A retrospective observational analysis of red blood cell transfusion practices in stable, non-bleeding adult patients admitted to nine medical-surgical intensive care units

Abstract

Background Red blood cell (RBC) transfusions are common procedures performed in the intensive care unit (ICU). However, conservative transfusion approaches have been recommended to avoid RBC transfusions that are not clinically necessary and to achieve optimal patient outcomes. The objective of this study was to examine the utilization and costs of RBC transfusions in medical-surgical ICUs and to compare this information against clinical guideline recommendations for best practice. Methods Retrospective observational analysis of RBC transfusions in stable, non-bleeding adult patients was examined in a geographically-defined, population-based cohort of nine integrated ICUs between April 1, 2014 and December 31, 2016. RBC transfusions associated with a pre-transfusion hemoglobin value of 70 g/L or more were examined through linear and logistic regression. The total costs of RBC transfusions, based on the RBC unit cost, were estimated. Results A total of 4632 RBC transfusions (2287 ICU admissions) were included. Pre-transfusion hemoglobin values were identified for 4487 transfusions. On average, 61% occurred at or above a hemoglobin value of 70 g/L (mean 73.4 ± 9.2 g/L). Factors associated with such transfusions included being male, age over 75, Sequential Organ Failure Assessment (SOFA) score greater or equal to 10, transfer from operating room, gastrointestinal bleeding, and trauma. A pre-transfusion hemoglobin value at or above 70 g/L was associated with increased odds of ICU mortality; there was no impact on overall hospital mortality. The total estimated cost of RBC transfusions was $2.99M Canadian dollars (CAD), with $1.82M CAD attributed to those with a hemoglobin value at or above 70 g/L. Conclusions Over half of the examined RBC transfusions may not have aligned with recommended best practice; this suggests significant opportunity for improvement. The present findings are an essential step towards optimizing RBC transfusions in the ICU. Electronic supplementary material The online version of this article (10.1186/s40560-019-0375-3) contains supplementary material, which is available to authorized users.

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

“…We report an increased LOS by 8.2 days (95% CI 4.09–12.43; p < 0.01) in those transfused for chronic blood loss in agreement with Goodnough et al and Fuller et al who reported an increase in hospital LOS by 3.9 and 13.4 days, respectively, with a liberal transfusion strategy 33,46 . In contrast Soril et al 22 in their descriptive study of liberal transfusion strategies involving a combined cohort of medical and surgical ICU patients with chronic blood loss anaemia reported an increase in hospital mortality (OR 1.14, 95% CI 0.99–1.31) but a lower LOS ( β 1 –5.36, 95% CI −8.81 to −1.91; p = 0.002). These findings are contrary to our observations and published literature, thus far.…”

“…Similarly, transfusion events in opposition to a restrictive threshold impacts clinical outcomes (mortality, LOS) with economic consequences (cost of care). Patients had a mean pre‐transfusion Hb trigger of 6.75 g/dl in conformity with AABB guidelines and in contrast to the prevailing literature 20‐24 . Emphasis on clinician education and electronic medical record best practice advisories and decision support tools advocated at our institution could be attributed to this observation (Table S2).…”

“…Restrictive PRBC guidelines have been adopted by several hospitals and academic institutions, including ours. Current adherence to the aforesaid guidelines is unknown given how recent these guidelines are, and previous reports indicate varying blood management practice patterns with a wide range of pre‐transfusion Hb in the medical intensive care unit (MICU) (ranging 7–9 g/dl) 20‐24 . Equally, the physiological compulsions that coerce the physician to deviate from established guidelines and the cost accrued with liberal transfusion strategies in the critically ill have not been clearly elucidated.…”

Optimizing red blood cell transfusion practices in the intensive care unit: a multi-phased health technology reassessment

“…The HTR programme is comprised of three phases and the findings from the first two completed phases (30–32) are summarized in the Supplementary Methods. For the present study, Phase III, a small-scale pilot implementation study was conducted in a single ICU to evaluate the feasibility of implementing a bundle of behavior change interventions aimed at optimizing RBC transfusions (22).…”

“…Therefore, to add to the practical HTR knowledge base, we set out to complete a multi-phase HTR of the candidate technology, RBC transfusions for critically ill patients. In alignment with the conceptual model, this HTR consisted of three phases and the findings from Phase I and II have been previously published (30–32). In this present study, we report the results of the third and final phase of the HTR: Policy Action .…”