Blood Transfusion Reduction - QI Project

Study Overview
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Brief Summary
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Blood Banks of large medical centers have large annual budgets, typically millions of dollars. Blood product wastage results in not only in a loss of the product's cost, but also of the fees involved in transporting, handling, and administering these products. Optimal utilization of blood products requires a balance between maximizing patient clinical outcomes while avoiding unnecessary costs and risks associated with transfusions. This project will specifically focus on packed red blood cell transfusions (pRBCs). There are clear guidelines for transfusing pRBCs however these guidelines are not always followed. pRBC transfusions outside of recommended guidelines is associated with increased risk of harm to patients. Our aim is to improve adherence to guideline indicated pRBC transfusions for patient in the UCHealth system thereby decreasing inappropriate (non-guideline indicated) pRBC transfusions. We will conduct a QI project seeking to improve pRBC transfusion guideline adherence. This project will involve data review to establish baseline rates, multimodal interventions to improve adherence to pRBC transfusion guidelines including provider education, modifications to the electronic ordering interface, and changing blood back policies at participating institutions.

Official Title
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Blood Transfusion Reduction Quality Improvement Project

Conditions
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Blood Transfusion

Intervention / Treatment
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* Behavioral: General improvement
* Behavioral: In-line help text
* Behavioral: Interruptive alert


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: All physicians and nurses with access to order inpatient blood transfusions through a hospital-based EMR. All physicians and nurses ordering blood for individuals over the age of 18. Exclusion Criteria: All physicians and nurses ordering blood transfusion ordering blood in the OR Blood ordered through massive transfusion protocol
Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: General improvement<br>Using the expertise of the study personnel, electronic-health record system architects working for UCHealth, and incorporating feedback from the users who participated in the user-centered design sessions we made changes to the blood transfusion order-set as well as the prepare and transfuse orders. The intention of the changes to the interface are to be more intuitive for ordering clinicians. | Behavioral: General improvement<br>* Changes to interface to be more intuitive.<br>|
| Experimental: In-line help text<br>In addition to general improvement changes, subjects exposed to the in-line help text arm receive text detailing evidence-based transfusion recommendations that appear if the most recent hemoglobin level is above 7.0 g/dL. This text appears within the transfusion order but is non-interruptive as it does not require users to acknowledge the text nor does is require any additional keystrokes or clicks. | Behavioral: In-line help text<br>* General improvement + in-line help text<br>|
| Experimental: Interruptive alert<br>In addition to general improvement changes, subjects exposed to the interruptive alert arm receive text detailing evidence-based transfusion recommendations that appear if the most recent hemoglobin level is above 7.0 g/dL. In contrast to the in-line help text arm, this arm includes an interruptive alert that appears when the user selects the transfusion order. This alert offers users the option to remove the order which results in no-blood product ordered. Alternatively, users may continue to order blood and are asked to select the reason for proceeding with the intended order. | Behavioral: Interruptive alert<br>* General improvement + interruptive alert<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Blood Transfusion Orders | Number of patients who received blood transfusions during the study by arm. | 78 weeks | 
| Guideline Concordance Measured by Pre-Transfusion Hemoglobin Values Per Transfusion | The American Association of Blood Banks recommends a restrictive threshold of a pre-transfusion hemoglobin level of less than 7.0g/dL for the vast majority of inpatients. Transfusions with Hemoglobin levels above 7 will be compared in arm 1 vs 2 +3 combined; arm 2 vs arm 3. | 78 weeks | 
| Guideline Concordance Measured by Number of Units Ordered Per Transfusion | The American Association of Blood Banks recommends a restrictive threshold of a single unit pRBC transfusion for the vast majority of inpatients. This outcome will compare hemoglobin levels, units transfused in arm 1 verses arms 2 and 3 combined and arm 2 verses arm 3. | 78 weeks | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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blood transfusion, EHR interventions, user-centered design, high-value care