performed in U.S. Hospitals, 2011. Pfuntner A, Wier LM, Stocks C. Oct 2013. Accessed Apr 24, 2017. https://www.hcup-us.ahrq.gov/ reports/statbriefs/sb165.pdf. 2. Rogers MA, et al. Utilization of blood transfusion among older adults in the United States. Transfusion. 2011;51:710– 718. 3. Qian F, et al. Variation of blood transfusion in patients undergoing major noncardiac surgery. Ann Surg. 2013;257: 266–278. 4. Frank SM, et al. Variability in blood and blood component utilization as assessed by an anesthesia information management system. Anesthesiology. 2012;117:99–106. 5. Shander A, et al. Appropriateness of allogeneic red blood cell transfusion: the International Consensus Conference on Transfusion Outcomes. Transfus Med Rev. 2011;25:232– 246.e53. 6. Callum JL, et al. The AABB recommendations for the Choosing Wisely campaign of the American Board of Internal Medicine. Transfusion. 2014;54:2344–2352. 7. Hébert PC, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl
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J Med. 1999 Feb 11;340:409–417. Erratum in: N Engl J Med. 1999 Apr 1;340:1056. Holst LB, et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med. 2014 Oct 9;371:1381–1391. Robertson CS, et al. Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial. JAMA. 2014 Jul 2;312:36–47. Hajjar LA, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA. 2010 Oct 13;304:1559–1567. Moskowitz DM, et al. The impact of blood conservation on outcomes in cardiac surgery: is it safe and effective? Ann Thorac Surg. 2010;90:451–458. Carson JL, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011 Dec 29;365:2453–2462. Villanueva C, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan 3;368:11– 21. Carson JL, Carless PA, Hébert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2012 Apr 18:CD002042. Carless PA, et al. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2010 Oct 6:CD002042. Salpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review. Am J Med. 2014;127:124–131.e3. Goodnough LT, Shander A. Patient blood management. Anesthesiology. 2012;116:1367–1376. Rhode JM, et al. Health care–associated infection after red blood cell transfusion: a systematic review and meta-analysis. JAMA. 2014 Apr 2;311:1317–1326. Choosing Wisely®. Clinician lists. Accessed Apr 24, 2017. http://www.choosingwisely.org/clinician-lists. Jenkins I, et al. Anemia Prevention and Management Program Implementation Guide. Philadelphia: Society of Hospital Medicine. Accessed Apr 24, 2017. http:// tools.hospitalmedicine.org/resource_rooms/imp_guides/ anemia/anemia_toolkit_final.pdf. The Joint Commission. Implementation guide for the Joint Commission Patient Blood Management Performance Measures. 2011. Accessed Apr 24, 2017. https:// www.jointcommission.org/assets/1/6/ PBM_Implementation_Guide_20110624.pdf. AABB. Building a Better Patient Blood Management Program: Identifying Tools, Solving Problems and Promoting Patient Safety. An AABB White Paper. Apr 2015. Accessed Apr 24, 2017. http://www.aabb.org/pbm/Documents/pbmwhitepaper-form-website.html. US Department of Health and Human Services (DHHS), Office of the Assistant Secretary for Health. The 2011 National Blood Collection and Utilization Survey Report. Washington, DC: DHHS, 2011. Accessed Apr 24, 2017. https://www.aabb.org/research/hemovigilance/ bloodsurvey/Documents/11-nbcus-report.pdf. Marques MB, et al. How we closed the gap between red blood cell utilization and whole blood collections in our institution. Transfusion. 2012;52:1857–1867. Politsmakher A, et al. Effective reduction of blood product use in a community teaching hospital: when less is more. Am J Med. 2013;126:894–902.
ARTICLE IN PRESS Volume ■■, No. ■■, ■■ 2017 26. Garrioch M, et al. Reducing red cell transfusion by audit, education and a new guideline in a large teaching hospital. Transfus Med. 2004;14:25–31. 27. Rana R, et al. Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry. Crit Care Med. 2006;34:1892–1897. 28. Fernández Pérez ER, Winters JL, Gajic O. The addition of decision support into computerized physician order entry reduces red blood cell transfusion resource utilization in the intensive care unit. Am J Hematol. 2007;82:631– 633. 29. Adams ES, et al. Computerized physician order entry with decision support decreases blood transfusions in children. Pediatrics. 2011;127:1112–1119.
7 30. Rothschild JM, et al. Assessment of education and computerized decision support interventions for improving transfusion practice. Transfusion. 2007;47:228–239. 31. Goodnough TL, et al. Improved blood utilization using real-time clinical decision support. Transfusion. 2014;54:1358–1365. 32. Goodnough LT, Baker SA, Shah N. How I use clinical decision support to improve red blood cell utilization. Transfusion. 2016;56:2406–2411. 33. UC San Diego Health System Transfusion Committee/Patient Blood Management Task Force. Transfusing Wisely: Save Blood—Save Lives—Know the Indications. Video. Oct 20, 2014. Accessed Apr 24, 2017. https://youtu.be/ TC7moFLd_Sw.
Transfusing Wisely: Clinical Decision Support Improves Blood Transfusion Practices Ian Jenkins, MD, SFHM; Jay J. Doucet, MD; Brian Clay, MD; Patricia Kopko, MD; Donald Fipps, MS, MT (ASCP), DBB; Eema Hemmen, MPH; Debra Paulson, MS
Background: The cost and risks of red blood cell (RBC) transfusions, along with evidence of overuse, suggest that improving transfusion practices is a key opportunity for health systems to improve both the quality and value of patient care. Previous work, which included a BestPractice Advisory (BPA), was adapted in a quality improvement project designed to reduce both exposure to unnecessary blood products and costs. Methods: A prospective, pre-post study was conducted at an academic medical center with a diverse patient population. All noninfant inpatients without gastrointestinal bleeding who were not within 12 hours of surgical procedures were included. The interventions were education, a BPA, and other enhancements to the computerized provider order entry system. Results: The percentage of multiunit (≥ 2 units) RBC transfusions decreased from 59.9% to 41.7% during the intervention period and to 19.7% postintervention (p < 0.0001). The percentage of inpatient RBC transfusion units administered for hemoglobin (Hb) ≥ 7 g/dL declined from 72.3% to 57.8% during the intervention period and to 38.0% for the postintervention period (p < 0.0001). The overall rate of inpatient RBC transfusion (units administered per 1,000 patientdays without exclusions) decreased from 89.8 to 78.1 during the intervention period and to 72.7 during the postintervention period (p < 0.0001). The estimated annual cost savings was $1,050,750. Conclusion: The interventions reduced multiunit transfusions (by 67.1%) and transfusions for Hb ≥ 7 g/dL (by 47.4%). The improvement in the overall transfusion rate (19.0%) was less marked, limited by better baseline performance relative to other centers.
R
ed blood cell (RBC) transfusion, which has been identified as the most frequently performed hospital procedure in the United States, increased by 134% from 1997 to 2011.1 However, 50% or more of RBC transfusions may be unnecessary,2–5 and the rate of RBC transfusion of RBCs in other developed countries, including Canada, the United Kingdom, and the Netherlands, is more than 25% lower than in the United States.6 A number of clinical trials have shown that restrictive RBC transfusion strategies are either noninferior to or have advantages compared with liberal transfusion strategies in patients with critical illness,7 septic shock,8 closed head injury,9 cardiac surgery,10,11 orthopedic surgery,12 and gastrointestinal bleeding.13 Meta-analyses have suggested in-hospital or overall mortality advantages with restrictive transfusion strategies, as well as superior or equal outcomes with regard to heart failure, rebleeding, infections, and myocardial infarction.14–16 These benefits likely relate to the known risks of blood transfusion, which include hemolytic reactions, circulatory overload, acute lung injury, transmission of infection,17 and a predisposition to hospital-acquired infections of disparate types.18 The cost and risks of RBC transfusions, along with evidence of overuse, suggest that improving transfusion practices 1553-7250/$-see front matter © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjq.2017.04.003
is a key opportunity for health systems to improve both the quality and value of patient care. Excessive transfusions have been identified as an improvement priority in the Choosing Wisely lists of wasteful practices by six professional organizations, including obstetric, hematology, critical care, and anesthesiology societies, and the Society of Hospital Medicine (SHM),19 and reducing excessive transfusion is the subject of an SHM–Society for the Advancement of Blood Management improvement guide.20 The Joint Commission, the AABB, and the US Department of Health and Human Services have recognized the importance of improving blood management.21–23 Previous transfusion improvement efforts have shown both benefits and limitations. Some used labor-intensive interventions24–26 or were limited to the critical care setting.27–29 One effort that focused on education plus audit was associated with a 25% reduction in blood utilization but required intensive chart review and provider contacts.24 Another site achieved a 19% reduction in blood utilization with extensive education, but the mean posttransfusion hemoglobin (Hb) was still > 10 g/dL, indicating high baseline use and insufficient improvement. 26 By requiring approval for nonemergency blood transfusion by a transfusion safety officer, one hospital reduced RBC transfusions by 38%; the hospital also reduced transfusion of plasma and platelets, saving more than $2 million.25 However, this method requires additional staff and may be politically unfeasible. More improvement efforts have focused on computerized provider order entry (CPOE) enhancements, which have
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Clinical Decision Support Improves Blood Transfusion Practices
varied from requiring rationales for transfusions, to providing alerts or recommendations tied to lab values or even vital signs, all of which are less labor intensive. In the ICU setting, CPOE interventions reduced transfusions by 13%–20%.27,28 One study achieved a larger impact in a pediatric ICU.29 In a randomized study, education reduced inappropriate transfusions, and computer decision support reduced it further, but only slightly: from 72% to 60% inappropriate.30 In perhaps the best example of a simple intervention with hospitalwide impact, Goodnough et al. used a BestPractice Advisory (BPA) to achieve 24% fewer transfusions, with an estimated annual savings of $1.6 million.31 They later showed that the effort was associated with improved inpatient mortality,32 but the work has not been duplicated. University of California San Diego (UCSD) Health’s transfusion rates for the first three quarters of 2014 were lower than mean rates at Vizient-participating academic medical centers (64.9 per 1,000 discharges vs. 92.1 for California centers and 79.2 nationally). We hypothesized that the use of a revised CPOE transfusion protocol and a BPA for transfusions above the Hb threshold, supported by an educational campaign and provider feedback, would further reduce inappropriate transfusions. We adapted the BPA used by Goodnough et al.,31 with exceptions for perioperative patients and active bleeding, and studied the effects in a quality improvement project with a pre-post design. METHODS Setting and Overview
UCSD Health is a 563-bed urban, academic medical center with active oncology, bone marrow transplant (BMT), trauma, orthopedic, and cardiothoracic surgery services, which transfuse significant volumes of blood, and a 49-bed neonatal ICU. From January 1, 2014, through September 30, 2014, our baseline total inpatient RBC transfusion rate was 89.8 units per 1,000 patient-days. This figure excludes neonatal transfusions, which are small fractions of units of blood, but includes rare pediatric patients. A multidisciplinary team was formed in January 2014 with representatives from transfusion medicine, surgery, critical care, nursing, hematology-oncology, hospital medicine, performance improvement, and information technology. The team reviewed the transfusion literature, focusing on clinical trials, meta-analyses, guidelines, and improvement efforts, and developed a list of evidence-based indications for RBC transfusion (Table 1) as well as educational tools. The tools included a quick reference ID badge card (Appendix 1, available in online article), handouts (Appendix 2, available in online article), and posters (Appendix 3, available in online article) reviewing the transfusion indications and reminders about the risks of transfusion; subtle differences among them reflected formatting constraints. We also prepared a video featuring hospital leaders33 and Microsoft PowerPoint presentations to be used in teaching sessions for trainee and
Table 1. The “4 S” Indications for Blood Transfusion Severe Symptoms due to Anemia (In)Stability: unstable blood volume due to bleeding Seven g/dL, if an Hb threshold is used And Single Unit transfusions are preferred unless the patient is unstable. For patients with active cardiac or brain ischemia, an Hb target of 8 g/dL is advised. Hb, hemoglobin.
faculty physicians, which covered current performance, clinical trials, guidelines, and the work-flow changes (available from the authors, prepared for adoption by other facilities). CPOE Enhancements
We revised the existing RBC transfusion order set in our hospital’s electronic medical record (EMR) system (Epic Systems Corporation, Verona, Wisconsin) by adapting the BPA of Goodnough et al.31 Minor changes included permitting transfusion for perioperative patients rather than only cardiothoracic surgery patients, as cardiac disease and anemia risk are not limited to cardiothoracic procedures. The transfusion protocol default RBC dose was changed from two units to one unit. Pre-transfusion options for acetaminophen and diphenhydramine, which were previously ordered automatically, were reconfigured such that they would not be given unless actively ordered; links to evidence-based literature on premedication were provided. Providers were already required to select an indication for transfusion from a dropdown list of options. These indications were revised to comply with the new transfusion guideline. The BPA (Figure 1) was designed to appear when the patient’s last known Hb value exceeded 7 g/dL. The BPA displayed the most recent Hb and required a reason for deviation from protocol (active blood loss, anticipated surgery, Hb < 8 g/dL and either acute myocardial or cerebral ischemia, or “other,” with space to explain off-protocol transfusion). We allowed transfusions for other reasons because we knew that there would be valid explanations (for example, clinical trials and certain specialty treatments requiring higher Hb values) and because providers who wanted to transfuse might otherwise falsify the indication as a workaround. In addition, admission order sets for the BMT service were revised. Existing standing orders for transfusion, which allowed the selection of Hb targets of 8, 9, or 10 g/dL, were replaced with a single option with the institutionwide 7 g/ dL threshold. Implementation
Educational presentations; e-mail notifications, including links to the video; and distribution of badge cards and handouts began in September 2014. The CPOE order set revisions and the BPA were launched on October 4, 2014. The
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BestPractice Advisory (BPA)
Figure 1: The BPA, adapted from the BPA developed by Goodnough et al. (Improved blood utilization using real-time clinical decision support. Transfusion. 2014;54:1358–1365), was designed to appear when the patient’s last known Hb value exceeded 7 g/dL. It advises providers that they are ordering blood for a patient whose most recent Hb value is >7 g/dL and requires them to remove the orders or specify a valid reason for deviating from the 7 g/dL transfusion threshold. HGB [Hb], hemoglobin; PRBC, packed red blood cells; UCSD, University of California San Diego.
revisions to the BMT order set went live on February 2, 2015. Because it was initially possible to bypass the BPA alert without documenting the indication why RBCs were being ordered at an Hb > 7 g/dL, the BPA was reconfigured on March 4, 2015, to require documentation of the indication for off-protocol transfusion of RBCs. After several months, the charts of patients who received multiunit (≥ 2 units) transfusions or RBCs for Hb values ≥ 8 g/dL were reviewed for the necessity of transfusion (8 g/dL was chosen as a threshold to focus attention on more serious outliers and because of the role of clinical judgment for Hb values between 7 and 8 g/dL). Ordering physicians were contacted by e-mail with the results of chart review and a reminder of the new transfusion indications.
tered for Hb ≥ 7 g/dL, and the percentage of multiunit RBC transfusions. RBC transfusions were divided into three periods: • Baseline (January 1, 2014–September 30, 2014) • Intervention (October 1, 2014–April 30, 2015) • Postintervention (May 1, 2015–September 30, 2016) The chi-square test was used to analyze and compare data between the three periods. Finally, our Medicare case mix index (CMI) for all inpatients receiving blood transfusion was monitored to identify any external drivers of changing transfusion rates. UCSD’s Institutional Review Board identified the project as a quality improvement effort and waived the requirement for formal review.
Data Collection and Analysis
RESULTS
All noninfant inpatient RBC transfusions given at UCSD Health between January 1, 2014, and September 30, 2016, were included in our analysis, with two exceptions: units given to patients with ICD-9-CM or ICD-10-CM (International Classification of Diseases, Ninth [or Tenth] Revision) codes for gastrointestinal bleeding, or within 12 hours of a surgical procedure. These transfusions were excluded because of the higher probability of unstable blood volume or special circumstances that might justify off-protocol transfusion. Inpatient discharges with RBC transfusion were identified using transfusion services information system (SoftBank; SCC Soft Computer, Clearwater, Florida). These data were joined with EPIC data to determine the rate of inpatient RBC units transfused per 1,000 patient-days (without exclusions), the percentage of inpatient RBC transfusion units adminis-
There were 65,861 inpatient discharges, 464,424 patientdays, and 36,386 administered RBC units during the study period. The percentage of multiunit transfusion orders are shown in Figure 2a, and the percentage of transfusions given to patients with pretransfusion Hb values ≥ 7 g/dL are shown in Figure 2b. Multiunit transfusions decreased by 67.1%—from 59.9% at baseline to 41.7% during the intervention period and 19.7% during the postintervention period (p < 0.0001). Transfusions for Hb values ≥ 7 g/dL decreased by 47.4%, from 72.3% at baseline to 57.8% during the intervention period and 38.0% during the postintervention period (p < 0.0001). Both measures improved with the launch of the new protocol but showed greater improvement after the BMT order sets and the reconfigured BPA were put in place. A histogram displaying the characteristics of transfusions
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Clinical Decision Support Improves Blood Transfusion Practices
Percentage of Red Blood Cells Transfusion Orders for (a) ≥ 2 Units and (b) Hb ≥ 7 g/dL During the Baseline, Intervention, and Postintervention Periods a
b
Figure 2: As shown in Figure 2a, the interventions were associated with reductions in multiunit transfusions by 67.1%—from 59.9% at baseline (January 1, 2014–September 30, 2014) to 41.7% during the intervention period (October 1, 2014–April 30, 2015) and 19.7% during the postintervention period (May 1, 2015–September 30, 2016) (p < 0.0001). As shown in Figure 2b, transfusions for Hb values ≥ 7 g/dL decreased by 47.4%—from 72.3% at baseline to 57.8% during the intervention period and 38.0% during the postintervention period (p < 0.0001). Hb, hemoglobin; LCL, lower control limit; UCL, upper control limit; Q, quarter.
given to patients on the BMT service is shown in Figure 3. Monthly data points are graphed with the percentage of transfusions for Hb ≥ 7 g/dL on the x-axis and the percentage of multiunit transfusions on the y-axis. Dramatic improvement is evident by the shift to the left and down (arrow). The total RBC transfusion rate (units administered per 1,000 patient-days) decreased from 89.8 at baseline to 78.1 during the intervention period and 72.7 during the postintervention period (p < 0.0001). This reduction translates into approximately 4,203 RBC units during the postintervention period. The estimated savings based on an acquisition cost of $250 per unit was about $1,050,750 per year. Our Medicare CMI increased from 3.57 at baseline to 3.96 during the intervention period, and 4.03 during the postintervention period. DISCUSSION
Our BPA led to a prompt and meaningful improvement in compliance with our transfusion standards. Our project used methods that should be relatively easy to adapt to other hospitals: a CPOE protocol, a BPA, and educational initiatives and tools. Hospitals using paper charts could create similar
written protocols. In addition, the effort was sustainable: Continued use of the BPA required no effort or modification, and ongoing data gathering burden was minimal. Our results are noteworthy because they represent a meaningful improvement in a system already using relatively little blood—our baseline transfusion rate was 18% lower than the national average of Vizient-participating academic medical centers. It is difficult to make a direct comparison with the study conducted by Goodnough et al., which examined systemwide RBC transfusions per 1,000 inpatient discharges, but our preproject transfusion rate was about 75% of their postproject rate (679 vs. about 900 units transfused per 1,000 inpatient discharges). At the same time, our prestudy performance limited the impact of our project. Goodnough et al. limited transfusions for Hb ≥ 8 g/dL to 24% of total transfusions, saving $1.6 million annually; 31 we limited transfusions for Hb ≥ 7 g/dL to 38.0% of the total (and transfusions for Hb ≥ 8 g/dL to less than 8.5% of the total), but our cost savings (at our acquisition cost of $250 per unit; theirs was $225) was only 58.5% of theirs. Like Rana et al.,27 we were more successful at reducing off-protocol transfusions than
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Distribution of Transfusion Orders on the Bone Marrow Transplant (BMT) Service with Hb ≥ 7 g/dL, January 1, 2014–September 30, 2016
Figure 3: Monthly data points are graphed, with the percentage of transfusions for Hb ≥ 7 g/dL on the x-axis and the percentage of multiunit (≥ 2 units) transfusions on the y-axis. Dramatic improvement, as evident by the shift to the left and down (arrow) from the baseline (January 1, 2014–September 30, 2014), intervention (October 1, 2014–April 30, 2015), and postintervention periods (May 1, 2015–September 30, 2016), is shown. Hb, hemoglobin.
total transfusions. We suspect that many transfusions were delayed, rather than prevented, causing the discrepancy between marked improvement in processes and lesser improvement in total utilization. In addition, substantial contributions to month-to-month RBC use occur with massive transfusion and bleeding. Our hospital provides Level 1 trauma care, transplantation services, extracorporeal membrane oxygenation, and ventricular assist device therapies, and treats many cirrhotic patients. This high bleeding risk population might have attenuated the impact of a protocol aimed at restricting transfusions in stable patients. Our study has limitations. We focused on blood management, which is only one way to manage anemia and does nothing to prevent it. We have programs to discourage excessive phlebotomy (educating clinicians about the discomfort, anemia, vein exhaustion, sleep disruption, and other harms and costs of phlebotomy; discouraging “daily labs” and recurring lab orders) and to identify and treat anemia in highrisk patients before admission (for example, elective surgery patients), and to optimize use of platelets and plasma. These measures are partially implemented and are the subject of ongoing improvement efforts. For our protocol compliance measures, we excluded transfusions in patients with acute gastrointestinal bleeding, although such patients also benefit from restrictive transfusion strategies,13 because of the difficulties of assessing clinical stability from hospital charts alone. Future efforts to address this population could include a BPA triggered by normal vital
signs, or targeted education for emergency physicians and gastroenterology consultants who would be involved in most of these cases. We also excluded transfusions given within 12 hours pre- or postsurgery. We know of evidence for restrictive transfusion practices in surgical patients7,10,12 but not in the immediate perioperative period. Such transfusions could be targeted by providing feedback to surgeons and anesthesiologists regarding their patients’ postoperative Hb values, to encourage self-assessment. Also, we did not address outpatient transfusions, which are sometimes made for higher Hb values so patients are not inconvenienced by repeated trips to the infusion center. Also, outpatient transfusions may have been given more often because of our intervention; the combination of outpatient and inpatient transfusions costs yielded 15% less savings than did inpatient transfusions alone. The greatest limitation of our study is a pre-post design, which is somewhat mitigated by the use of run charts to demonstrate trends. Other trends in blood management besides our interventions may have influenced blood utilization, such as the knowledge of trainee physicians beginning to work in July 2014, increased awareness of cost issues or clinical trial results, or other factors. However, the Medicare CMI at UCSD Health increased during the study, which may actually have attenuated our improvement. Data from the latest American Red Cross and the National Blood collection and utilization survey showed an 8.2% decrease in RBC transfusion from 2008 to 2011;23 if that trend continued locally, it could have explained some of our improvement. However,
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the abrupt changes in blood utilization associated with our CPOE enhancements suggest a causal relationship.
8.
CONCLUSION
A restrictive transfusion strategy implemented using a typical quality improvement framework and based on education and CPOE enhancements significantly reduced off-protocol and total blood transfusions. Our success, the success of others,26–28,31 and the availability of resources to support blood management projects19 demonstrate the feasibility of the strategy. Hospital systems can improve patient outcomes while enjoying cost savings with similar efforts; the savings, however, likely depend on the baseline performance, with high-performing institutions saving less than low-performing institutions. Funding. The work was supported by University of California, San Diego Health’s Performance Improvement and Patient Safety Department. Conflicts of Interest. All authors report no conflicts of interest.
Ian Jenkins, MD, SFHM, is Clinical Professor, Department of Medicine, and Chair, Patient Safety Committee, Hospital Medicine, University of California San Diego Health. Jay J. Doucet, MD, is Professor of Surgery, Department of Surgery. Brian Clay, MD, is Clinical Professor, Department of Medicine. Patricia Kopko, MD, is Clinical Professor, Department of Pathology. Donald Fipps, MS, MT(ASCP), SBB, is Director, Clinical Laboratory. Eema Hemmen, MPH, is Director of Analytics; and Debra Paulson, MS, is Analyst, Performance Improvement and Patient Safety. Please address correspondence to Ian Jenkins, [email protected].
ONLINE-ONLY CONTENT See the online version of this article for Appendix 1. Quick Reference Badge Card. Appendix 2. Educational Handout. Appendix 3. Educational Poster.
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7 30. Rothschild JM, et al. Assessment of education and computerized decision support interventions for improving transfusion practice. Transfusion. 2007;47:228–239. 31. Goodnough TL, et al. Improved blood utilization using real-time clinical decision support. Transfusion. 2014;54:1358–1365. 32. Goodnough LT, Baker SA, Shah N. How I use clinical decision support to improve red blood cell utilization. Transfusion. 2016;56:2406–2411. 33. UC San Diego Health System Transfusion Committee/Patient Blood Management Task Force. Transfusing Wisely: Save Blood—Save Lives—Know the Indications. Video. Oct 20, 2014. Accessed Apr 24, 2017. https://youtu.be/ TC7moFLd_Sw.