CBBS: Standardized Transfusion Orders And Guideline Worksheet

A physician in San Diego has creating a Standardized Transfusion Orders And Guideline Worksheet and would like comments and insights from colleagues, before he finalizes it. He would appreciate feedback, including citations to published evidence to support any proposed edits to the DRAFT.

The following comments have submitted in reponse:

1. A physician in Boston has provided a copy of his own hospital's "Transfusion Ordering Form". He adds that the Boston hospital's ordering form pays special attention to indications for transfusions for the purpose of transfusion review. He would appreciate comments on the form. He adds that the form has been transitioned for use with Computerized Physician Order Entry; they are still "tweaking" the form. He also comments that in his opinion, the form provided by the San Diego physician seems quite restrictive with regards to the use of irradiated blood products, given that several institutions irradiate all cellular products, to avoid giving a non-irradiated product to a patient who actually needs the product to be irradiated.
   
   He also comments on a publication published in 1993 in the Archives of Internal Medicine, Transfusion Practice in Medical Patients in which at least four of five expert reviewers were required to agree that a transfusion was justified, when doing retrospective chart review. To the Boston physician, this paper provided a great demonstration of the difficulty of chart review of transfusions, in particular when such reviews are required for credentialing.
   
   The Bostonian is trying to launch a more statistically oriented review process of physician ordering practices in comparison within their peer-group; transfusion profiles as he calls it. He says that a colleague of his, who is located in Maine, has reported dramatic changes in ordering practices using transfusion report cards; a summary of the poster's content follows. The poster was #SP101 from Transfusion 2008-Vol. 48 Supplement: Implementation of a Blood Conservation Program by a Hospital Transfusion Service (authors; I Gross, E LaChance, S Townsend, L Sherman)
   
   The authors commented that under the direction of the Transfusion Service Medical Director (TSMD), Eastern Maine Medical Center (EMC) initiated a Blood Conservation Program (BCP) in October 2006. The decision to implement a BCP was driven by increasing costs for blood acquisition and growing evidence that transfusion alternatives are cost effective and associated with comparable or better clinical outcomes. The authors' report that after investigation of other BCPs, a multifaceted approach was designed to create the program at EMC. Transfusion Service technologists were enlisted to implement a prospective transfusion review process, screening transfusions against established laboratory criteria, and then notifying the TSMD of the need for clinical consultation with the ordering provider prior to release of the blood component. At the same time, the BCP was introduced to the hospital through the following:
   • Extensive physician education by the TSMD at clinical service meetings
   • Nursing education on all units
   • A monthly transfusion newsletter
   • An indication-driven transfusion order process that incorporated documentation of the indication for transfusion as a required element.
   
   A number of databases were developed by the authors to track transfusions by diagnosis and provider. Provider specific report cards were created to give feedback to the providers on their transfusion practice, as well as how they compared to their peers. In addition, the Transfusion Service established a protocol to select the most appropriate platelet product and to monitor the response to platelet transfusion for patients on long term therapy at risk for alloimmunization. With direction from the Transfusion Service, access to transfusion alternatives was expanded, particularly in the operating room. According to the authors, this included:
   • Introduction of a pre-operative anemia management program to optimize hemoglobin prior to surgery
   • Reintroduction of acute normovolemic hemodilution
   • Expanded use and optimization of intraoperative cell salvage and administration
   • Appropriate use of pharmacologic hemostatic and antifibrinolytic agents
   
   Implementation of the BCP resulted in a significant decrease in transfusion rate. The authors found that compared to the base fiscal year (FY) 2006, blood utilization in FY 2007 declined 31% with a 27% decrease in red cell use, 42% decrease in platelet use, 32% decrease in plasma use, and a 42% decrease in cryoprecipitate use. This corresponds to a financial savings of approximately $860,000. At the same time, the number of patients transfused decreased by 20%. Total patient days remained essentially the same during this time period.
   
   The authors concluded that most BCPs are directed by one of the clinical services (anesthesia or surgery), not the Transfusion Service. They believe that EMC has shown that a transfusion service based BCP can be effective in decreasing transfusions and reducing costs.
   
   Finally, one of the authors of the above poster comments: "I think the most important thing is to promulgate evidence based transfusion guidelines with EFFECTIVE implementation. Where most hospitals have been unsuccessful is not in the content of their guidelines but in failing to gain physician compliance to the guidelines. We do very little retrospective review in transfusion committee but rather have moved to limited prospective review when a transfusion falls outside our guidelines. Change in behavior should (must) be data driven. Our 'physician report cards' provide each physician with information of their transfusion practices compared to their peers in their specialty, i.e. the data is stratified by medical service (surgery, orthopedics, etc.). For red cells, they see their average pre-transfusion hematocrit, the percentage of red cells ordered as individual units (we discourage multi-unit transfusions in hemodynamically stable patients), and the percentage of red cells ordered when the patients hematocrit is >24%. They also see how many patients they transfused and the number of total units transfused per month. With this information, we provide the mean values for the service and a 2 S.D. confidence limit so they can see if they are outliers. Similar information is provided for platelets and plasma. The data is not blinded; each physician’s name appears on the report. Institution-wide data includes a monthly report on percentage of inpatients transfused, red cell transfusions per thousand patient days normalized for CMS case mix index, average pre-transfusion hematocrit and percentage of red cells ordered as single unit transfusions. With regard to irradiation, we are one of the hospitals currently practicing 'universal' irradiation. However, now that we have a computerized ordering process, we likely will be going back to 'indication specific' irradiation. This is prompted, in part, by my concerns that irradiation adds to the 'storage lesion'. Independent of the increase in potassium 'leak', I am concerned about the impact that irradiation has on the red cell membrane in the context of recent data that suggests storage of blood and age of blood may affect clinical efficacy and even have a negative impact on morbidity and mortality in some patient populations."

2. A director of a Blood Management Program in Georgia comments that there are several sample Blood Component Order Sets on the SABM website. In her experience, several of these examples have been in use at various insititutions for several years and have helped in reducing inappropriate transfusion orders.

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