(P-PB-3) A Hemoglobin Threshold Quality Initiative to Improve Pediatric Red Cell Transfusion Justification Compliance

Background/Case Studies: : Blood Transfusion monitoring is required by regulatory agencies as part of a hospital’s Transfusion Committee activities. Pediatric patients also have an increased risk of fluid overload, in addition to risk of unnecessary exposure to blood products. During Red Cell utilization audits, the Transfusion Service performs a primary review based on pre-transfusion hemoglobin (Hgb) levels. Red Cell transfusions are considered “compliant” for neonates if the pre-transfusion Hgb < /= 10g/dl, and for patients over 4 months of age, “compliance” is if the pre-transfusion Hgb is < /= 8g/dl. Transfusions that fall out of “compliance” are then forwarded to a QI specialist for chart review to confirm the indication for transfusion. The objective of the project was to challenge providers to think more resourcefully by reducing unnecessary transfusions and increase the # of “compliant” transfusions to ≥ 75% and sustain that for 1 year.

Study

Design/Methods: Data was compiled for all red cell transfusions (excluding RBC exchange transfusions) that occurred over a 14-month time period to serve as a baseline. The initial “compliance” rate for that timeframe was 64%. A QI team was then created that developed key drivers and interventions to improve compliance.

Results/Findings: Through education, including development of a clinical practice guideline/ clinical pathway and electronic decision support at the time of ordering, we reached 75% “compliance” within 6 months of initiation. The compliance has subsequently been sustained > 75%.

Conclusions: Clinical practice guidelines with a clinical pathway, in addition to electronic decision support are helpful tools to reduce potential unnecessary red cell transfusions.

Importance of research: With the national red blood cell supply in constant flux, and patient safety with blood management being scrutinized more, the ability to limit transfusions and demonstrate the clinical need for the product is of greater importance.