(P-PB-7) Assessing the Impact of a Blood Utilization Guideline Tool on the Appropriateness Red Blood Cell Transfusions and Clinician Ordering Practices

Background/Case Studies: Monitoring compliance with our system wide blood utilization guideline is a challenge. To improve patient safety and reduce medically unnecessary transfusions (MUT), our system implemented standardized transfusion (Tx) guidelines and built our CPOE to require selection of one of the approved indications. While auditing can identify MUT, not all indications include a lab value upon which to base an assessment and some providers select indications that do not include a lab value to avoid auditing. In late 2019, our system developed a reporting tool “BUG” that identifies all transfusions (Txs) each month that fall outside of guidelines. BUG filters all Txs ordered using the CPOE and identifies red blood cells (RBCs) ordered and transfused (Txed) to patients who had a pre-Tx hemoglobin (Hb) >7g/dL and the value/date/time of the pre-Tx and post-Tx Hb. Not all orders flagged by BUG are MUT. The hospitals were charged with reviewing outliers and improving ordering behavior. We sought to assess RBC ordering practices and determine how many RBC Txs fell outside of guidelines.

Study

Design/Methods: Data from monthly BUG reports from 2020 and 2022 were reviewed to determine the number of RBCs ordered, the number of orders that fell outside of guidelines, the Tx indications that were being filtered into the BUG report, and the average pre-Tx Hb of the outliers. Results were assessed using the Student’s T-test.

Results/Findings: From 1/1/20-12/31/20 29363 RBCs were Txed, BUG flagged 6573 orders for 8738 (mean:728 per month) RBCs that had a pre-Tx Hb >7g/dL. From 1/1/21-12/31/22 35432 RBCs were Txed, BUG flagged 6884 orders for 8993 (mean:749 per month) RBCs that had a pre-Tx Hb >7g/dL. Figure A shows that 30.0% of RBCs Txed in 2020 and 25.3% in 2022 were flagged (p-value < 0.0001). The indications most captured by BUG (>100 per month) were 1) Hb<=7g/dL with symptomatic anemia (Hb < 7) and 2) acute bleeding (AB). The mean pre-Tx Hb for Hb < 7 orders was 7.8g/dL in 2020 and 7.9 in 2022. The mean pre-Tx Hb for AB was 8.7g/dL in 2020 and 8.9g/dL in 2022. The mean pre-Tx Hb was statically higher for AB (p-value < 0.002) and higher for Hb < 7 (p-value < 0.06) in 2022 than 2020. Statistically fewer orders for >=3 RBCs were flagged by BUG in 2022 than 2020 (p-value < 0.01).

Conclusions: Use of the BUG report led to statistically fewer RBCs being Txed in 2022 outside of system guidelines. Some clinicians continue to select Tx indications that their patients’ conditions do not satisfy. Hospitals within our system that currently do not perform prospective auditing of RBC orders should be encouraged to do so to prevent MUT.

Importance of research: This research shows that a hospital system on its own can use its own data and reporting tools to drive change and reduce medically unnecessary transfusions of RBCs. It demonstrates that you do not need to pay for external consulting services to improve patient safety and change ordering provider ordering practices.