Peer Review of Transfusion Practice

[ChrisW]

We are an 800 bed hospital that transfuses in excess of 24000 products annually. We are reviewing the processes we use to report to Transfusion Practice Committee in an attempt to make it more efficient and more effective. We do not currently have a formal Blood Product Management program so all data collection and chart review falls on Transfusion Services – with chart review being the most labor intensive. We are looking for ways to streamline that process while still meeting the AABB requirements for peer review of transfusion practices of all categories of blood and components. For those facilities that are 500 beds or more, how do you perform peer review of transfusions? How do you gather information as to which charts to review? Do you choose charts by individual physician, service line, or some other method? And what do you do with those results? Any and all ideas will be greatly appreciated!

[kirkaw]

I would love to know this too. My hospital is only 375 beds but we are stretching the truth by saying we are doing peer review of transfusion practices. I (blood bank manager) do a monthly blood utilization report and submit it to my medical director, our VP for Quality and the transfusion committee. If I notice a patient that appears to have been transfused outside of our transfusion guidelines, I submit it to a clinical nurse leader and hospitalist for review and that's what we are calling peer review. 

[David Saikin]

When I worked in a 700+ bed tertiary care hosp our HIS (not the BBIS) would flag any component requests (and subsequent transfusions) that "fell out" of defined acceptable parameters.  These would then be investigated by our donor room staff.  Eventually investigation was performed by the resident assigned to the Blood Bank.  The HIS was programmed so that H&H or PT/aPTT or plt ct had to be input when an order was being generated.

[tbostock]

I agree with David; see what your HIS can give you as far as reports. With the volume you have it is a very difficult process to do manually.

[ChrisW]

We do have reports for transfusions with pre- and post- lab values; but again, it requires a lot of manual intervention to review those reports and the carts to determine if the hgb of 8 was for a ischemic cardiac patient or a general surgery patient. I'm wondering if it would be acceptable report, for example, the number of RBCs transfusions for patients with hgb above 10 or the plt transfusions with plt count >10,000 with and normal platelet function test results. Or do specific cases have to be reviewed and reports? What are your experiences with CAP and AABB regarding peer review?

[tbostock]

We do have reports for transfusions with pre- and post- lab values; but again, it requires a lot of manual intervention to review those reports and the carts to determine if the hgb of 8 was for a ischemic cardiac patient or a general surgery patient. I'm wondering if it would be acceptable report, for example, the number of RBCs transfusions for patients with hgb above 10 or the plt transfusions with plt count >10,000 with and normal platelet function test results. Or do specific cases have to be reviewed and reports? What are your experiences with CAP and AABB regarding peer review?

Usually they just recommend a percentage, but I like your idea better of "picking your battles" by targeting ones that have a higher likelihood of being unnecessary transfusions. Because that's the area that you want to make an impact on. Picking a random percentage and then having to look at a 1 unit red cell transfusion for a 4 Hgb seems to be a waste of time.

[David Saikin]

there is no standard that calls for 100% review.  Your targeting idea is excellent.

[ChrisW]

We do target but wonder if we need to look at specific charts or if reporting the number that fell out per Service Line would be sufficient.

[David Saikin]

There really are not set guidances for peer review.  You (your Medical Director) should determined the review process.  Check out CAP standard TRM.40875 - defines the Medical Director's responsibility.  Does not tell you how or what to do but does offer suggestions

[goodchild]

I would also pose that considering it's a 'peer review', the individual/group that actually performs the chart review should be from a clinical background.

[Auntie-D]

I'd be less concerned about the numbers transfused - at the end of the day that is a clinical decision and who are we to disagree with their medical judgement. I am more concerned with the timings - routine topups ordered and transfused out of hours, 'urgent' crossmatches ordered out of hours but not used, routine topups ordered out of hours etc.

 

We also operate the policy of 'don't give two without review' - we electronically issue so this isn't an issue for us timewise. Our hospital transfuses to clinical need - for example a patient today was transfused only one unit, enough to alleviate his symptoms, with a Hb of 43. Previously the hospital would have ordered (and transfused) at least 4 units - on appearance not numerically excessive as it would still only, in theory, have raised to Hb to 80, but in this case it it would have exceeded clinical need.

 

I think the laboratory assessing need is wrong - we are not dealing with the patient at that moment in time. We can educate them as to what is appropriate use, but at the end of the day they are the ones responsible for the patient.