NYC H+H/Bellevue & NYU Grossman School of Medicine New York, New York, United States
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 single donor platelets (SDP) ordered and transfused (Txed) to patients who had a pre-Tx platelet count (PLTC) >50X109/L and the value/date/time of the pre-Tx and post-Tx PLTC. Not all orders flagged by BUG are MUT. The hospitals were charged with reviewing outliers and improving ordering behavior. We sought to assess SDP ordering practices and determine how many SDP Txs fell outside of guidelines.
Study
Design/Methods: Data from monthly BUG reports from 2020 and 2022 were reviewed to determine the number of SDPs 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 PLTC of the outliers. Results were assessed using the Student’s T-test.
Results/Findings: From 1/1/20-12/31/20 3462 SDPs were Txed, BUG flagged 1134 SDP orders for 1314 SDPs that had a pre-Tx PLTC >50X109/L. From 1/1/21-12/31/22 4641 SDPs were Txed, BUG flagged 1194 orders for 1335 SDPs that had a pre-Tx PLTC >50X109/L. Figure A shows that 38.0% of SDPs Txed in 2020 and 28.8% in 2022 were flagged (p-value < 0.0037). The indications most captured by BUG were 1) bleeding or immediately pre-operatively in a patient with documented platelet dysfunction or on anti-platelet drugs, 2) PLTC < 10X109/L with or without bleeding, 3) PLTC < 50X109/L with bleeding or undergoing a major procedure, and 4) PLTC < 100X109/L undergoing neurosurgery or ophthalmic procedure. Although the mean pre-Tx PLTCs were higher than the numeric thresholds of the orders, no differences were seen in mean pre-Tx PLTCs in any of these categories. Conclusions: Use of the BUG report led to statistically fewer SDPs 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 SDP 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 SDPs. It demonstrates that you do not need to pay for external consulting services to improve patient safety and change provider ordering practices.
