Optimizing Inpatient Blood Utilization Using Real-Time Clinical Decision Support

Abstract

Background Red blood cell (RBC) transfusion is a common medical procedure. While it offers clinical benefits for many, hemodynamically stable patients are often subjected to unwarranted transfusions, with the potential to lead to adverse consequences. We created a real-time clinical decision support (CDS) tool in the electronic health record system to address this problem and optimize transfusion practice as part of an institutional multidisciplinary, team-based patient blood management program. Methods The real-time CDS tool incorporated the transfusion guidelines published by the AABB. The tool was deployed as a dynamic order set within the computerized provider order entry interface. Prior to implementation, extensive education and outreach to increase provider engagement were provided. The CDS tool was launched in September 2015. Results The percentage of guideline-indicated RBC transfusions increased from a baseline of 43.6 to 54.2% while the percentage of multiunit (≥ 2 units) RBC transfusions decreased from 31.3 to 22.7% between September 2014 and July 2019. The estimated minimum cost saving over the entire study period was $36,519.36. Conclusion Our intervention increased guideline-indicated transfusions by 10.6% and reduced multiunit transfusions by 8.6%. The adoption of a dynamic order set for the CDS tool, as opposed to an interruptive alert that displays static alert messages, allowed for more customized and tighter control of RBC orders, leading to a sustained improvement in our transfusion practice.

Passive order auditing associated with reductions in red blood cell utilization: National blood shortage experience

“…[4][5][6]10 A restrictive transfusion policy incorporating active, passive, or retrospective audits can reduce unnecessary transfusions. [11][12][13][14][15][16][17] Active auditing involves reviewing RBC orders and contacting providers at the time of order. While effective at reducing transfusion, this strategy is resource intensive and delays blood product release.…”

“…Passive order auditing can be accomplished by integrating best practice alerts (BPA) and real-time clinical decision support (CDS) into computerized order entry. [11][12][13][14]18,19 CDS incorporating pre-transfusion hemoglobin values can increase adherence to restrictive transfusion guidelines and reduce RBC utilization and associated costs. 11,12,14,16 CDS can be an effective tool to complement a patient blood management program.…”

“…[11][12][13][14]18,19 CDS incorporating pre-transfusion hemoglobin values can increase adherence to restrictive transfusion guidelines and reduce RBC utilization and associated costs. 11,12,14,16 CDS can be an effective tool to complement a patient blood management program. 5,11,[20][21][22] In addition to conserving inventory, reducing unnecessary transfusions also reduces associated risks and complications.…”

“…11,12,14,16 CDS can be an effective tool to complement a patient blood management program. 5,11,[20][21][22] In addition to conserving inventory, reducing unnecessary transfusions also reduces associated risks and complications. 5,11,17,23 The 2016 Clinical Practice Guidelines from the AABB recommend a pre-transfusion hemoglobin threshold of 7-8 g/dL in most hemodynamically stable adult patients.…”

“…5,11,[20][21][22] In addition to conserving inventory, reducing unnecessary transfusions also reduces associated risks and complications. 5,11,17,23 The 2016 Clinical Practice Guidelines from the AABB recommend a pre-transfusion hemoglobin threshold of 7-8 g/dL in most hemodynamically stable adult patients. 24 Lowering the pre-transfusion hemoglobin threshold from 7.0 to 6.5 g/dL or lower in stable, asymptomatic patients, while outside of evidence-based practice, has been proposed as one strategy to conserve RBCs during long-term severe blood supply shortages.…”