Comparing the safety and efficacy of red blood cell transfusion dose in hematopoietic stem cell transplant patients: single versus double unit transfusions

Abstract

Until recently, the national standard practice for blood transfusions in bone marrow transplant patients was two units of red blood cells (RBCs) per transfusion episode. This practice was called into question due to safety concerns, suggesting that one unit of RBCs per transfusion episode may be an equivalent or even safer and less costly practice (assuming factors such as amount of bleeding and hemoglobin level are equal). Following a thorough review of existing blood management practices and review of the literature, our academic medical center changed practice to routinely transfuse one unit of RBCs per low hemoglobin (7-8 g/dL) episode if certain clinical criteria were met. Following IRB approval, a retrospective medical record review began to evaluate this practice change among two groups of hematology-oncology patient populations (allogeneic and autologous bone marrow transplant). Patient records from these two groups of patients are being evaluated before and after the practice change (one vs two units of RBCs/transfusion) looking at average units of blood products transfused per patient, impact on length of stay, and estimate of nursing time costs. The project is expected to generate new knowledge regarding safe blood management practices in hematology oncology patients. The project is using the hematology oncology inpatient unit log of admissions and discharges to identify adult allogeneic and autologous bone marrow transplant patients who received a blood transfusion for a hemoglobin of 7-8g/dl and hematocrit above 21%; and were not actively bleeding, septic, experiencing a major infection, or pregnant. Patient data are being obtained from the University HealthSystem Consortium (UHC) database. 400 cases are being enrolled, 200 from pre-practice change (7-1-2009 to 6-30-2011) and 200 from post-practice change (9-1-2011 to 8-31-2013). A two-month gap was purposefully included between the two time periods to allow for full transition to the new practice standard of one unit of RBCs/transfusions. Data thus far suggests a reduction in red blood cell utilization at an average of 1.3 units per hospital discharge. Based on these utilization trends, we are estimating a cost savings of at least $1300 per month just in purchase cost ($200 per RBC unit X 1.3 units per discharge X an average of 5 patients/month). Additionally, we are estimating a savings in nursing hours of approximately 13 hours per month (2 hours per RBC transfusion X 1.3 units per discharge X an average of 5 patients/month). Preliminary project findings indicate promise for the standard practice of transfusing one unit of RBCs per low hemoglobin episode for allogeneic bone marrow transplant and autologous bone marrow transplant patients. After data collection is complete, formal statistics will be completed to compare the mean number of RBC units between the practice of routinely transfusing 1 RBC unit and the practice of routinely transfusing 2 RBC units, as well as comparing length of stay and costs. Early conclusions suggest the goal of improving the safety of blood transfusions and preserving a precious resource might be achieved with this important practice change for two groups of oncology patients. These results will inform other practice settings to improve their use of blood management products for oncology patients and promote patient safety and cost-effective practices. Use of the UHC database as a meaningful resource for practice improvement projects and research studies will be highlighted. Continued evaluation and ongoing improvement of blood management practices at the project site will be discussed with suggestions for other settings and practices. This will help improve the safety of blood transfusions. It could guide future studies with baseline information from this transfusion practice change. Other oncology areas could adopt a similar practice change, educate patients and clinicians on safe transfusion practices.