Red blood cell (RBC) transfusion has been cited as one of the five most overutilized therapeutic procedures in the United States.^1,2 This is of significant concern because blood transfusions carry serious risks and are costly.

Given this, Stanford Hospital & Clinics (SHC) implemented real-time clinical decision support and best practice alerts (BPAs) when physicians entered blood transfusion orders into its electronic medical records system in an effort to improve SHC’s blood utilization. The findings were detailed in two articles published in Transfusion.^3,4

To implement a system of concurrent self-utilization review, a transfusion threshold of 7 g/dL hemoglobin (Hb) was used, or 8 g/dL for patients with acute coronary syndromes. If the threshold exceeded these levels when a physician ordered a blood transfusion, an interruptive BPA would pop up, with a link to relevant literature and a request to provide a reason for the order.³

“If someone knows that they are being watched, they may change their behavior,” said Lawrence Tim Goodnough, MD, director of the Stanford Medical Center Transfusion Service and professor in the departments of pathology and medicine at Stanford University, who was the lead author of both papers. In addition, it is important to weigh other factors, such as a patient’s age and comorbidities, because Hb levels can be very misleading, he added. In the case of anemia, better alternatives to blood transfusions often exist.

As a result of the program, the number of RBC transfusions at SHC decreased by 24 percent between 2009 and 2013.³ Patients’ mortality rates (55.2 to 33.0, P<0.001), length of stay (10.1 to 6.2 days, P<0.001), and 30-day readmission rates (136.9 to 85.0, P<0.001) all improved significantly.⁴ The total estimated savings from 2010 to 2013 was $6.4 million in acquisition product costs and is projected to be three to five times that number in total transfusion-related costs.⁴

Dr. Goodnough said the results are reassuring because they show that patients do just as well or better when transfusion is used more conservatively. “Less is more,” he said.

It’s also noteworthy that in the year preceding the BPAs, more than half of RBC transfusions were administered to patients with Hb levels greater than 8 g/dL. By 2013, that number was less than 30 percent.³ “I wouldn’t have predicted such an immediate reduction in RBC transfusions,” Dr. Goodnough said. “We needed to determine if this was a sustained effect, and to my surprise and gratification, it was.”

Dr. Goodnough is confident that the initiative has changed the hospital’s culture and believes the program should continue. “I wouldn’t want to withdraw the pop-ups, as they are a valuable tool that has been instrumental in change,” he said. “Education alone will not get us to where we want to go.”

References

1. Proceedings from the National Summit on Overuse. September 24, 2012. The Joint Commission Web Site. Available at: http://www.jointcommission.org/overuse_summit. Accessed May 18, 2015.
2. Bulger J, Nickel W, Messler J, et al. Choosing wisely in adult hospital medicine: five opportunities for improved healthcare value. J Hosp Med. 2013;8:486-492.
3. Goodnough LT, Shieh L, Hadhazy E, et al. Improved blood utilization using real-time clinical decision support. Transfusion. 2014:54:1358-1365
4. Goodnough LT, Maggio P, Hadhazy E, et al. Restrictive blood transfusion practices are associated with improved patient outcomes. Transfusion. 2014;54:2753-2759.