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
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.
References (14)
- et al.
Computerized provider order entry in the clinical laboratory
J Pathol Inform
(2011) - et al.
Contemporary issues in transfusion medicine informatics
J Pathol Inform
(2011) - et al.
The physician compliance of red blood cell transfusion by computerized transfusion decision support system
Kaohsiung J Med Sci
(2012) Use of a computer-assisted system for blood utilization review
Transfusion
(2007)- et al.
Evidence-based red cell transfusion in the critically ill: quality improvement using computerized physician order entry
Crit Care Med
(2006) - et al.
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
(2007) - et al.
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
(2011)
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Present address: Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, United States.