Abstract & Commentary
If Less is More, How Can We Get There?
By Kenneth P. Steinberg, MD, FACP, Editor
Professor of Medicine, University of Washington School of Medicine, Seattle, WA
Dr. Steinberg reports no financial relationships in this field of study.
SOURCE: Corwin HL, et al. Red blood cell transfusion: impact of an education program and a clinical guideline on transfusion practice. J Hosp Med 2014;9:745749.
This study, done at a tertiary care university hospital here in the U.S., was initiated in an attempt to improve patient safety, conserve a vital resource, and reduce costs — a laudable tripartite goal. At this institution, a program was created to align RBC transfusion practices with best-practice RBC transfusion guidelines in adults. Prior to the study, there was no institutional RBC transfusion protocol or guideline. The study consisted of three primary interventions that were rolled out sequentially over the first 9 months of the 18-month study period. First, there was an educational program that consisted of grand rounds presentations for all major clinical departments, along with separate targeted educational presentations to high-transfusing services, nursing units, and residency programs. Then, six months later, the hospital medical board approved a transfusion guideline that was based on published best-practice guidelines. This guideline was disseminated to the entire medical staff. Lastly, three months later, an RBC transfusion order form was created within the hospital’s electronic medical record provider order entry system. This order form had the RBC transfusion guideline incorporated into it, but there was no "hard-stop" for a transfusion order that was outside the guidelines.
The outcomes of the study included patient mortality, total inpatient RBC units transfused, RBC units transfused per adult hospital admission, and RBC units transfused per 100 patient-days. The data were divided into three time periods: the 18-month baseline period prior to the first intervention, the six months after the educational intervention, and the 12 months after the roll-out of the transfusion guideline and electronic order set.
The number of admissions and the patient demographics during the 3 time periods were comparable. There was no significant difference in hospital mortality in the pre- or post-RBC program time periods. However, there was a 25% reduction in total RBC units transfused, from 923 ± 68 to 852 ± 40 after the educational program (P=0.02) and then down to 690 ± 52 after the rollout of the guideline and order set (P<0.0001). When analyzed other ways, there was a 29% reduction in mean RBC units transfused per hospital admission and a 27% reduction in mean RBC units transfused per 100 patient-days (P=0.0001 for both statistics). The decrement was sustained and seen in all units of the hospital though the smallest change was in the surgical ICU. The authors conservatively calculated an estimated cost savings of $1.7 million based on the reduction in the number of RBC units transfused.
This study reminds me of how challenging it can be in medicine to change physician practice. Over the past 10-20 years, the literature has been accumulating regarding the lack of efficacy and potential harm of RBC transfusion across many different clinical conditions. Despite this literature, and the consistency of several guidelines for transfusion, there still remains significant variability in physician practice around RBC transfusion.
This is not unique to the concept of transfusion thresholds; the delay for evidence in clinical studies to be incorporated into clinical practice can be considerable and has been observed in many different fields.
This study is not the first to demonstrate a change in clinical practice around RBC transfusion, but it has several strengths. First and foremost, the study consisted of a multifaceted approach to changing clinician behavior that included an educational component, a new hospital guideline, and a structural change to the EMR (a new electronic order set that incorporated the new guideline). There was a significant and important decrease in RBC transfusion after the educational program but an even greater and more persistent decrease after the change to the EMR. Thus the administrative changes reinforced the educational program in a sustained way. I think there is an important lesson here for hospitalists who want to work toward reducing unnecessary RBC transfusions in their hospitals. In addition to provider education, there needs to be buy-in and approval at the highest levels in the hospital and administrative changes (in this case, a new electronic order form) that support the evidence behind the change in practice.
Other strengths of the study include the length of pre-intervention period to establish a steady baseline and the duration of the observation period after the changes to assess for stability. The fact that the demographics and severity of illness of patients did not change over this time strongly implies that it was the intervention that led to the 25% decrease in RBC units transfused. The only weaknesses are that it is a single-center study and that, as a multifaceted intervention, it is unclear which is the most effective component of the entire program.
In conclusion, I agree with the authors. We’ve known for some time now that less is more when it comes to RBC transfusions, but it has been hard to fully implement this new knowledge. Corwin and colleagues have shown us the way: An educational program coupled with culture change (institutional adoption of a guideline) and administrative support (a new order set in the EMR) can lead to sustainable reductions in RBC transfusion without patient harm and with significant resource and cost savings.