How do I audit hospital blood product utilization?

Abstract

B lood transfusion continues to be an everincreasing activity within the medical community; recent survey data shows an approximate 6% increase in red blood cell (RBC) transfusions, 12% increase in plasma transfusions, and 20% increase in platelet (PLT) transfusions between 2006 and 2008 equating to approximately 21 million blood products being transfused annually. Moreover, the financial burden of blood at many institutions is significant; for instance, at our institution, an academic tertiary medical center, blood acquisition costs comprise approximately 35% of the annual supply budget for the Department of Pathology. Given the prominence of blood transfusion in the practice of clinical medicine, the importance of transfusion and blood safety, and the continued escalation of health care costs, assessment of blood utilization practice is an important aspect of institutional quality and safety programs and is endorsed by the Joint Commission and the Center for Medicare Services. AABB Standard 8.2 also requires this review and lists 10 areas that should be monitored. Two of these areas are “appropriateness of use” and “compliance with peer review recommendations.” Aside from these mandates, there is relatively little guidance on the mechanics of blood component utilization review. The AABB technical guidance document, published in 2001, describes general approaches to utilization audits (i.e., prospective, concurrent, and retrospective) as well as suggestions for thresholds for evaluating the appropriateness of transfusions (e.g., “PLT count < 50 ¥ 10/L and impending surgery”). There are benefits and shortcomings of the various approaches to utilization review. Under ideal circumstances, prospective review of blood product orders for both appropriateness of product selection and timing of administration offers the best opportunity to avoid unnecessary transfusion. However, the prospective review of all blood product requests is labor-intensive and risks, in urgent situations, delay of optimal patient care delivery. A concurrent review process involves review of blood component use within hours to 1 to 2 days after the transfusion episode. The advantage to this approach is that the reviewer can obtain all pertinent laboratory and clinical data surrounding the transfusion event and make a judgment as to the appropriateness of blood component use. If the transfusion episode appears to be out of line with good clinical practice, the reviewer has the opportunity to interact with the clinician who, based on the proximity to the event, will more than likely still be caring for the patient. Retrospective review is, without a doubt, the easiest approach to utilization review. With this approach, transfusion episodes can be assessed using preset review criteria. Cases that fall outside of these criteria can be evaluated more closely to determine whether or not extenuating clinical circumstances justified the request for blood products. The disadvantage of this approach is that the opportunity for effective intervention is lost since the ordering physician is likely no longer involved with the patient (particularly when the transfusion event occurs in an acute care setting) nor likely to recall the specifics of the event triggering the request for blood component transfusion. While recognizing the pros and cons to the various approaches to utilization review is important, the AABB technical guidance document does not delve into operational specifics of creating an audit program because “each transfusion committee . . . is responsible for developing its own blood utilization procedures and audit criteria.” In this article, we provide more direct “how to” information by describing our system for auditing blood product utilization.