Should surgical intensive care units be exempt from prospective review of transfusion practices?

The medical director of the surgical intensive care unit has requested that blood administered in that patient care setting be exempt from prospective review as he believes the practitioners in the ICU are expert in blood transfusion and prospective review results in delays. Thus, his hospital does not prospectively review blood administered in their surgical ICU. The inquiring colleague would appreciate knowing if other institutions perform prospective reviews of their surgical ICU's transfusion practices, and if so, why did their 'experts' in their ICU agree to have their transfusion practices prospectively reviewed.

The Editors suggest review of the previous discussion, What information is routinely available to blood bank laboratories when blood products are requested for transfusion?

The following comments have been submitted in response.

ADDENDA June 12, 2009

1. A physician who is extremely experienced with transfusion practices in surgical ICUs comments that it is laudable that an institution performs prospective review of transfusions, since in his opinion, this is the most effective means to ensure appropriate transfusion practice. Retrospective review is significantly less effective as a mechanism to improve physician transfusion practice but more importantly does not benefit the patient with guidance at the time of the transfusion decision. The responding physician acknowledges that in his large community hospital they do not perform prospective review, but they do have "concurrent self review" in the form of a transfusion order set, a practice previously described in another CBBS e-Network Forum discussion, What information is routinely available to blood bank laboratories when blood products are requested for transfusion? This order set has been an interim measure awaiting a computerized order entry system with decision support. The overall effectiveness of this order set is augmented by broad provider education on the current risks and benefits of blood component therapy and multidisciplinary efforts to improve blood management practices.
   
   With regards to whether these "expert" physicians should be exempt from prospective review, the responding physician would first comment that prospective review should logically be withheld for any transfusion that is emergent in nature, regardless of where it occurs. However, urgent or emergent transfusions typically constitute less than 5- 10% of RBC transfusions (and an even smaller percentage of coagulation factor transfusions) leaving the majority safely available for prospective review. Emergent transfusions aside, the responding physician believes that utilization review should be applied uniformly throughout any institution. All physicians should be open to peer review of their practices, and to exclude certain physician groups invites an appearance of favoritism and is counter to a hospital-wide standard of care. This is a particularly important for something as inherently hazardous as blood transfusions. An interesting side question is what constitutes these SICU physicians as transfusion experts? While it is true that critical care physicians as a whole have been leaders in better blood transfusion efforts (witness the TRICC trial by Hebert et al), the fact that they hold that medical specialty does not qualify them as de facto experts. Further, practice patterns within any group of physicians are notoriously variable, and most physicians lack formal training in blood component therapy. Finally, even experts should not exempt themselves from oversight and continuous process improvement efforts. In the opinion of the respondent, he can assure us that no one would want to step onto an airplane if commercial pilots held that opinion.
   
   In closing, his advice would be to remind these SICU physicians that the most important part of the transfusion safety chain in 2009 is the medical decision to transfuse, so their support of this prospective review as a patient safety initiative would be much appreciated. He would also applaud them for their interest in appropriate transfusion therapy and invite this "expert" group to actively participate in the hospital’s transfusion committee.

Submit comments to the e-Network Forum at enetworkforum@cbbsweb.org

Ira A. Shulman, MD
CBBS e-Network Forum Senior Editor & Moderator

W. Tait Stevens, MD
CBBS e-Network Forum Editor & Moderator

Elizabeth M. St. Lezin, MD
CBBS e-Network Forum Associate Editor & Moderator