The appropriateness of red blood cell use and the extent of overtransfusion: right decision? Right amount?

Abstract

BACKGROUND:Shrinkage of the donor pool coupled with an increasing demand for blood presents a major challenge to maintaining an adequate blood supply. Consequently it has become even more important to reduce inappropriate blood use, including decisions about when and how much blood to prescribe. This study aimed to ascertain the levels of inappropriate practice and factors associated with it. STUDY DESIGN AND METHODS:The medical records of a randomly selected sample of hospital patients in Northern Ireland who received a red blood cell transfusion during 2005 (n = 1474) were reviewed, and inappropriate transfusion and overtransfusion criteria were applied. Logistic regression models were used to identify factors associated with inappropriate practice and overtransfusion. RESULTS: In this study 23% of transfusions were considered inappropriate, occurring most commonly where the lowest hemoglobin (Hb) threshold for transfusion applied. Younger patients, those undergoing surgery, and those with lower comorbidity and higher Hb values were most likely to have an inappropriate transfusion. Among patients appropriately transfused, 19% were overtransfused. Females and those of lower weight (<65 kg) were most likely to be overtransfused. CONCLUSION: While the choice of criteria used to judge decisions will influence the absolute level of inappropriate or overtransfusion reported, our findings suggest that a significant minority of clinicians are either unaware of or are reluctant to accept lower transfusion thresholds. To improve further improve transfusion practice we suggest that barriers to the implementation of recommended transfusion thresholds should be examined and guidance on an appropriate posttransfusion Hb level developed.

Transfusions in Danish medical patients: adherence to guidelines and effect of interventions

“…Number of cases of overtransfusion in this subgroup was 10 (13%), when overtransfusion was defined as post transfusion Hb of 1.2 mmol/L higher than the threshold set for that group of patients. 6 In most inpatient transfusion episodes, it was not possible to determine the charge of the person making the primary transfusion decision, since decisions were made in a team of junior and senior doctors. All transfusion decisions in the outpatient clinic were made by or supervised by a senior specialist.…”

“…Other studies have shown that overtransfusion is frequent 6 when the level of post transfusion hemoglobin (Hb) is compared to current guidelines. 3 This seems to be one of the reasons for the high transfusion rate in Denmark, and our hypothesis was…”

Variation in red blood cell transfusion thresholds in critically ill patients

“…Despite this, substantial variability in transfusion practice persists [2]. It is important to identify contemporary variability, and which patient, provider, and institutional factors drive this variability.…”

Single‐unit transfusions in the obstetric setting: a qualitative study

“…Although small in absolute terms, this is high relative to other high-resource countries. 3 Wide variation in transfusion rates [4][5][6][7][8] is evident, including between hospitals. 3 Studies reporting transfusion practices outside of obstetrics frequently report a preference for at least 2 units when blood is transfused.…”

“…3 Studies reporting transfusion practices outside of obstetrics frequently report a preference for at least 2 units when blood is transfused. 4,9,10 In nonobstetric patients, liberal blood transfusion has been associated with higher morbidity (cardiac, renal, and neurologic events and higher infection rates) and increased mortality compared with patients who received more restrictive transfusion. 7,8,11 Other transfusion risks include receiving the wrong blood, transfusion-transmitted infection, immunomodulation, 11 and red cell alloimmunization.…”