Case review reveals latest on overtransfusion

Anne Paxton

March 2023—A retrospective study of patients who received blood transfusions at 15 community hospitals found that just over half of the patient encounters reviewed could have been managed without the transfusion of at least one component type, and 45 percent could have been managed without any transfusion (Jadwin DF, et al. Jt Comm J Qual Patient Saf. 2023;49[1]:42–52).

The researchers performed 1,558 retrospective case evaluations between 2012 and 2018 and found that “92 percent of the patients received one, or typically more than one, unit they didn’t need,” says coauthor David Jadwin, DO, chief executive officer and chief medical officer of Columbia Healthcare Analytics in Seattle, which is a provider for hospitals of external and independent chart review.

“The instances of overtransfusion found in this study are magnitudes higher than instances of undertransfusion,” he says.

Dr. Jadwin and others examined anonymized patient records from about 100 sequential encounters per hospital, amounting to 6,696 total component transfusion events. The aim was to determine if hospital transfusion guidelines accurately identify unnecessary blood component use. The 15 hospitals—nine faith-based, three for-profit, three independent—are located in five states. Each hospital had a qualified transfusion director, and all met accreditation oversight requirements for blood review. Three had patient blood management programs.

“The rates of overtransfusion are astonishing,” says study coauthor Jonathan Waters, MD, chief of anesthesiology at UPMC Magee-Women’s Hospital and professor of anesthesiology and perioperative medicine, University of Pittsburgh School of Medicine.

“Unfortunately,” Dr. Waters says, “since medical school we’ve been trained that transfusion is fairly benign. Clinicians fear anemia way more than they fear the side effects of the transfusion. Transfusion is kind of standard of care now, and from a medicolegal perspective, there’s not much legal risk in providing the standard of care. And we’re still a long way from shifting away from that traditional pattern.”

“There are so many priorities in health care,” Dr. Jadwin says, “I think blood use has fallen by the wayside.”

Still, cost, patient outcomes, blood supply shortages, and even a staffing crisis make it hard not to take note.

Two pathologist reviewers—Dr. Jadwin and coauthor Patricia Fenderson, MD, PhD, of Oregon Health and Science University, each of whom have more than 20 years of transfusion director experience—conducted the primary comprehensive chart reviews to determine if the patient could have been managed without transfusion or with less transfusion. The two then did a secondary blind review using two sets of 70 patient encounters (140 total) to test intra-reviewer and inter-reviewer agreement. They reviewed both sets of encounters without their knowing which of them had done the initial review or what was assigned to the encounter in the initial review. The Cohen kappa inter-rater coefficient (κ), used to measure intra- and inter-rater agreement during these internal reviews, was substantial (0.60–0.80) to excellent (>0.80), Dr. Jadwin says. “These were not controversial decisions. These were not the difference between maintaining a hemoglobin value of 7 g/dL or 8 g/dL, but were unnecessary transfusions,” he says.

Independent external confirmation was performed by five clinicians, three transfusion medical directors, one transfusion medicine fellow, and one pathology resident. The κ coefficient for this external rater agreement was substantial to perfect, he says.

Among the study findings:

• Forty-five percent (±17 percent) of red blood cells, 54.9 percent (±19.3 percent) of plasma-cryoprecipitate, and 38 percent (±15.6 percent) of plateletpheresis encounters could likely have been managed without transfusion.
• Between 2,713 units (40.5 percent) and 3,306 units (49.4 percent) were likely unnecessary.
• The median hemoglobin values were 9.4 g/dL (pre-transfusion) and 9.5 g/dL at time of discharge, indicating signficant premature transfusion and overtransfusion, Dr. Jadwin says. Nearly 92 percent had a discharge Hb of greater than or equal to 8 g/dL. Thirty-seven percent had a discharge Hb of greater than or equal to 10 g/dL.

“If we could reduce by 30 percent the number of overtransfusions,” Dr. Waters says, “that would take care of the undersupply of blood and leave blood available for patients who truly need it.”

Whether the computerized provider order entry criteria most hospitals used were met was one part of the chart evaluation, but full evaluation of the medical record was conducted in addition to that, including all relevant clinical data and not just laboratory results, Dr. Jadwin says. “For RBC transfusion, hospitals commonly use Hb less than 7 g/dL or bleeding as justification for RBC transfusion. However, Hb less than 7 is not an indicator of good patient blood management. The hemoglobin may be less than 7 due to the failure to employ good patient blood management, which otherwise may have prevented the hemoglobin from dropping below 7, so comprehensive chart review is required to judge the adequacy of non-transfusion PBM.”

Similarly, he adds, some physicians check “bleeding” as a default indication for transfusion when the Hb is not less than 7 g/dL, without assessing whether better patient blood management may have helped reduce the need for transfusion. “We encountered instances when CPOE indicators were not met.” In addition, while “GI bleeding” may seemingly be an indication for RBC use, 38 percent of those encounters received only one or two units of RBC. Of these, 98.7 percent (±7.0) of those who received one RBC unit and 54.4 percent (±28.3) of those who received two RBC units likely could have been managed without blood.

With 40 to 49 percent of units found to be likely unnecessary, the authors identified “substantial unnecessary blood use,” none of which the hospitals recognized prior to review. The authors point to three causes: overreliance on laboratory transfusion criteria, failure to follow standard patient blood management principles, and a rush to transfuse.

Although other studies have identified overtransfusion, Dr. Jadwin says, they have tended to target a single class of patient such as GI bleeding, ICU, or cardiac surgery. Says Dr. Waters, “There has been a lot of work published on overtransfusion, but this study looks at it from a multicenter perspective as well as with a variety of different hospitals, mostly community hospitals, over several years.”

The findings from their study are similar to what has been seen in the UPMC hospital network, which had about a 40 percent overtransfusion rate in its pre-patient blood management period, says Dr. Waters, who directs the UPMC patient blood management program. “That’s right in line with what I’ve seen in other hospital systems.” The 40 hospitals in the UPMC system transfuse about 300,000 units of blood a year, and though the overtransfusion rate has come down, “it’s still high enough to be a significant cost savings if we’re able to continue our reduction efforts,” Dr. Waters says.

For many clinicians, there can be a rush to transfuse stemming from a strong sense that if hemoglobin is less than 7 g/dL or there is bleeding, they must do something, Dr. Jadwin says. “And this has seemingly led to habit-based behavior. Physicians tend to have a reflex of ‘Let’s transfuse immediately.’ It’s a stimulus-response, rather than sitting back and assessing the patient, perhaps being more conservative, watching the patient for another 12, 24, or 36 hours.”

“Yes, when patients are actively bleeding you have to transfuse them right away,” he continues. “But in our paper, a number of transfused patients were clinically stable and were not actively bleeding. But physicians can be very fearful that somebody’s going to question their decision, and they just have to be really proactive and order transfusion.”

“A retrospective review like this gives physicians a chance to look at their case management and learn how to provide better care.”

None of the 15 hospitals in this study had documented retrospective chart review like that employed in the study. “Hospitals did chart review years ago, but then CPOE criteria indications were created and transfusion dashboards were developed, and over the years hospitals defaulted to these as measures of good performance,” Dr. Jadwin says.

“So if there’s a hemoglobin of 6.9, most of the time those patients get transfused because it’s less than 7 and the hospital says we’ll let the physician use their clinical judgment in that case. That’s how rigid the application rule is. But what we show is that when you do the detailed chart review, you can see things aren’t quite as they seem. A patient’s hemoglobin may drop from 10 g/dL to 7 or 6.9 and two units of RBCs are transfused, but then the discharge Hb is 12 g/dL because the original drop in hemoglobin was due to fluid overload.”

“If retrospective review isn’t performed, then instances of unnecessary use like this will not be uncovered,” Dr. Jadwin continues. “With retrospective review, you see the consequences of blood transfusion. Perhaps transfusion was seemingly indicated, but there was no transfusion benefit or worse—an adverse outcome. At the end of the day, the transfusion wasn’t helpful.”

At UPMC, efforts to curb overtransfusion are ongoing. In fact, the openness to patient blood management was part of what attracted Dr. Waters to UPMC. A pop-up alert in the CPOE system is triggered when a warning against transfusion is called for. “But we also provide an override for the physician caring for the patient to proceed with transfusing,” which occurs about 15 percent of the time. However, it may occur more often, Dr. Waters says, because clinicians might be using a workaround. “You don’t really know whether or not they are going back into our CPOE systems after they’ve been blocked” the first time to place a subsequent order.