"Seven Is the New Ten" - Comprehensive Quality Improvement Project to Adopt Restrictive Transfusion Strategies in a Community Hospital

Introduction:

An estimated 13,785,000 units of packed red blood cells (PRBC) were transfused in the US in 2011 of which an estimated 57.9% were found to be from the medical service. Risks of blood transfusion include infections and transfusion reactions.

In 2012, the American Association of Blood Banks released new guidelines for PRBC transfusion in hospitalized, hemodynamically stable patients. These guidelines set a threshold Hb of ≤7 g/dL in critically-ill patients, and a Hb ≤8 g/dL for surgical patients, for patients with pre-existing cardiovascular disease, or for patients with symptoms (tachycardia, chest pain or hypotension not corrected by crystalloids).

Methods:

An IRB-approved retrospective study of inpatient PRBC transfusions at New Hanover Regional Medical Center in Wilmington, NC was conducted in 2013. The average pre-treatment Hb was noted to be 7.42 ± 0.92 (p=0.0009) and average number of units transfused were 1.78 ± 0.58 (p=0.1133). The average number of units transfused were =1.5, and 31% of the time 1 unit was given.

This data prompted a quality improvement initiative to improve in hospital transfusion strategies. The PDSA cycle included the following interventions: Hospital administration created a "Transfusion Safety Officer." A transfusion committee championed by the Blood Bank Director was formed. In addition, a series of hospital wide didactics centered on restrictive transfusion practices were held, targeting nursing and physicians of all disciplines. A public relations campaign was launched by the hospital involving posters, newsletters, bulletins, and emails centered around slogans "7 is the new 10" and "1 is better than 2." Four months after this, a new computerized physician order set was created by the Transfusion Committee and instituted in September 2014. The order set specifically separated out chronic anemia from acute blood loss anemia. Under the chronic anemia tab, practitioners can select the reason for PRBC transfusion based off of AABB guidelines, but are restricted to only transfusing 1 unit of PRBC at a time. Finally a new "My Report" has been built within EPIC EMR to allow a physician to see their transfusion average Hb and number of units ordered.

An IRB-exempt review of PRBC transfusions after the quality improvement impact and post CPOE go-live date was conducted. A total of 493 PRBC transfusions in non-acute blood loss patients were given between 9/11/14-11/1/14. The average pre-treatment Hb 7.0 of which 59% of the time 1 unit was PRBC was ordered.

Discussion:

A comprehensive, interdisciplinary QI project can successfully reduce unnecessary PRBC transfusions. By applying the PDSA cycle and harnessing the power of the EMR, we can improve the rapidity with which physicians adopt new evidence based guidelines. The success of a hospital-wide QI project of this magnitude hinges on a motivated project management team able to engage all necessary stake-holders, to include the hospital C-Suite.