(P-PB-11) Implementation of a computerized physician order entry alert for double dose red cell orders

Background/Case Studies: Double dose red cell transfusions continue to occur in nonbleeding, hospitalized patients despite the 2014 Choosing Wisely recommendation to give single dose transfusions. Clinical decision support tools embedded in computerized physician order entry (CPOE) systems may be leveraged to encourage this practice. In this retrospective study, we describe our implementation of CPOE-based alerts to reduce double dose red cell orders in a large health care system.

Study

Design/Methods: In November 2022, a CPOE-based double dose red cell alert was implemented across all inpatient and outpatient units, except the operating room, in our enterprise. The alert triggered if a double dose red cell order was placed when the patient’s last recorded hemoglobin within 24 hours was within 1.0 g/dl of the transfusion threshold (7.0 – 8.0 g/dL). Ordering providers were asked to select the indication for transfusion from a drop-down menu and could provide additional information. When an alert was triggered, the double dose order was replaced with a single dose order, but this change could be overridden. If the indication for transfusion was acute hemorrhage, the double dose order was not altered.
Alerts were reviewed in weekly increments once per month following implementation. A chart review was performed for each alert to determine the transfusion outcome, pre- and posttransfusion hemoglobin values, clinical circumstances, appropriateness, and length of hospital stay (LOS). Continuous variables were compared using an unpaired t-test. A two-tailed p value of < 0.05 was considered significant. All data analysis occurred in Stata/BE.

Results/Findings: Representative weeks from four months following implementation of the double dose red cell alert policy were reviewed. A total of 122 double dose alerts (median 30 alerts/week) occurred. On average 21% of alerts per week (range: 13 to 31%) resulted in a switch to a single dose order or cancellation of the order (Figure 1). The mean pretransfusion hemoglobin for double dose orders which resulted in double- or single-dose transfusion were similar (7.0 vs. 7.3, p = 0.12). There was no difference in mean LOS between patients who received double or single-dose transfusions (12.6 vs 15.6 days, p = 0.40). Sixty percent of double dose transfusions were deemed inappropriate by chart review. The most common clinical scenarios for inappropriate double dose red cell transfusions were postoperative anemia (31%), anemia due to unclear causes (22%), and anemia of chronic disease (14%).

Conclusions: CPOE-based double dose red cell alerts result in sustained reduction of double dose red cell orders without affecting patient LOS. However, most continued double dose orders led to inappropriate transfusions. Periodic retrospective evaluation of inappropriate double dose transfusions may identify opportunities for targeted quality improvement efforts.

Importance of research: We report on the successful implementation of double dose red cell alerts in computerized physician order entry (CPOE) for a large health care system. CPOE based alerts resulted in sustained reductions in double dose red cell orders by 21% without increasing the hospital length of stay. Our study supports integration of clinical decision support tools into CPOE to encourage adherence to society-based recommendations for single dose red cell transfusions in nonbleeding, hospitalized patients.