Improving red blood cell orders, utilization, and management with point-of-care clinical decision support

The computerized order for red blood cell (RBC) transfusion within our electronic health record was redesigned with integrated clinical decision support (CDS) to reinforce our restrictive transfusion policy. These changes encouraged 1-unit (1U) RBC orders, clarified hemoglobin (Hb) transfusion triggers, and discouraged unnecessary orders. This study assessed whether these changes resulted in durable effects on provider practices.

The study compared three 1-year subperiods from August 2011 to August 2014, with each year corresponding to a historical control period, preintervention and postintervention years. This study analyzed ratios of 1U versus 2-unit (2U) orders and the absolute rate of RBC orders, units charged, Hb transfusion triggers, repeat transfusion orders, and selected clinical indications both institution-wide and across several subpopulations.

Our institution-wide ratio of 1U versus 2U orders increased from 0.50 to 1.20 (p < 0.0001) in the pre- to postintervention subperiods, respectively. The number of units charged per day decreased from 15.68 to 13.53 (p < 0.001), while rates of initial and repeat orders remained stable. Proportion of clinical indications used and mean Hb triggers demonstrated generally positive results. The changes observed between the pre- and postintervention years were far greater than changes between historical control versus preintervention years, reinforcing attribution of results to computerized physician order entry changes.

Use of computerized orders and CDS encouraged a restrictive transfusion policy, which was highly successful in changing provider practices. We also succeeded in decreasing mean Hb triggers and overall utilization of RBCs. These findings persisted across many subpopulations.