Clinical question: Why do providers continue to transfuse blood products outside of recommended guidelines, despite best practice alerts (BPAs)?
Background: There is evidence that a restrictive approach to blood transfusion versus a liberal approach is beneficial in reducing cost, morbidity, and mortality. It is unclear why providers continue to order transfusions outside of recommended guidelines in spite of interruptive prompts.
Study design: Retrospective cohort.
Setting: Academic, tertiary care medical care center in California.
Synopsis: Researchers reviewed 10,642 blood transfusion-triggered BPAs. The BPA led to abortion of only 2% of the transfusions in this study. From the predefined institutional accepted transfusion indication list, acute bleeding was the most common (34%), followed by protocol-driven behaviors in specialty services, i.e., stem cell transplant service.
“Other” accounted for 56% of the responses; of these, only 37% entered a free text comment elaborating on the reason to override. Symptomatic anemia was the most common indication cited for these blood transfusions, followed by peri-operative transfusion and anticipation of imminent discharge. The vast majority of providers who interacted with the BPA were resident physicians (55%).
The major limitation of this study is the substantial portion (>60%) of nonspecific “other” overrides.
Bottom line: Protocol-driven behaviors and subjective indications for transfusion, such as symptomatic anemia, are unlikely to be influenced by BPAs.
Citation: Chen JH, Fang DZ, Goodnough LT, Evans KH, Porter ML, Shieh L. Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts [published online ahead of print July 7, 2014]. J Hosp Med.