Reducing Unnecessary Blood Transfusions With Clinical Decision Support

photo of blood transfusion

Blood transfusions have the power to save lives. But when used inappropriately, they can harm patients, generate excessive costs and waste an important, limited resource.

Armed with studies showing up to 40 percent of transfusions in the U.S. are unnecessary1, University of Missouri Health Care leaders saw an opportunity to improve patient safety and reduce costs by implementing a red blood cell (RBC) transfusion clinical decision support alert.

Nine months after embedding the alert into the electronic health record, staff at the Columbia, Missouri-based ITWorks client reduced the health system’s overall RBC transfusion rate by 13.34 percent2, saving approximately $195,000 in acquisition costs3 and avoiding between $505,000 and $1.14 million4 in indirect costs for things like transfusion administration, patient blood testing and overhead.

Emily Coberly, MD
Emily Coberly, MD

"We always want to support our providers in delivering evidence-based care,” said Emily Coberly, MD, medical director of transfusion services at MU Health Care. “When you're working with a procedure as common as a blood transfusion, there's an opportunity for small changes to make a big impact."

The alert, designed to reflect evidence-based guidelines, appears when clinicians place RBC transfusion orders for admitted patients with a hemoglobin level greater than 7.0 g/dL or no hemoglobin level documented in the past 24 hours — excluding orders for patients in the neonatal intensive care unit, operating room and emergency department.

Clinicians who encounter the alert can either cancel their order with a single click or proceed by selecting an override reason.

The alert helps reduce RBC transfusions in two ways: It provides clinicians with best-practice guidance as they’re placing the order, influencing their immediate behavior while simultaneously informing or deterring future orders. The process also generates data showing how clinicians interact with the alert, highlighting opportunities for additional education.

MU Health Care leaders regularly deliver targeted education on RBC transfusion best practices to departments with high alert override rates. One department’s alert override rate dropped 29 percent a month after receiving targeted education.

"The alert data helps highlight variability in ordering patterns across different clinicians or departments, allowing us to target education and align practices throughout our organization,” Coberly said.

MU Health Care leaders plan to continue building upon the project's success by monitoring RBC transfusion rates and alert overrides and increasing targeted patient blood management education. They also plan to create similar alerts for other blood product transfusion orders, including plasma, platelets and cryoprecipitate.

1 Shander A, et al. “Appropriateness of allogeneic red blood cell transfusion: the international consensus conference on transfusion outcomes.” Transfus Med Rev. 2011 Jul, doi: 10.1016/j.tmrv.2011.02.001.

2 Comparing October 2015 - November 2017 to December 2017 - August 2018

3 Based on MU Health Care’s acquisition cost to supplier of $202 per unit

4 Based on data published by the National Center for Biotechnology Information estimating the average indirect cost per red blood cell transfusion is between $522 and $1,183. Shander et al. (2010).

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