Manya Gupta, MD, a hospitalist and Assistant Professor at Rush University Medical Center, connected with an institutional quality improvement initiative to standardize how clinicians order blood transfusions.
These efforts, which started in 2013, coincided with the release of the Society of Hospital Medicine’s (SHM) Choosing Wisely® list, which included a recommendation to avoid transfusions of red blood cells for arbitrary hemoglobin thresholds and in the absence of symptoms of active coronary disease, heart failure or stroke.
Dr. Gupta and her colleagues found that clinicians at Rush were transfusing blood at higher hemoglobin thresholds than the evidence suggested was necessary. Additionally, there seemed to be no standardization as to how many units were given at a time.
“We needed to revamp the way we teach our residents,” Dr. Gupta said. “We launched a pretty aggressive educational campaign to draw attention to the latest research and Choosing Wisely recommendations.”
They held an educational conference with house staff, students and faculty. Everyone involved was educated about the new restrictive transfusion strategy that included specific hemoglobin thresholds, as well as the evidence behind the new recommendations.
At the same time, Dr. Gupta and her team also found that indications clinicians could select when they placed orders for transfusions in the electronic medical record (EMR) were too vague. With institutional backing, they created a more specific set of indications tied to the hemoglobin thresholds.
The team collected data for 14 months after the interventions and compared them to the previous 14 months. After controlling for census, results showed that blood units transfused decreased from 1,491 to 953 (36 percent) and transfusions in patients with hemoglobins greater than 8 decreased from 320 to 121 (60 percent) with no adverse impact on patient care.
“We were especially excited about the second set of findings,” Dr. Gupta said. “They showed that the transfusions we were giving were falling more within the guidelines. I really think that both the education and EMR update were necessary to sustainably change physician ordering behaviors.”
Earlier this year, Dr. Gupta and her team earned an honorable mention in the SHM Choosing Wisely® Case Study Competition for this work.
As part of a side project, Dr. Gupta focused on another SHM Choosing Wisely recommendation: avoid unnecessary blood draws. The team found that nearly all hospitalized general medical patients got labs drawn every day; they undertook a similar process of education and changing the ordering set to reduce the number of daily lab draws.
“Now, we are interested to see if there is any correlation between fewer blood draws and further reduction in blood transfusions,” she said. “We are also hoping to expand this work to investigate more global blood utilization practices at our institution, and identify other areas of unnecessary blood use which could lead to further cost savings and overall improved quality of care for our patients.”