Targeting continuing medical education on decision makers: Who decides to transfuse blood?

Abstract

A communication analysis study was designed and conducted to analyze patterns of communication between operating room (OR) personnel about transfusion practice during open heart surgery. The purpose was to identib the transfusion medicine decision maker in order to target OR personnel for subsequent continuing medical education (CME). Targeting the decision makers for CME intervention would ( I ) improve transfusion practice for quality assurance and ( 2 ) increase the efficiency ofproviding CME. The results of our analysis indicate that the surgical team is the primary decision maker and that transfusion medicine education programs designed to reduce homologous blood exposure in open heartsurgery should be directed particularly at this group. This may provide a mechanism for more efJicient CME by focusing on physicians responsible for making decisions about resource allocation.

Survey to assess knowledge, attitude and practices for safe and efficient vein‐to‐vein transfusion practices and effect of educational intervention in a hospital setting

“…The results of this analysis indicated that transfusion medicine education programmes should be designed to reduce homologous blood exposure. 17 Ironic compared to the usual concept that good knowledge translates to good practice, in the present study, practices were found to be better than attitude and knowledge. This was probably because the induction and educational module consisted more of pictorial depictions and video demonstrations, which influence practices better.…”

Discharge haematocrit as clinical indicator for blood transfusion audit in surgery patients

“…One inherent difficulty in assessing the relative risks and benefits in the decision to transfuse is that the benefit of blood for the individual patient can be appreciated immediately, whereas the complications of blood are often seen at a time remote to the transfusion event, many years later (Welch et al, 1992). Within the traditional concept that blood is a useful therapeutic intervention, it is understandable that efforts to curtail unnecessary transfusions have been largely unsuccessful; despite guidelines (NIH, 1988) and utilization review recommendations (JCAHO, 1988;Silberstein et al, 1989) for blood transfusions, evidence indicates continued inappropriate use (Friedman, 1978;Friedman et al, 1980;Coffin et al, 1989;Goodnough et al, 1991). The concept of blood transfusion as an outcome to be avoided if possible (American College of Physicians 1992; Welch e l al., 1992) has arisen from issues of blood risks over the last 10 years; the legislation of blood shield laws by nearly every state that defines blood as a service, rather than as a product whose safety cannot be warranted is based on the concept that blood administration has inherent risks (Zuck, 1990).…”

“…In coronary artery bypass graft surgery, 79% of blood units were transfused on the day of surgery (Goodnough et al, 1994), so that utilization review criteria and physician education programmes that focus on the nadir haematocrit as a clinical indicator (NIH, 1988;Silberstein et af., 1989) may have limited effectiveness in this setting. Secondly, the discharge haernatocrit has been used as a parameter to determine blood lost during hospitalization (Goodnough et al, 1991), and could therefore serve as a clinical indicator in which utilization review for transfusion appropriateness is defined by each patient's red cell losses as a percentage of their initial circulating red cell volume. Finally, transfusion decisions prior to discharge are made on the basis of this recorded haematocrit, in which the blood volume status of the patient is stable and the degree of anaemia is accurately reflected by the level of haematocrit.…”

“…These are particularly difficult to apply to patients recovering postoperatively because anaemia is only one of many factors that affect recovery. The discharge haematocrit may need to be coupled with other factors, such as admission haematocrit, in order to determine the red cell volume lost as a percentage of each patient's initial red cell volume in order to evaluate transfusion therapy in the surgical setting (Goodnough et al, 1991). Among the three surgical groups in our study, the prevalence of patients who were identified by the discharge haematocrit suggests that this clinical indicator can be used effectively for utilization review and for physician-targeted transfusion medicine education programmes (Salem-Schatz et al, 1990;Lomas et al, 1991;Welch et al, 1992).…”

“…Four hundred and ninety-eight coronary artery bypass graft (CABG) patients (surgical Group I) were audited from 18 tertiary care hospitals affiliated to Transfusion Medicine Academic Award (TMAA) programmes (Goodnough et al, 1991). Patients scheduled for elective, first-time CABG were monitored for transfusion events; patients who predonated autologous blood, patients who died in hospital, and patients who underwent re-exploration during hospitalization were excluded.…”