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Lin Y, Levinson W, Day D, Lett R, Petraszko T, Huynh T, Patey AM. Using Blood Wisely: lessons learnt in establishing a national implementation programme to reduce inappropriate red blood cell transfusion. BMJ Open Qual 2024; 13:e002660. [PMID: 38569664 PMCID: PMC11002408 DOI: 10.1136/bmjoq-2023-002660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 03/17/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Up to 50% of blood is transfused inappropriately despite best evidence. In 2020, Choosing Wisely Canada launched a major national programme, 'Using Blood Wisely', the aim was to engage hospitals to audit their red blood cell transfusion use against national benchmarks and participate in a programme to decrease inappropriate use. STUDY DESIGN Using Blood Wisely is a quality improvement programme including national benchmarks, an audit tool, recommended evidence-based effective interventions and a designation to reward success. Hospital engagement was measured using the number of hospitals signing up, performing a baseline audit, submitting the planning survey, entering two or more audits and achieving hospital designation. Barriers to implementation were collected. RESULTS From 1 September 2020 to 31 December 2022, 229 individual hospitals signed up over time to participate. Their results are reported as 159 hospitals and hospital groups. Collectively, this accounts for 72% of the blood used in Canada. Overall, 147 (92%) performed a baseline audit, 10 (6%) submitted a planning survey and 130 (82%) entered two or more audits. At baseline (time of enrolment), 75 (51%) met both benchmarks. The designation was awarded to 62 (39%) hospital groups (a total of 105 individual hospitals) that met and sustained benchmarks. Barriers to implementation included human resource shortages, lack of local expertise to advise the team, need for more education of transfusion prescribers and competing priorities. CONCLUSION In its initial phase, Using Blood Wisely engaged a substantial number of hospitals in transfusion quality improvement work and maintained that engagement. This large-scale engagement across a big country was more successful than anticipated. Additional efforts are needed to rigorously evaluate the programme's impact on utilisation.
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Affiliation(s)
- Yulia Lin
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Wendy Levinson
- Choosing Wisely Canada, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Doreen Day
- Choosing Wisely Canada, Toronto, Ontario, Canada
| | - Ryan Lett
- Department of Anesthesiology, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Tanya Petraszko
- Canadian Blood Services, Ottawa, Ontario, Canada
- Department of Medicine, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Tai Huynh
- Choosing Wisely Canada, Toronto, Ontario, Canada
| | - Andrea M Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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2
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Evans HG, Murphy MF, Foy R, Dhiman P, Green L, Kotze A, von Neree L, Palmer AJ, Robinson SE, Shah A, Tomini F, Trompeter S, Warnakulasuriya S, Wong WK, Stanworth SJ. Harnessing the potential of data-driven strategies to optimise transfusion practice. Br J Haematol 2024; 204:74-85. [PMID: 37964471 DOI: 10.1111/bjh.19158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/24/2023] [Accepted: 10/03/2023] [Indexed: 11/16/2023]
Abstract
No one doubts the significant variation in the practice of transfusion medicine. Common examples are the variability in transfusion thresholds and the use of tranexamic acid for surgery with likely high blood loss despite evidence-based standards. There is a long history of applying different strategies to address this variation, including education, clinical guidelines, audit and feedback, but the effectiveness and cost-effectiveness of these initiatives remains unclear. Advances in computerised decision support systems and the application of novel electronic capabilities offer alternative approaches to improving transfusion practice. In England, the National Institute for Health and Care Research funded a Blood and Transplant Research Unit (BTRU) programme focussing on 'A data-enabled programme of research to improve transfusion practices'. The overarching aim of the BTRU is to accelerate the development of data-driven methods to optimise the use of blood and transfusion alternatives, and to integrate them within routine practice to improve patient outcomes. One particular area of focus is implementation science to address variation in practice.
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Affiliation(s)
- H G Evans
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - M F Murphy
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
| | - R Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - P Dhiman
- Centre for Statistics in Medicine, Botnar Research Centre, Oxford, UK
| | - L Green
- Blizard Institute, Queen Mary University of London, London, UK
- Barts Health NHS Trust, London, UK
- NHS Blood and Transplant, London, UK
| | - A Kotze
- Leeds Teaching Hospitals, Leeds, UK
| | - L von Neree
- University College London Hospitals NHS Foundation Trust, London, UK
| | - A J Palmer
- Nuffield Orthopaedic Centre, Oxford University NHS Foundation Trust, Oxford, UK
| | - S E Robinson
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Shah
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - F Tomini
- Queen Mary University of London, London, UK
| | - S Trompeter
- University College London Hospitals NHS Foundation Trust, London, UK
- University College London, London, UK
| | - S Warnakulasuriya
- University College London Hospitals NHS Foundation Trust, London, UK
- University College London, London, UK
| | - W K Wong
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S J Stanworth
- NIHR Blood and Transplant Research Unit in Data Driven Transfusion Practice, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK
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3
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Liao YH, Tang KP, Chou CY, Kuo CF, Tsai SY. Assessment of factors influencing physicians' intention to prescribe transfusion using the theory of planned behavior. BMC Health Serv Res 2023; 23:973. [PMID: 37684594 PMCID: PMC10492397 DOI: 10.1186/s12913-023-09946-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Blood shortage is a persistent problem affecting Taiwan's health-care system. The theory of planned behavior (TPB) has been commonly used in studies of health advocacy. The purpose of this study was to develop a questionnaire measuring clinicians' intention to prescribe transfusion based on the TPB. METHOD A questionnaire comprising 15 items for assessing clinicians' intention to prescribe blood transfusion was developed, and it collected demographic characteristics, tested patient blood management (PBM) and perceived knowledge of PBM. Furthermore, the questionnaire contained four subscales related to the TPB. A total of 129 clinicians participated in this pilot study between July and December2020. Item analysis and exploratory factor analysis were conducted to examine the validity and reliability of this measurement instrument. RESULTS The results indicated no statistically significant correlations between the demographic characteristics and PBM test scores. Regarding perceived knowledge, the results of a one-way analysis of variance revealed that the effect of age, hierarchy of doctors, and education level were significant. In terms of subjective norms, a significant effect on education level was noted [t (129) = 2.28, p < 0.05], with graduate school graduates receiving higher scores than college graduates. An analysis of variance demonstrated the effects of hierarchy, education level, and medical specialty on perceived behavioral control. The results of the regression analyses revealed that perceived knowledge (β = 0.32, p < 0.01) and subjective norms (β = 0.22, p < 0.05) were significantly related to clinicians' behavioral intentions. CONCLUSIONS This study revealed that factors affecting clinicians' blood transfusion management can be explained using the TPB-based questionnaire. This study demonstrated that physicians' perceptions of whether most people approve of PBM and their self-assessment of their PBM knowledge affect their intentions to proceed with PBM. According to this finding, a support system among physicians must be established and maintained to increase physicians' confidence in promoting PBM.
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Affiliation(s)
- Yu-Han Liao
- Department of Medicine, Mackay Medical College, New Taipei City, 252, Taiwan
| | - Kung-Pei Tang
- Department of Early Childhood & Family Education, National Taipei University of Education, Taipei City, Taiwan
| | - Chih-Yu Chou
- Department of Medicine, Mackay Medical College, New Taipei City, 252, Taiwan
| | - Chien-Feng Kuo
- Department of Medicine, Mackay Medical College, New Taipei City, 252, Taiwan
- Department of Internal Medicine, Division of Infectious Diseases, Mackay Memorial Hospital, Taipei, Taiwan
- Department of Nursing, MacKay Junior College of Medicine, Nursing and Management, New Taipei City, 25245, Taiwan
| | - Shin-Yi Tsai
- Department of Medicine, Mackay Medical College, New Taipei City, 252, Taiwan.
- Department of Laboratory Medicine, Mackay Memorial Hospital, Taipei City 104, Taiwan.
- Institute of Biomedical Sciences, Mackay Medical College, New Taipei City, Taiwan.
- Institute of Long-Term Care, Mackay Medical College, New Taipei City, Taiwan.
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 21205, USA.
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4
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Adkins BD, Murfin R, Luu HS, Noland DK. Paediatric clinical decision support: Evaluation of a best practice alert for red blood cell transfusion. Vox Sang 2023; 118:746-752. [PMID: 37431735 DOI: 10.1111/vox.13497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND AND OBJECTIVES Providing red blood cell (RBC) transfusion to paediatric patients with a haemoglobin (Hb) level of <7 g/dL is the current best practice, but it is often difficult to ensure appropriateness of RBC transfusion on a health system level. Electronic health record (EHR) clinical decision support systems have been shown to be effective in encouraging providers to transfuse at appropriate Hb thresholds. We present our experience with an interruptive best practice alert (BPA) at a paediatric healthcare system. MATERIALS AND METHODS An interruptive BPA requiring physician response was implemented in our EHR (Epic Systems Corp., Verona, WI, USA) in 2018 based on Hb thresholds for inpatients. The threshold was initially <8 g/dL and later changed to <7 g/dL in 2019. We assessed total activations, number of RBC transfusions and hospital metrics through 2022 compared to the 2 years prior to implementation. RESULTS The BPA activated 6956 times over 4 years, slightly less than 5/day, and the success rate, with no RBC transfusions within 24 h of order attempt, was 14.5% (1012/6956). There was a downward trend in the number of total RBC transfusions and RBC transfusions per admission after implementation, non-significant (p = 0.41 and p = >0.99). The annual case mix index was similar over the years evaluated. The estimated cost savings based on acquisition costs for RBC units were 213,822 USD or about $51,891 per year. CONCLUSION BPA implementation led to sustained change in RBC transfusion towards best practice, and there were long-term savings in RBC expenditure.
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Affiliation(s)
- Brian D Adkins
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pathology, Children's Health, Dallas, Texas, USA
| | - Roberta Murfin
- Department of Pathology, Children's Health, Dallas, Texas, USA
| | - Hung S Luu
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pathology, Children's Health, Dallas, Texas, USA
| | - Daniel K Noland
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Department of Pathology, Children's Health, Dallas, Texas, USA
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5
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Optimizing red blood cell transfusion practices in the intensive care unit: a multi-phased health technology reassessment. Int J Technol Assess Health Care 2021; 38:e10. [DOI: 10.1017/s0266462321001653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Background
Health technology reassessment (HTR) is a process to manage existing health technologies to ensure ongoing optimal use. A model to guide HTR was developed; however, there is limited practical experience. This paper addresses this knowledge gap through the completion of a multi-phase HTR of red blood cell (RBC) transfusion practices in the intensive care unit (ICU).
Objective
The HTR consisted of three phases and here we report on the final phase: the development, implementation, and evaluation of behavior change interventions aimed at addressing inappropriate RBC transfusions in an ICU.
Methods
The interventions, comprised of group education and audit and feedback, were co-designed and implemented with clinical leaders. The intervention was evaluated through a controlled before-and-after pilot feasibility study. The primary outcome was the proportion of potentially inappropriate RBC transfusions (i.e., with a pre-transfusion hemoglobin of 70 g/L or more).
Results
There was marked variability in the monthly proportion of potentially inappropriate RBC transfusions. Relative to the pre-intervention phase, there was no significant difference in the proportion of potentially inappropriate RBC transfusions post-intervention. Lessons from this work include the importance of early and meaningful engagement of clinical leaders; tailoring the intervention modalities; and, efficient access to data through an electronic clinical information system.
Conclusions
It was feasible to design, implement, and evaluate a tailored, multi-modal behavior change intervention in this small-scale pilot study. However, early evaluation of the intervention revealed no change in technology use leading to reflection on the important question of how the HTR model needs to be improved.
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6
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Vlot EA, van Dongen EPA, Willemsen LM, Berg JMT, Hackeng CM, Loer SA, Noordzij PG. Association of Plasma Fibrinogen and Thromboelastography With Blood Loss in Complex Cardiac Surgery. Clin Appl Thromb Hemost 2021; 27:10760296211016541. [PMID: 34013768 PMCID: PMC8142233 DOI: 10.1177/10760296211016541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Postoperative coagulopathic bleeding is common in cardiac surgery and is
associated with increased morbidity and mortality. Ideally, real-time
information on in-vivo coagulation should be available. However, up to now it is
unclear which perioperative coagulation parameters can be used best to
accurately identify patients at increased risk of bleeding. The present study
analyzed the associations of perioperative fibrinogen concentrations and whole
blood viscoelastic tests with postoperative bleeding in 89 patients undergoing
combined cardiac surgery procedures. Postoperative bleeding was recorded until
24 hours after surgery. Regression analyses were performed to establish
associations between blood loss and coagulation parameters after cardiopulmonary
bypass including a prediction model with known confounding factors for bleeding.
Coagulation tests show large changes over the perioperative course with the
strongest coagulopathic deviations from baseline after cardiopulmonary bypass.
After adjustment for multiple confounders, viscoelastic clot strength instead of
fibrinogen concentration showed a similar performance for 24 hour blood loss and
a better performance for 6 hour blood loss. This makes intraoperative
viscoelastic testing a useful tool to strengthen early clinical decision-making
with the potential to reduce perioperative blood transfusions.
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Affiliation(s)
- Eline A Vlot
- Department of Anaesthesia, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Eric P A van Dongen
- Department of Anaesthesia, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Laura M Willemsen
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Jur M Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Christian M Hackeng
- Department of Clinical Chemistry, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Stephan A Loer
- Department of Anaesthesia, Intensive Care and Pain Medicine, Amsterdam UMC, The Netherlands
| | - Peter G Noordzij
- Department of Anaesthesia, Intensive Care and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
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7
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Mehta N, Murphy MF, Kaplan L, Levinson W. Reducing unnecessary red blood cell transfusion in hospitalised patients. BMJ 2021; 373:n830. [PMID: 33824140 DOI: 10.1136/bmj.n830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Nishila Mehta
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Michael F Murphy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | | | - Wendy Levinson
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Choosing Wisely Canada, Toronto, Ontario, Canada
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8
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Keir A, Grace E, Stanworth S. Closing the evidence to practice gap in neonatal transfusion medicine. Semin Fetal Neonatal Med 2021; 26:101197. [PMID: 33541808 DOI: 10.1016/j.siny.2021.101197] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Significant resources are directed towards world-class research projects, but the findings are not necessarily translated into better healthcare outcomes, either at all or in a sustained way. There is a clear need to dedicate further resources to understanding how to promote the uptake of evidence and effectively change neonatal transfusion practice to improve outcomes. Approaching blood transfusion behaviour change more systematically, and working across disciplines and involving families, holds the potential to increase the rate of uptake of emerging evidence in clinical practice. This approach holds the potential to save costs, conserve resources, and improve clinical outcomes. Our paper focuses on the use of quality improvement to bridge the gap between evidence-based knowledge and transfusion practice in neonatal units around the world.
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Affiliation(s)
- Amy Keir
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, South Australia, Australia; Adelaide Medical School and the Robinson Research Institute, The University of Adelaide, South Australia, Australia; Women's and Babies Division, Women's and Children's Hospital, North Adelaide, South Australia, Australia.
| | - Erin Grace
- SAHMRI Women and Kids, South Australian Health and Medical Research Institute, South Australia, Australia; Adelaide Medical School and the Robinson Research Institute, The University of Adelaide, South Australia, Australia; Women's and Babies Division, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Simon Stanworth
- National Health Service (NHS) Blood and Transplant/Oxford University Hospitals NHS Trust, Oxford, United Kingdom
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9
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Kron AT, Collins A, Cserti-Gazdewich C, Pendergrast J, Webert K, Lieberman L, Zeller MP, Harding SR, Nahirniak S, Prokopchuk-Gauk O, Lin Y, Mendez B, Armali C, Lee C, Watson D, Arnott D, Xun F, Blain H, Panchuk H, Hughes H, Chorneyko K, Angers M, Pilutti N, Lett R, Dowsley S, Ruijs T, Cupido T, Kichinko T, Thompson T, Afshar-Ghotli Z, Callum J. A prospective multi-faceted interventional study of blood bank technologist screening of red blood cell transfusion orders: The START study. Transfusion 2021; 61:410-422. [PMID: 33423316 DOI: 10.1111/trf.16243] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/20/2020] [Accepted: 10/25/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Transfusion of red blood cells (RBC) is a common procedure, which when prescribed inappropriately can result in adverse patient outcomes. This study sought to determine the impact of a multi-faceted intervention on unnecessary RBC transfusions at hospitals with a baseline appropriateness below 90%. STUDY DESIGN AND METHODS A prospective medical chart audit of RBC transfusions was conducted across 15 hospitals. For each site, 10 RBCs per month transfused to inpatients were audited for a 5-month pre- and 10-month post-intervention period, with each transfusion adjudicated for appropriateness based on pre-set criteria. Hospitals with appropriateness rates below 90% underwent a 3-month intervention which included: adoption of standardized RBC guidelines, staff education, and prospective transfusion order screening by blood bank technologists. Proportions of RBC transfusions adjudicated as appropriate and the total number of RBC units transfused per month in the pre- and post-intervention period were examined. RESULTS Over the 15-month audit period, at the 13 hospital sites with a baseline appropriateness below 90%, 1950 patients were audited of which 81.2% were adjudicated as appropriate. Proportions of appropriateness and single-unit orders increased from 73.5% to 85% and 46.2% to 68.2%, respectively from pre- to post-intervention (P < .0001). Pre- and post-transfusion hemoglobin levels and the total number of RBCs transfused decreased from baseline (P < .05). The median pre-transfusion hemoglobin decreased from a baseline of 72.0 g/L to 69.0 g/L in the post-intervention period (P < .0001). RBC transfusions per acute inpatient days decreased significantly in intervention hospitals, but not in control hospitals (P < .001). The intervention had no impact on patient length of stay, need for intensive care support, or in-hospital mortality. CONCLUSION This multifaceted intervention demonstrated a marked improvement in RBC transfusion appropriateness and reduced overall RBC utilization without impacts on patient safety.
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Affiliation(s)
- Amie T Kron
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Allison Collins
- Ontario Regional Blood Coordinating Network (ORBCoN), Toronto, Ontario, Canada
| | - Christine Cserti-Gazdewich
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Jacob Pendergrast
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Kathryn Webert
- Canadian Blood Services, Ottawa, Ontario, Canada.,Department of Molecular Medicine and Pathology, McMaster University, Hamilton, Ontario, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Michelle P Zeller
- Canadian Blood Services, Ottawa, Ontario, Canada.,Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Sheila R Harding
- Department of Laboratory Medicine and Pathology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Susan Nahirniak
- Department of Laboratory Medicine and Pathology, Alberta Precision Laboratories, Grande Prairie, Alberta, Canada.,Department of Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Oksana Prokopchuk-Gauk
- Department of Laboratory Medicine and Pathology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Brent Mendez
- Department of Laboratory Medicine and Pathology, Alberta Precision Laboratories, Grande Prairie, Alberta, Canada.,Department of Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
| | - Chantal Armali
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Christina Lee
- Department of Laboratory Medicine and Genetics Program, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Danielle Watson
- Department of Transfusion Medicine, Laboratory Services, Grey Bruce Health Services, Owen Sound, Ontario, Canada
| | - Dena Arnott
- Department of Laboratory Medicine and Pathology, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Fengju Xun
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Human Biology Program, Faculty of Arts and Science, University of Toronto, Toronto, Ontario, Canada
| | - Heather Blain
- Department of Laboratory Medicine and Pathology, Alberta Precision Laboratories, Grande Prairie, Alberta, Canada
| | - Heather Panchuk
- Department of Laboratory Medicine and Pathology, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Hertha Hughes
- Department of Laboratory Medicine, Quinte Healthcare Corporation, Belleville, Ontario, Canada
| | - Kathy Chorneyko
- Department of Laboratory Services, Brant Community Healthcare System, Brantford, Ontario, Canada
| | - Michael Angers
- Laboratory Medicine Program, Lakeridge Health, Ajax, Ontario, Canada
| | - Nicole Pilutti
- Department of Laboratory Services, Windsor Regional Hospital, Windsor, Ontario, Canada
| | - Ryan Lett
- Department of Laboratory Medicine and Pathology, Saskatchewan Health Authority, Regina, Saskatchewan, Canada
| | - Shauna Dowsley
- Department of Laboratory Medicine and Genetics Program, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Theodora Ruijs
- Department of Pathology, William Osler Health System, Brampton, Ontario, Canada
| | - Tracy Cupido
- Department of Anesthesiology, Quinte Healthcare Corporation, Belleville, Ontario, Canada
| | - Tracy Kichinko
- Department of Laboratory Services, Brant Community Healthcare System, Brantford, Ontario, Canada
| | - Troy Thompson
- Ontario Regional Blood Coordinating Network (ORBCoN), Toronto, Ontario, Canada
| | - Zohreh Afshar-Ghotli
- Department of Transfusion Medicine, Laboratory Services, Grey Bruce Health Services, Owen Sound, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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10
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Kruse RL, Neally M, Cho BC, Bloch EM, Lokhandwala PM, Ness PM, Frank SM, Tobian AAR, Gehrie EA. Cryoprecipitate Utilization Patterns Observed With a Required Prospective Approval Process vs Electronic Dosing Guidance. Am J Clin Pathol 2020; 154:362-368. [PMID: 32445461 DOI: 10.1093/ajcp/aqaa042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We evaluated the impact of electronic medical record (EMR)-guided pooled cryoprecipitate dosing vs our previous practice of requiring transfusion medicine (TM) resident approval for every cryoprecipitate transfusion. METHODS At our hospital, cryoprecipitate pooled from five donors is dosed for adult patients, while single-donor cryoprecipitate is dosed for pediatric patients (defined as patients <50 kg in weight). EMR-based dosing guidance replaced a previously required TM consultation when cryoprecipitate pools were ordered, but a consultation remained required for single-unit orders. Usage was defined as thawed cryoprecipitate; wastage was defined as cryoprecipitate that expired prior to transfusion. RESULTS In the 6 months prior to intervention, 178 ± 13 doses of pooled cryoprecipitate were used per month vs 187 ± 15 doses after the intervention (P = .68). Wastage of pooled cryoprecipitate increased from 7.7% ± 1.5% to 12.7% ± 1.4% (P = .038). There was no change in wastage of pediatric cryoprecipitate doses during the study period. These trends remained unchanged for a full year postimplementation. CONCLUSIONS Electronic dosing guidance resulted in similar cryoprecipitate usage as TM auditing. Increased wastage may result from reduced TM oversight. Product wastage should be balanced against the possibility that real-time audits could delay a lifesaving therapy.
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Affiliation(s)
- Robert L Kruse
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Melissa Neally
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Brian C Cho
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Evan M Bloch
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Parvez M Lokhandwala
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Paul M Ness
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Steven M Frank
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aaron A R Tobian
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Eric A Gehrie
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
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Blood component utilization before and after implementation of good transfusion practice measures in a pediatric emergency department. Transfus Apher Sci 2020; 59:102719. [PMID: 31953106 DOI: 10.1016/j.transci.2020.102719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/23/2019] [Accepted: 12/23/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We aimed to determine the pattern of blood component utilization in pediatric Emergency Department (ED) and compare the utilization rate before and after the implementation of simple good transfusion practice measures. MATERIAL AND METHODS This was a prospective pre/post interventional study conducted between February 2015 and April 2016. The study included 3 phases [1] Pre-intervention phase (6 weeks) consisting of baseline data collection [2] Intervention phase (3 months) involving education on transfusion triggers and periodic mailers about good practice and designated 'transfusion resident' for supervision. [3] Post- intervention phase (6 weeks) collecting data while continuing interventions. RESULTS During pre-intervention, 379 blood components [Packed red cells(PRBC) - 227, Platelet concentrate(PC) - 78, Fresh Frozen Plasma(FFP) - 74] were requested for 280 children; 195 were transfused with an overall utilization rate of 51.5 %. PRBC had the poorest utilization rate (30 %) followed by PC (72 %) and FFP (96 %). About 79 % of the requisitions sent by residents in first training year were not utilized before intervention. Indications such as anticipated surgery, congenital heart disease, pneumonia and sepsis had lower utilization rate. Post intervention, there was 14 % reduction in blood component requests (325 requests in 258 patients). Both overall utilization rate (56 %) and PRBC utilization (37.4 %) showed improvement but the difference was statistically not significant. CONCLUSIONS Red blood cells were the most frequently requested blood components yet poorly utilized in ED. Simple interventions targeting providers in early stages of training could potentially improve the blood component utilization and transfusion practices in busy emergency departments.
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Pavithran P, Rajesh MC, Kaniyil S, Kaniachalil K, Anoop B, Jithin TN. Current transfusion practices of anesthesiologists in a major city in South India. J Anaesthesiol Clin Pharmacol 2019; 35:261-266. [PMID: 31303719 PMCID: PMC6598582 DOI: 10.4103/joacp.joacp_296_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Aims: Allogenic blood transfusion is a double edged sword with a delicate balance between benefits and risks. There is heavy use of blood products in the perioperative setting mostly initiated by anesthesiologists. Limited research has been done in evaluating the transfusion practices of anesthesiologists especially in Indian setting. We conducted a survey among the anesthesiologists in our city to assess their blood transfusion practices, to evaluate the level of adherence to principles of Patient Blood Management and to look for innovative strategies to improve the perioperative transfusions. Methods: A validated questionnaire with four sets of questions was distributed among the practitioners in the Indian Society of Anaesthesiologists city branch and the responses were collected and analysed. The first and second parts were structured to assess the current blood transfusion practices. The third part evaluated the keenness of participants in further updating their practices as per the recommended protocols of patient blood management. The last part assessed how the participants would act in a given clinical scenario. Statistical analysis was done using Statistical Package for the Social Sciences version 21. Results are expressed in numbers and percentages. Results: Moderate preoperative anemia was acceptable to majority of the responders. There was a high demand for continuing medical education in transfusion medicine and for formulating Indian guidelines for perioperative transfusion. The clinical scenarios demonstrated the restrictive transfusion strategy of the majority of our anesthesiologists. The lack of institutional protocols and blood transfusion committees was also seen. Conclusion: The restrictive strategy of our practitioners was an encouraging finding. There is lack of uniformity in patient blood management services. Regular educational interventions are needed to update the clinicians. Formulation and implementation of institutional protocols for perioperative blood transfusion is mandatory.
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Affiliation(s)
| | - M C Rajesh
- Department of Anaesthesiology, BMH, Calicut, Kerala, India
| | - Suvarna Kaniyil
- Department of Anaesthesiology, Govt. Medical College, Calicut, Kerala, India
| | | | - Bindiya Anoop
- Department of Anaesthesiology, MEITRA, Calicut, Kerala, India
| | - T N Jithin
- Department of Anaesthesiology, BMH, Calicut, Kerala, India
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Lee TC, Murray J, McDonald EG. An online educational module on transfusion safety and appropriateness for resident physicians: a controlled before-after quality-improvement study. CMAJ Open 2019; 7:E492-E496. [PMID: 31345787 PMCID: PMC6658213 DOI: 10.9778/cmajo.20180211] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Several professional societies have made value-based statements in support of restrictive transfusion strategies. The aim of this study was to determine whether completion of an accredited online training program in transfusion safety could improve transfusion knowledge among medical residents and increase transfusion appropriateness. METHODS We performed a controlled before-after evaluation of a mandatory accredited self-directed training program (Bloody Easy Lite for Physicians) that provides education about transfusion medicine on a 47-bed medical clinical teaching unit at a university-affiliated hospital centre in Montréal. The program consists of 2 modules and takes about 30 minutes to complete. We used the 45-bed medical teaching unit at another Montréal hospital as a contemporary control. We compared resident physicians' pre- and posttest scores and evaluated the impact on transfusion appropriateness by comparing the proportion occurring below a hemoglobin concentration of 80 g/L before (April 2013-June 2015) and after (July 2015-January 2016) the intervention. RESULTS Of the 55 residents on the intervention unit, 53 (96%) completed the training. The median pretest score was 50% (inter-quartile range [IQR] 40%-60%). The median posttest score was 90% (IQR 80%-90%) for module 1 and 80% (IQR 80%-90%) for module 2 (p < 0.001 for both pre-post comparisons). The proportion of transfusions below 80 g/L increased from 80.1% to 86.9% (p = 0.04) on the intervention unit and remained relatively unchanged on the control unit (75.6% v. 71.1%, p = 0.4). Although there was no statistically significant difference between the units in the proportion of transfusions below 80 g/L before the intervention (p = 0.07), a significant difference was observed after the intervention (p = 0.002). INTERPRETATION Mandatory training in transfusion safety via an online program resulted in improved transfusion knowledge among residents and an increase in the proportion of transfusions occurring at a hemoglobin concentration below 80 g/L. This low-cost educational initiative may improve transfusion appropriateness.
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Affiliation(s)
- Todd C Lee
- Clinical Practice Assessment Unit (Lee, Murray, McDonald) and Division of General Internal Medicine (Lee, McDonald), Department of Medicine, McGill University Health Centre, Montréal, Que
| | - Jennifer Murray
- Clinical Practice Assessment Unit (Lee, Murray, McDonald) and Division of General Internal Medicine (Lee, McDonald), Department of Medicine, McGill University Health Centre, Montréal, Que
| | - Emily G McDonald
- Clinical Practice Assessment Unit (Lee, Murray, McDonald) and Division of General Internal Medicine (Lee, McDonald), Department of Medicine, McGill University Health Centre, Montréal, Que.
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Derzon J, Alford A, Clarke N, Gross I, Shander A, Thurer R. Anemia Management and Audit Feedback Practices for Reducing Overuse of RBC Transfusion: A Laboratory Medicine Best Practice Systematic Review and Meta-Analysis. Am J Clin Pathol 2019; 151:18-28. [PMID: 30357323 DOI: 10.1093/ajcp/aqy123] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objectives To evaluate the effectiveness of anemia management and audit with feedback practices in reducing overuse of RBC transfusion. Methods This review follows the Centers for Disease Control and Prevention's Laboratory Medicine Best Practice Systematic Review (A-6) method. We searched the literature and solicited unpublished studies on practices to reduce overuse of RBC transfusions as measured by reductions in units transfused and proportion of patients transfused. Results Thirteen studies on preoperative anemia management and three studies on audit feedback practices met inclusion criteria. Strength of evidence was high to moderate for reducing the number of units and proportion of patients transfused. Conclusions Preoperative anemia management reduces the proportion of patients transfused and units of RBCs transfused. Audit with feedback across cases, physicians, and/or service areas, as part of a continuous quality improvement practice, reduces the proportion of patients and units of RBCs transfused.
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Affiliation(s)
- James Derzon
- RTI International, Social, Statistical, and Environmental Sciences, Washington, DC
| | - Aaron Alford
- National Network of Public Health Institutes, Research and Evaluation, Washington, DC
| | | | | | - Aryeh Shander
- Englewood Hospital and Medical Center, Englewood, NJ
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