February is my favorite month to discuss improving blood utilization because it is the anniversary of the Transfusion Requirements in Critical Care (TRICC) trial, published in the New England Journal of Medicine on February 11th, 1999.1 In this landmark study2, 838 anemic critically ill patients were prospectively randomized into one of two treatment strategies: transfuse at a hemoglobin level of 10 gm/dL, a very traditional approach to these challenging patients, or transfuse at a hemoglobin level of 7 gm/dL, which was a significant departure from common practice in 1999. The results of this study changed the practice of transfusion medicine because the patients who were transfused at the more liberal trigger of 10 gm/dL had substantially worse outcomes than those transfused at the more conservative trigger of 7 gm/dL, engendering the phrase “less is more for transfusions,” a concept whose evidence has grown even stronger over the last twelve years. If you are interested in learning more about the TRICC trial and the importance of effective blood utilization committees, check out last February’s article.
Along the lines of better blood use, a recurring question I get from hospital administrators is what is the biggest “bang for the buck” to improve blood utilization within their hospitals? I think in many cases they are expecting me to offer some magic bullet drug, procedure, or reporting system, but the answer ultimately comes down to behavioral change. In my experience, the single most effective mechanism to improve blood utilization is the successful implementation of evidence based transfusion guidelines. As such, I want to discuss briefly my lessons learned in this area.
The AABB published an excellent “how to” book on transfusion committees back in 2006, and I wrote the chapter on implementing transfusion guidelines.3 One area I reviewed was the science of implementing clinical practice guidelines. This literature supports several conditions that should be met in the process of guideline implementation:
- The guidelines should be based on scientific evidence, and their application must be meaningful in clinical practice (they must be worth the effort).
- Key local physicians who are responsible for adapting them to local circumstances should formulate the guidelines and affected users should have the opportunity to critique them. This condition emphasizes the need for transparency but does not seek to gain 100% consensus, and also recognizes the importance of local opinion leaders (all politics are local).
- The guidelines should have readily discernible benchmarks or targets for good practice, emphasizing that data and metrics are key.
- Active educational efforts should accompany dissemination of the guidelines to all affected healthcare providers, and manual or computerized reminder systems should prompt use of the guidelines at points of intervention. Providing guidance at the time of the clinical decision is not only important for behavioral modification; it is also a patient safety issue for blood transfusions.
- Implementation of the guidelines must include either direct feedback on performance to individual physicians or general feedback on system performance. A multitude of studies have been done on the relative merits of prospective, concurrent and retrospective transfusion audits, with predictable results.
- Accountability for adherence to the guidelines must come from peer pressure, administrative sanction, and/or financial incentives or disincentives. This condition of course refers to the proverbial carrot or stick, and the situation is rapidly changing with the advent of Accountable Care Organizations (ACOs).
As I list these six criteria, it should stand to reason that a combination of approaches is more effective than single modalities. To round off the topic, guideline implementation techniques shown to be ineffective are those that rely on passive dissemination (such as stuffing mailboxes) or a voluntary change in practice that lacks an accountability component.
Now that we’ve covered the general concept of guideline implementation, next month we’ll cross over to the favorite question of every blood management medical director I’ve ever worked with: discussing “the number.”
- Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled trial of transfusion requirements in critical care. NEJM 1999;340(6):409-68.
- Blajchman MA. Landmark studies that have changed the practice of transfusion medicine. Transfusion 2005;45:1523-30.
- Hannon TJ. Transfusion guidelines: development and impact on blood management. In: Saxena S, Shulman IA. eds. The transfusion committee: putting patient safety first. Bethesda,MD: American Association of Blood Banks Press, 2006:115–29.