Implementation of a simple electronic transfusion alert system decreases inappropriate ordering of packed red blood cells and plasma in a multi-hospital health care system

doi:10.1016/j.transci.2014.10.022

Transfusion and Apheresis Science

Volume 51, Issue 3, December 2014, Pages 53-58

https://doi.org/10.1016/j.transci.2014.10.022 Get rights and content

Abstract

Background and objectives

Prescriber adherence to institutional blood component ordering guidelines can be low. The goal of this study was to decrease red blood cell (RBC) and plasma orders that did not meet institutional transfusion guidelines by using data within the laboratory information system to trigger alerts in the computerized order entry (CPOE) system at the time of order entry.

Methods

At 10 hospitals within a regional health care system, discernment rules were created for RBC and plasma orders utilizing transfusion triggers of hemoglobin <8 gm/dl and INR >1.6, respectively, with subsequent alert generation that appears within the CPOE system when a prescriber attempts to order RBCs or plasma on a patient whose antecedent laboratory values do not suggest that a transfusion is indicated. Orders and subsequent alerts were tracked for RBCs and plasma over evaluation periods of 15 and 10 months, respectively, along with the hospital credentials of the ordering health care providers (physician or nurse).

Results

Alerts triggered which were heeded remained steady and averaged 11.3% for RBCs and 19.6% for plasma over the evaluation periods. Overall, nurses and physicians canceled statistically identical percentages of alerted RBC (10.9% vs. 11.5%; p = 0.78) and plasma (21.3% vs. 18.7%; p = 0.22) orders.

Conclusions

Implementing a simple evidence-based transfusion alert system at the time of order entry decreased non-evidence based transfusion orders by both nurse and physician providers.

Introduction

Management of a hospital system's blood supply is a vital task, and part of this process involves monitoring blood component orders. Many clinicians, house staff, and nursing staff may not understand or not be aware of guidelines for issuing blood products, and thus order these products based on criteria that are not evidence-based. Implementing a system that integrates data in the electronic medical record (EMR) with computerized physician order entry (CPOE) is one efficient method for attempting to guide blood component orders that adhere to institutional transfusion criteria [1], [2], [3].

It has been previously demonstrated that implementation of actionable technology at the time of order entry can lead to cost savings, decreased use of laboratory resources, and reveal deviations from institutional evidence-based transfusion guidelines [4], [5], [6], [7]. In light of this, an electronic alert system was implemented using CPOE in conjunction with our laboratory information system for ordering of packed red blood cells (RBCs) and plasma in 10 hospitals in a regional healthcare system. Among the hospitals, the largest facility transfuses approximately 28,000 units of RBCs and 24,000 units of plasma annually. The goal was to decrease RBC and plasma orders that did not meet institutional transfusion guidelines.

Section snippets

Materials and methods

Institutional transfusion guidelines were developed by the hospital transfusion committees and were based on the current literature of transfusion thresholds and clinical outcomes. The same criteria for ordering RBCs and plasma and alert settings were used at all 10 hospitals within this healthcare system. The phrasing of the alerts was approved by each of the hospital's transfusion committee. For RBCs, the alert was triggered if an order was placed and the patient's most recent hemoglobin

Results

Over the 15 month evaluation period, 15,352 RBC orders triggered alerts, of which 11.3% (1694) were canceled. Table 1 demonstrates the total alerts and heeded alerts at each hospital. The percentage of canceled alerts remained steady over the 15 months evaluation period (p = 0.76; see Fig. 3a). During the month of July, 10% of orders (99/972) were canceled; this was not significantly different from the average percentage of alerts canceled per month over the evaluation period (11%, p = 0.16).

Discussion

Implementing an automated RBC and plasma alert within the CPOE system of the hospitals within a regional health care system as a prospective method of alerting health care providers of non-evidence based blood component orders resulted in an immediate decrease in the number of orders that were placed. These initial decreases were sustained over the evaluation periods for both RBCs and plasma orders. Other centers that have implemented prospective monitoring and triaging, either by manual or

Role of the funding source

None.

Contributors

MS: Analyzed the data, prepared and edited the manuscript.

DJT: Analyzed the data, edited the manuscript.

MHY: Analyzed the data, edited the manuscript.

MAR: Analyzed the data, edited the manuscript.

JHW: Analyzed the data, edited the manuscript.

JSR: Analyzed the data, prepared and edited the manuscript.

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¹: Present address: Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, United States.

View full text

Implementation of a simple electronic transfusion alert system decreases inappropriate ordering of packed red blood cells and plasma in a multi-hospital health care system

Abstract

Background and objectives

Methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

Role of the funding source

Contributors

J Pathol Inform

J Pathol Inform

Kaohsiung J Med Sci

Use of a computer-assisted system for blood utilization review

Transfusion

Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry

Crit Care Med

The addition of decision support into computerized physician order entry reduces red blood cell transfusion resource utilization in the intensive care unit

Am J Hematol

The effects of a computerized transfusion decision support system on physician compliance and its appropriateness for fresh frozen plasma use in a medical center

Am J Clin Pathol