How do I implement a more restrictive transfusion trigger of hemoglobin level of 7 g/dL at my hospital?

BACKGROUND: The red blood cell (RBC) transfusion trigger is a major driver of transfusion practice and affects health care costs and in some instances patient outcomes. Reducing the transfusion threshold will decrease RBC utilization and hospital costs. STUDY DESIGN AND METHODS: The hospital transfusion committee, endorsed by the medical staff executive committee, developed an educational program for physicians, nurses, and blood bank staff focusing on the scientific basis for a transfusion trigger of hemoglobin (Hb) of 7 g/dL rather than 8 g/dL as well as a program to discourage the routine 2-unit RBC transfusion. RBC transfusion practice review was performed and those physicians transfusing outside of the new variables were questioned as to the necessity for the transfusion. RESULTS: A total of 4492 RBC units were saved and 662 patients were not transfused over the three fiscal years (FYs), 2010, 2011, and 2012, compared to 2009 baseline. Direct cost savings over 3 years with a transfusion trigger of Hb of 7 g/dL was $943,320. If activity-based costing is used, the savings may have reached as high as $5,314,036. The number of single-unit RBC transfusions increased steadily over the course of the study while the number of 2-unit transfusions remained relatively stable over the three FYs 2010 to 2012. CONCLUSION: A Hb level of 7 g/dL is the transfusion threshold which is being adopted by many hospitals. Institutional culture change to a Hb level of 7 g/dL can be implemented with the right champion when endorsed by upper echelon medical leadership and hospital administration.

Comparison of outcomes of group O vs non-group O premature neonates receiving group O RBC transfusions.

OBJECTIVES: At some institutions all infants requiring RBC transfusions in neonatal intensive care units (NICUs) receive only group O RBCs. Although transfused group O plasma is minimized in packed RBCs, small amounts of residual anti-A, anti-B, and anti-A,B in group O packed RBCs may bind to the corresponding A and B antigens of non-group O RBCs, possibly hemolyzing their native RBCs and thereby releasing free hemoglobin, theoretically resulting in hypercoagulability and promoting bacterial growth from free iron. METHODS: Premature infants in the University of Kentucky Children's Hospital NICU database who were transfused (all received group O transfusions) were compared for a number of severity markers to determine if non-group O patients had worse outcomes than group O patients. RESULTS: In this NICU sample, 724 neonates received at least 1 blood component. No significant differences were found between group O and non-group O infants with regard to final disposition or complications. CONCLUSIONS: This reassuring finding validates the longstanding neonatal transfusion practice of using group O packed RBCs for infants of all blood groups in the NICU. However, a recent study shows increased mortality from necrotizing enterocolitis in group AB neonates at a facility transfusing only group O RBCs to neonates of all blood groups and suggests a change in neonatal transfusion practice to ABO group-specific RBCs; therefore more studies may be warranted.

Blood utilization: fostering an effective hospital transfusion culture.

An effective hospital transfusion culture should encourage clinicians to consider the possibility of transfusion in their patients well before the need actually arises, and to plan ahead in an attempt to use blood products most efficiently. Strategies for improved blood utilization include timely and adequate preoperative assessment of risk, optimization of baseline hemoglobin, anticipation of potential transfusion problems, intraoperative techniques to minimize blood loss, blood conservation technologies, transfusion guidelines and targeted therapy, point of care testing, and massive transfusion protocols. Attention to these elements promotes a safe and cost-effective transfusion culture.

Impact of intraoperative red blood cell salvage on transfusion requirements and outcomes in radical prostatectomy.

BACKGROUND: Preoperative autologous blood donation lowers preoperative hemoglobin (Hb) levels, and the collected blood is frequently wasted. Intraoperative red blood cell (RBC) salvage provides fresher autologous blood in proportion to surgical blood loss, making cell salvage (CS) in radical prostatectomy (RP) feasible for study. STUDY DESIGN AND METHODS: This retrospective study compared two strategies to reduce allogeneic RBC transfusion requirements in RP: preoperative autologous donation (PAD) versus CS. Patients underwent RP by one surgeon at one institution during two comparable time periods in 2005 (PAD-Group 1) and 2006 (CS-Group 2). RESULTS: Group 1 patients (n = 40) underwent PAD, collecting 63 autologous RBC units; 36 units (57.1%) were reinfused and 27 (42.9%) were wasted. No Group 1 patient received allogeneic blood. Group 2 patients (n = 63) underwent intraoperative CS and received a mean of 287 mL of salvaged blood. In Group 2, two patients (3.2%) with preoperative Hb levels too low to permit autologous donation each received 2 units of allogeneic RBCs. Group 1 patients had significantly lower preoperative (-1.4 g/dL) and postoperative (-0.8 g/dL) Hb values compared to the CS group. There were no significant differences between groups in procedure times, length of stay, or numbers of cancer recurrences over the 24- to 36-month follow-up period. CONCLUSION: Perioperative CS can effectively replace PAD for RP patients, offering similar avoidance of allogeneic transfusion, with greater convenience and superior postoperative Hb levels.

Enhanced detection of blood bank sample collection errors with a centralized patient database.

BACKGROUND: Pittsburgh's Centralized Transfusion Service (CTS) provides transfusion support to 16 hospitals and features an electronic database that contains patient transfusion and serologic histories. This database can be accessed from any hospital in the system. A major cause of ABO-incompatible transfusions is the "wrong blood in tube" (WBIT) phenomenon, that is, the sample is not from the recipient identified on the label. We hypothesized that having access to patient historical ABO types from anywhere in the CTS system can identify WBIT errors and prevent mistransfusions. STUDY DESIGN AND METHODS: The transfusion committee records of the 16 CTS hospitals from March 2005 to September 2007 were reviewed for major collection errors, that is, the current ABO type differed from the historical type in the database. The patient's historical ABO type, the discrepant type, and the hospital(s) where these samples were collected were recorded. RESULTS: In 6 of 16 major collection errors for which complete information was available, the current and historical ABO types were obtained from different hospitals within the CTS system. In 3 cases, selection of ABO type-specific blood based on the current sample would have led to an ABO-compatible transfusion (e.g., correct type A, current type O). In the other 3 cases, an ABO-incompatible transfusion would have resulted (e.g., correct type O, current type A). CONCLUSIONS: Access to a centralized patient database detected 38 percent more ABO typing errors and prevented six mistransfusions, which would not have been prevented at a single institution. Centralization of patient transfusion data should be encouraged.