Evaluation of RBC Transfusion Practice in Adult ICUs and the Effect of Restrictive Transfusion Protocols on Routine Care

• Type of Material: Article
• Authors: Kevin P. Seitz, University of Washington; Jonathan Sevransky, Emory University; Greg Martin, Emory University; John D Roback, Emory University; David J Murphy, Emory University
• Language: English
• Date: 2017-02-01
• Publisher: Lippincott, Williams & Wilkins
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2017 Society of Critical Care Medicine and Wolters Kluwer Health, Inc.
• Final Published Version (URL): http://dx.doi.org/10.1097/CCM.0000000000002077
• Title of Journal or Parent Work: Critical Care Medicine
• ISSN: 0090-3493
• Volume: 45
• Issue: 2
• Start Page: 271
• End Page: 281
• Grant/Funding Information: Dr. Martin received support for article research from the NIH and received funding from CR Bard, Cumberland Pharmaceuticals, and Grifols. His institution received funding from the NIH & FDA, Baxter Healthcare.; Dr. Murphy received support for article research from the National Institutes of Health (NIH). His institution received funding (Supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR000454 and TL1TR000456).; Dr. Sevransky received funding from the Food and Drug Administration and received support for article research from the FDA. His institution received funding from the Society for Critical Care Medicine; Supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR000454 and TL1TR000456.; Dr. Seitz received support for article research from the National Institutes of Health (NIH) and disclosed other (He was supported by a grant from the National Center for Advancing Translational Sciences of the National Institutes of Health under award number UL1TR000454).
• Keywords: PHYSICIAN ORDER ENTRY; COMPONENT UTILIZATION; CLINICAL-PRACTICE GUIDELINE; erythrocyte transfusion; Science & Technology; CRITICALLY-ILL PATIENTS; UNITED-STATES; critical care/therapy; Life Sciences & Biomedicine; STATES CRITICAL ILLNESS; evidence-based medicine; clinical protocols; General & Internal Medicine; Critical Care Medicine; BLOOD-CELL TRANSFUSION; intensive care unit/organization and administration; ACUTE LUNG INJURY; SYSTEM; CRITICAL ILLNESS OUTCOMES
• Research Categories: Health Sciences, Epidemiology; Health Sciences, Medicine and Surgery

Abstract

Objective: Research supports the efficacy and safety of restrictive transfusion protocols to reduce avoidable RBC transfusions, but evidence of their effectiveness in practice is limited. This study assessed whether admission to an ICU with an restrictive transfusion protocol reduces the likelihood of transfusion for adult patients. Design: Observational study using data from the multicenter, cohort Critical Illness Outcomes Study. Patient-level analyses were conducted with RBC transfusion on day of enrollment as the outcome and admission to an ICU with a restrictive transfusion protocol as the exposure of interest. Covariates included demographics, hospital course (e.g., lowest hematocrit, blood loss), severity of illness (e.g., Sequential Organ Failure Assessment score), interventions (e.g., sedation/analgesia), and ICU characteristics (e.g., size). Multivariable logistic regression modeling assessed the independent effects of restrictive transfusion protocols on transfusions. Setting: Fifty-nine U.S. ICUs. Patients: A total of 6,027 adult I CU patients. Interventions: None. Measurements and Main Results: Of the 59 study ICUs, 24 had an restrictive transfusion protocol; 2,510 patients (41.6%) were in an ICU with an restrictive transfusion protocol. The frequency of RBC transfusion among patients with severe (hematocrit, < 21%), moderate (hematocrit, 21-30%), and mild (hematocrit, > 30%) anemia in restrictive transfusion protocol ICUs was 67%, 19%, and 4%, respectively, compared with 60%, 14%, and 2% for those in ICUs without an restrictive transfusion protocol. Only 27% of transfusions were associated with a hematocrit less than 21%. Adjusting for confounding factors, restrictive transfusion protocols independently reduced the odds of transfusion in moderate anemia with an odds ratio of 0.59 (95% CI, 0.36-0.96) while demonstrating no effect in mild (p = 0.93) or severe (p = 0.52) anemia. Conclusions: In this sample of ICU patients, transfusions often occurred outside evidence-based guidelines, but admission to an ICU with an restrictive transfusion protocol did reduce the risk of transfusion in moderately anemic patients controlling for patient and ICU factors. This study supports the effectiveness of restrictive transfusion protocols for influencing transfusions in clinical practice.