Faculty Bibliography

Background/Case Studies: Roughly 25% of the 15 million RBC transfusions (TXN) in the United States are medically unnecessary. Many studies have demonstrated the safety of using lower hemoglobin (Hgb) TXN thresholds. In 2010, our hospital adopted more restrictive RBC TXN triggers and began prospective auditing of orders, which specified a particular Hgb level, to minimize unnecessary RBC TXN. The adult triggers were A) Hgb <7 g/dl and symptomatic anemia, B) Hgb <9 g/dl with significant cardiac, neurological, or respiratory disease, C) Blood loss >20% refractory to fluid resuscitation, D) Pre-op for major surgery with anticipated blood loss >1000 ml and Hgb <7 g/dl, and E) "Other." Education was part of the roll-out of the new triggers and auditing process. In 2011, we saw an 8.7% reduction but discovered that 25% of all RBC orders were placed on the basis of "Other," likely to avoid prospective auditing. In 2013, we began prospectively evaluating the "Other" orders in addition to those placed using triggers A and B. In 2014, we evaluated the impact of this addition of prospective auditing of "Other" orders to determine whether it led to a further decrease in RBC TXN. Study Design/Methods: The number of RBC units and patients transfused from 1Q12 to 3Q12 was compared to the number transfused from 3Q13 to 1Q14. 4Q12 through 2Q13 were excluded due to the impact of Hurricane Sandy. The results were analyzed by using the Student's T-test. Results/ Findings: From 1Q12 to 3Q12, a mean of 692 patients (range 621-829) were transfused a mean of 1901 (range 1854-1950) RBC units per quarter. From 3Q13 to 1Q14, a mean of 681 patients (range 615-740) were transfused a mean of 1483 (range 1392-1566) RBC units per quarter. Although the number of patients transfused did not differ between the two time periods, there was a statistically significant reduction (mean 418 units) in the number of RBC units transfused (P value 0.002) per quarter (Table). The reduction led to a savings of $96,976 (mean RBC cost of $232 !

Background/Case Studies: Because platelet usage is driven by the types of services offered and the diagnoses treated in a given hospital, benchmarking usage is hard. Although single-donor platelet (SDP) transfusion (TXN) numbers are small, SDPs are a major cost. In 2Q10, new TXN triggers were introduced in the hospital's CPOE system, and the blood bank initiated prospective (PST) auditing of SDP orders. All SDP orders including a numeric platelet count (PLTC) as a part of the TXN trigger underwent PST audit, and SDPs were not issued if the most recent PLTC did not satisfy the selected trigger. A post-TXN PLTC was required prior to the release of a 2nd SDP unit in a non-rapidly bleeding patient. In 2011, we first evaluated the impact of the changes and noted that many orders were placed by using "other" as the TXN trigger. In 3Q13, PST auditing was expanded to include the reason provided when placing an order using "other" as the TXN trigger. In 2014, we sought to evaluate the impact of PST auditing and the expansion to include "other" orders on SDP usage. Study Design/Methods: The number of SDPs transfused from 1Q07 through 1Q10 was compared to SDP usage from 2Q10 through 3Q12. The results were then compared to SDP usage from 3Q13 through 1Q14. 4Q12 through 2Q13 were excluded because of the impact of Hurricane Sandy. The results were analyzed by using the Student's T-test. Results/Findings: From 1Q07 to 1Q10, a mean of 555.9 SDPs (range 393-801) were transfused per quarter. From 2Q10 to 3Q12, a mean of 450 SDPs (range 370-557) were transfused per quarter. From 3Q13 to 1Q14, a mean of 363.7 SDPs were transfused per quarter. PST auditing of the PLTC alone significantly decreased mean usage by 105.2 units per quarter (P value 0.041) and reduced spending by $55,756 per quarter (assuming a mean SDP cost of $530 per unit). Although not statistically significant, the addition of PST auditing of "other" orders further decreased mean usage by 87 units per quarter (P value 0.098) and provided a mean addi!

BACKGROUND: Testing of platelets (PLTs) for bacterial contamination is required by the AABB Standards but is not fully standardized. On January 31, 2011, a new AABB Standard, 5.1.5.1.1, specified that bacterial detection methods for PLT components shall use assays either approved by the Food and Drug Administration (FDA) or validated to provide sensitivity equivalent to these FDA-approved methods. METHODS: An Internet-based survey of AABB member institutions was conducted from May to June 2012, to document current practices used in 2011 for bacterial detection in different PLT products and to assess the impact of the new standard. RESULTS: Of 1053 AABB member institutions surveyed, 40 of 99 blood centers (40.4%) and 184 of 954 hospital blood banks or transfusion services (19.3%) responded. Sixty-four respondents manufactured PLTs. Apheresis PLTs (APs) were predominantly screened with the BacT/ALERT system (89.5%); the majority (95.2%) were cultured with at least 8 mL of product. There was substantial variation in the minimum incubation time of cultures before release of PLTs (range, 0 to >24 hr). Recalls of released AP for possible bacterial contamination were largely successful (67.3%); successful interdiction before transfusion was associated with incubation for more than 12 hours before release (p < 0.01). After Standard 5.1.5.1.1 took effect, there was a decrease in production of whole blood-derived PLT concentrates (WBPCs). Point-of-issue ("rapid") immunoassays were used to screen a substantial proportion of WBPC PLTs, but were rarely used as secondary tests for previously cultured APs. CONCLUSION: The survey identified variability in culture methods and release times with AP, while use of WBPC decreased after AABB Standard 5.1.5.1.1 became effective.

Background/Case Studies: It is estimated that 25% of the 15+ million RBC units transfused annually in the US are clinically unnecessary. The Transfusion (TXN) Committee is charged with determining acceptable criteria and monitoring compliance with TXN triggers. All blood orders require the physician to select a TXN trigger. In 2010, new triggers were adopted. If "other" is selected, the physician must free text type the justification. Prospective auditing of some triggers began concurrently with the new triggers. After adoption, use of "other" increased. I sought to analyze the typed justifications for using "other." Study Design/Methods: The trigger entered with all orders placed from 1/1/11 to 12/31/11 was extracted from the EMR. "Other" orders were sorted. The typed reasons were analyzed and sorted into 13 categories. The hemoglobin (Hgb) level just prior to order placement was used as a surrogate for appropriateness of TXN. Results/Findings: From 1/1/11 to 12/31/11, there were 2308 RBC orders placed using "other." Although there is a pre-op trigger, 42.9% of orders were categorized as pre-op requests to be on hold for the OR. 12.1% were for active bleeding. 10.4% were for acute blood loss. 8.4% were for patients' undergoing chemotherapy and/or radiation treatment. 9.5% were for patients with symptomatic anemia of which 20.9% had Hgb > 10 g/dl (Table). Conclusion: "Other" was frequently selected even when the patient satisfied a specific approved RBC TXN trigger. Physicians appear to like to type their own reason for TXN rather than selecting it from a dropdown menu. A new TXN trigger with a higher Hgb level (8-9 g/dl) should be created for use in patients undergoing chemotherapy and/or radiation therapy. RBCs were unnecessarily transfused to patients who had Hgb levels > 10 g/dl who were not acutely bleeding or did not have acute blood loss. More education must be provided to the ordering physicians to reduce the number of unnecessary TXNs particularly in non-bleeding patients with Hgb > 10 g/dl. Consideration should be taken to eliminate the "other" category or limit its use. (Table presented)

Background/Case Studies: >25% of the 15 million RBC transfusions (TXN) in the US probably are medically unnecessary. Many studies have shown that restrictive transfusion is safe. In 2010 our institution adopted more restrictive RBC TXN triggers to minimize clinically unnecessary TXN. The adult triggers were A) Hgb <7 g/dl with symptomatic anemia, B) Hgb <9 g/ dl with significant cardiac, neurological, or respiratory disease, C) Blood loss >20% refractory to fluid resuscitation, D) Pre-op for major surgery with anticipated blood loss >1000 ml and Hgb <7 g/dl, E) Massive transfusion, and F) Other. Prospective auditing of orders began concurrently with the new triggers. Prior to issuing, the blood bank checks the patient's most recent Hgb in the EMR and verifies that the criteria are satisfied for all orders using trigger A or B. In 2011 we sought to evaluate the impact of the changes. Study Design/Methods: All RBC TXN orders from 1/1/11 to 12/31/11 were extracted from the hospital EMR. The orders were sorted by the TXN trigger selected by the ordering physician at the time of order placement. Because of the way the message comes from the blood bank computer system into the EMR, it is not possible to electronically extract the Hgb just prior to RBC issuance. Consequently we looked at the Hgb just prior to RBC order as a surrogate for adherence to the RBC TXN triggers. Results/ Findings: From 1/1/11 to 12/31/11, 8582 RBC orders were placed and 8482 RBCs were transfused. 13.2% had no pre-TXN Hgb. 21.7% were placed at Hgb <7 g/dl. 57.3% were placed at Hgb <9 g/dl. 21.1% were placed at Hgb >=10 g/dl. Despite selecting trigger A, and 72.9% of patients had a Hgb >=7 g/ dl at the time of order placement. Trigger F was selected in 26.4% of orders (Table). Conclusion: Despite having dropdown triggers built into order entry, many physicians opt to type in a justification using the "other" TXN trigger F. Roughly 50% of the "other" orders would be more appropriately ordered as TXN trigger D. Using our current prospective auditing procedure, 57.3% of RBC orders undergo lab value verification by the blood bank technologists prior to RBC issuance. By selecting TXN trigger C, D, E, or F, 42.7% of orders bypass prospective auditing thus preventing the blood bank from stopping medically unnecessary TXN. (Table presented)