Blood management by transfusion triggers: when less is more

We reviewed the annual blood utilisation data at our institution for the past 6 years. The number of packed red blood cell units for allogeneic transfusions gradually increased from 3,989 (in 2004) to 4,762 (in 2008): a 19% increase. This exceeded the 7% increase in annual admissions of patients during the same period (from 20,470 in 2004 to 21,908 in 2005).

In 2009, we introduced new transfusion guidelines ("triggers"), essentially adopting the recommendations of the Society for the Advancement of Blood Management. Most importantly, we reduced the trigger of blood transfusions in normovolaemic symptomatic chronic anaemia patients from 8 to 7 g/dL haemoglobin. At the same time, we created a new trigger of 9 g/dL haemoglobin for high-risk patients (e.g. those with cardiovascular and/or chronic pulmonary disease as well as those undergoing chemotherapy).

We monitored the indications for blood transfusions during 2009 (2,717 consecutive orders) and sent out letters of reminder of the new guidelines to our clinicians if criteria were not met (a total of 102 letters, representing 4% of the reviewed orders). Our annual blood utilisation in 2009 showed some improvement (4,648 units) compared to the previous year (4,762 units) despite the increase in admissions of patients (from 21,908 to 22,734): this represents a 6% decrease in blood utilisation when corrected for the admissions of patients. If this trends holds up, the predicted blood utilisation for 2010 based on the January to November data (4,280) promises to show a further improvement (an 11% decrease compared to 2008).

We conclude that blood utilisation may be improved in a community hospital setting by combining new, evidence-based transfusion triggers with physicians' education.