Reduction of RBC transfusions based on standardized
hemoglobin evaluation for adult non-ICU patients
Supported by Caring Wisely, a project of the UCSF Center
for Healthcare Value – Delivery Systems Initiative
Kathryn Curcione RN, BSN, ONC, NE-BC, Molly Rankin, PA-C, Delene Johnson, MS, MT
CM SBB, Traci Hoiting, RN, MS, NEA-BC, Jeff Lam, RN, MSN
BACKGROUND




Patient Blood Management (PBM) is the concept of pre-emptively and
significantly reducing the need to use RBC transfusions by addressing
anemia, blood loss and hypoxia as modifiable risk factors.
PBM was adopted by WHO in 2010 (WHA63.12) as a means to promote
availability of transfusion alternatives.
There is a need to increase awareness of the clinical implications of
transfusion, and the alternatives, with a focus on patient outcomes,
inappropriateness, cost, and availability.
Approximately $15M is spent annually at UCSF to purchase blood
products. The cost of patient testing, supplies, and lab and nursing labor
result in an estimated cost of $1000 for each RBC transfusion..
CURRENT TRANSFUSION PRACTICES*
SIZE
Page (2)= RBC number
Transfusion Orders by Service and Attending
COLOR
= median pre-transfusion hemoglobin
Transfusions without indication of "active bleeding"
Malignant Hematology
Hospital Medicine
DEVELOPMENT OF PILOT STUDY AND
RESULTS
•
Visiting anesthesiologist Dr. Pedro Gambus from Hospital Clinic de Barcelona in
Spain and Adjunct Associate Professor in the Department of Anesthesia
and Perioperative Care at UCSF noted that the rate of RBC transfusion for Total
Knee Replacements for his institution is less than 5 percent.
•
In FY 2011, 33% of UCSF’s total joint replacement patients were transfused with at
least 1 unit of RBCs, which is considerably higher than that reported by other
hospitals.
•
12 Long conducted a small informal pilot study starting in August 2012 to suggest
post-operative RBC transfusion guidelines (transfuse for Hgb below 7.0 g/dL for
healthy patients, and below 8.0 g/dL for adults with cardiac risk). An “unofficial”
request to Orthopedics providers (with voluntary participation) resulted in an 8%
reduction in RBC transfusions.
•
In 2011 with 757 cases the transfusion rate was 33%, while in 2013 YTD with 406
cases, the rate is 25%. This success led to submission of a proposal to the Center
for Healthcare Values for a house-wide transfusion reduction program at UCSF.
Marking:
(None)
Liver Transplant
Color by
Median(prior_hgb)
8.00
7.00
Empty
Size by
(Row Count)
Hierarchy
ClinicalService, OrderProvide
Project goal: To increase attention on the appropriate use, and reduce RBC
transfusions by 5% for adult non-ICU patients over the course of 1 year while
neither impacting patient safety nor increasing length of hospital stay
Kidney Transplant
Orthopedics
Gynecologic Oncology
Pediatric Hematolo …
Neurosurgery
Cardiology
Urology
Cardiac Surgery
TOLERANCE OF ANEMIA
Congestiv … Obstetrics Gyne … Pedi … Em …
General Surgery
Vascular Surgery
Neurology
Neur … Hep … Tra …
Otolaryn…
Pedia … Plas … Rad …
Critical Ca …
Colorect …
Thora … P … C Pe
O C
Int
A
P
P
P
TRANSFUSION OF RBC UNITS FY2011-2013
ORTHOPEDICS DEPARTMENT
TRANSFUSION
ORDERS
Page
--Half of providers initially order a 2 unit transfusion
Number of Units Ordered
Red segment indicates a transfusion threshold below 8 g/dL and blue a threshold above 8 g/dL
Marking:
Marking
Color by
prior_hgb_gt8
4000
0
1
3500
3000
Pre-Transfusion Hgb > 8.0
2500
(Row Count)
• Various trials and studies to address tolerance of anemia include TRICC,
TRACS, FOCUS, acute GI bleed trials, and a Cochrane Meta-analysis, plus
AABB guidelines.
• The TRICC Trial was a multicenter, randomized controlled clinical trial of
transfusion requirements in critical care patients.
• Critically ill patients were randomized to restrictive strategy (transfusion
threshold of Hb < 7) or liberal (Hb < 10)
• Overall, similar rates of organ dysfunction and 30-day mortality between
groups, however:
• In healthier patients (APACHE ≤ 20), lower mortality in restrictive (8.7%) v.
liberal (16.1%)
• In patients less than 55 years old, lower mortality in restrictive (5.7%) v.
liberal (13.0%)
• Conclusions: Restrictive strategy of RBC transfusion is at least as effective
and possibly superior to liberal strategy in critically ill patients, with possible
exception of patients with acute MI and unstable angina.
CM
(ASCP) ,
2000
1500
AABB GUIDELINES, July 2012
• Issued July 2012 for hemodynamically stable patients. Guidelines do not apply
to patients with active bleeding or preoperative patients when blood loss is
anticipated during a surgical procedure.
• The AABB recommends adhering to a restrictive transfusion strategy (Quality of
evidence: high; Strength of recommendation: strong)
• In adult and pediatric intensive care unit patients, transfusion should be
considered at hemoglobin concentrations of 7 g/dL or less.
• In postoperative surgical patients, transfusion should be considered at a
hemoglobin concentration of 8 g/dL or less or for symptoms (chest pain,
orthostatic hypotension or tachycardia unresponsive to fluid resuscitation, or
congestive heart failure).
Pre Transfusion Hgb < 8.0
1000
500
0
1
2
3
4
5
units_ordered_le4
* Visualizations
compliments of Dr. Alvin
Rajkomar
KEEP CALM AND TRANSFUSE JUST ONE
TAKE HOME POINTS

In view of the known risks, the potential for unknown risks, and the lack of
evidence of benefit, restrictive transfusion policies are being increasingly
implemented as best practice both in the US and internationally

Evidence demonstrates that a hemoglobin of 7-8 is well tolerated by most
patients; nevertheless, the decision to transfuse or not transfuse should not be
based on a single lab value alone, but also on risk factors and vital signs.

The risks of transfusion are dose-dependent.