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task force implemented a new trigger: 7 g/dl of hemoglobin or less.
In one year, they again reduced the number of transfusions—this
time from 35 percent to 15 percent.
In 2011, when adjusted patient days numbered 94,000, St. David’s
South Austin Medical Center transfused about 7,000 units of blood.
By the end of 2014, when the tally was 117,000, it transfused only
around 4,900 units.
“Our patient load has grown, but the number of units of blood
transfused has decreased dramatically,” Gros says. “More impor-
tant, though, we feel like we’re now delivering better medical care
to our patients.”
Trinity Health: Implementing Evidence-based
The Clinical and Care Optimization teams at Michigan-based
Trinity Health started its blood utilization program in late 2014 to
unify the use of evidence-based red blood cell transfusions across
the system. Driven by clinical data, team leaders standardized evi-
dence-based transfusion guidelines for their system of more than
80 hospitals and 120 continuing care facilities.
“We’ve made an effort to take the most current medical literature
and incorporate it into our decision-making process for all of our
physicians as they consider red blood cell transfusions for their
patients,” explains Robert Moser, M.D., chief of pathology and
chief medical informatics officer for Trinity’s St. Francis Medical
Center in Trenton, New Jersey.
Modeled after the CPOE Reducing Inappropriate Transfusions
(CRIT) Collaborative—a Stanford University-based approach to
blood management in pediatrics—the Trinity Health team worked
with its IT department to implement a guidance system in the blood
ordering process. Trinity Health is now the largest health system
represented in the CRIT Collaborative.
“We hardwired those evidence-based transfusion guidelines into
our computerized blood ordering set,” says Jeffry Komins, M.D.,
chief medical officer of the Trinity Health East Group and clinical
lead of the multidisciplinary Steering Team. “If a physician were
to order blood inappropriately, a screen would pop up to remind
that physician of the system’s evidence-based guidelines for blood
The Trinity Health team developed educational tools, posters and
presentations about appropriate blood use, and distributed system-
wide the most recent medical research and literature addressing
the use of blood transfusions in specific medical specialties.
Following this implementation phase, Trinity Health formed a
Care Optimization Team, led by Moser. Each Trinity Health hospital
has two representatives on the Care Optimization Team, a physician
or clinician plus the blood bank supervisor. Hospital representatives
meet regularly to discuss the successes and challenges of patient
blood management and share best practices.
“We’ve produce a daily, detailed report that covers all the trans-
fusion-ordering practices for every hospital in our system,” Moser
explains. “Each morning, I receive several emails with transfusion
reports. I can see who has ordered transfusions, why they were
ordered, how many units were ordered, whether a patient met the
right threshold and any necessary patient identifiers.”
Centura Health: Harnessing Technology
Before becoming chief medical officer of HCA’s Physician
Services Group, Christopher Ott, M.D., was chief medical officer
of the Mountain and North Denver Operating Group of Centura
Health. The blood utilization team at Centura Health implemented
a program to help physicians monitor how many transfusions they
“Old habits are hard to break,” Ott explains. “If you learned during
your training to transfuse at a given level, use blood products in par-
ticular ratios and for certain diagnoses, and have done so for years, it
can be difficult to adopt a new practice. In order to disrupt reflexive
ordering, the IT system is utilized to prompt a consideration of each
blood product order and require a reason for transfusing outside
of the data-supported range.”
If a physician logs in to the computer ordering system to order
red blood cells and the patient doesn’t meet the right threshold,
then a notification alerts the physician.
The system helped Centura reduce its overall use of blood prod-
ucts by 40 to 60 percent while significantly decreasing the risk of
patient harm, Ott adds. •
In 2011, the Joint Commission released six recommendations
for developing appropriate blood management programs.
1Develop a toolkit of clinical educational materials for
physicians. Include the risks and benefits of transfusion
and the best practices and guidelines supported by clinical
2Expand education on appropriate alternatives to transfu-
sion. Identify subject matter experts to provide guidance.
3 Advocate for accountability to organizational standards
and periodic assessments.
4Create a standard for performance metrics and data
collection. Measure the transfusion practices of
physicians as part of ongoing practice evaluations.
5Develop an informed consent process for transfusions
that communicates the risks and benefits.
6Identify research priorities to close evidence gaps in
what constitutes optimal transfusion practices.
Joint Commission Recommendations
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