Unnecessary (i.e., Avoidable) Blood Transfusion -- Looking at Some Hard Data
Posted Apr 14 2010 12:00am
I recently discussed unnecessary hospital blood transfusion and the relative merits of conducting such studies internally through the ever-present, but often ineffective, Blood Transfusion Committee, versus an external organization ( Reducing Wastage of Blood and Blood Products in Hospitals ). In the note, I cited Columbia Healthcare Analytics as a company that specializes in external review of transfusion practices in hospitals. Dr. David Jadwin, the founder and president of the company, has provided me with a PDF of a PowerPoint presentation in which he introduces the viewer to the basics of the review process managed by his company. I call you attention to slides number 65-67 in the stack that address the following topics: (1) algorithms for appropriate blood utilization; (2) critique process; and (3) critique: overall units. I want to focus in this note on this last slide that summarizes the blood transfusion experience in three hospitals.
in slide #65, we learn that there are no simple rules regarding appropriate blood use. Age, clinical status, and prognosis all come into play during the evaluations. The goal of any transfusion episode on the part of the transfusing physician, of course, is effective therapy and pursuit of the therapeutic plan.
In slide #66, we review the basics of a somewhat new vocabulary for the blood transfusion auditing process. Avoid means that the transfusion was avoidable. No exception means that the transfusion episode was deemed appropriate. Incomplete means that a decision could not be rendered due to missing information. Defer means that judgment was deferred due to missing data, too complex a scenario, or that the transfusion may have been premature.
Here are the results copied from slide #67: Charts reviewed: 1,458; Avoid: 1,735 (28.2%); No exception:725 (11.8%); Defer: 3,129 (50.8%); Incomplete: 574 (9.3%); Total assessments: 6,163.
I find these descriptors a little confusing but we are drifting into the world of audit-speak here. I personally would prefer the term unnecessary rather than avoidable. Similarly, I would prefer the term appropriate rather than no exception. However, I also understand that they are a lot of egos in play here so one really may need to mince words during the process.
So, no big surprise in these data. About a third of hospital transfusions are deemed avoidable using transparent, clear criteria and a comprehensive review of all relevant hospital records. No one is saying that unnecessary transfusions can be easily ratcheted down but rather that it's a very attractive QC target in terms of reducing hospital costs and patient risk reduction. If hospital administration, the blood transfusion committee, and the pathology department do not have the inclination to tackle the issue internally, it may be worth while to hire an external consultant such as Columbia Analytics to cast some light on the problem and perhaps minimize the angst among the hospital physicians. The process may be somewhat smoother if most of these physicians are hospitalists , which is to say hospital employees.