Red blood cell transfusion practices in two surgical intensive care units: A mixed methods assessment of barriers to evidence-based practice

David J. Murphy, Peter J. Pronovost, Christoph U. Lehmann, Ayse P. Gurses, Glenn J R Whitman, Dale M. Needham, Sean M. Berenholtz

Research output: Contribution to journalArticle

11 Citations (Scopus)

Abstract

Background Despite evidence supporting restrictive red blood cell (RBC) transfusion thresholds and the associated clinical practice guidelines, clinical practice has been slow to change in the intensive care unit (ICU). Our aim was to identify barriers to conservative transfusion practice adherence.

Study Design and Methods A mixed-methods study involving observation of prescriber (i.e., physicians, physician assistants, nurse practitioners) and bedside nurse daily bedside rounds, provider survey, and medical record abstraction was conducted in one cardiac surgical ICU (CSICU) and one surgical ICU (SICU) in an academic hospital in Baltimore, Maryland.

Results Of 52 patient encounters observed during bedside rounds, 38 (73%) involved patients without evidence of active bleeding or cardiac ischemia. Surveys were completed by 52 (93%) of the 56 providers participating in rounds. Prescribers in the CSICU and SICU (87 and 90%, respectively) indicated the ideal pretransfusion hemoglobin (Hb) to be not more than 7 g/dL in nonbleeding and/or nonischemic patients compared to a minority of nurses (8% [p = 0.002] and 42% [p = 0.015], respectively). Prescribers and nurses in both ICUs overestimated the typical pretransfusion Hb in their units (CSICU, p < 0.001; SICU, p = 0.019). During rounds, providers infrequently explicitly discussed Hb monitoring or transfusion thresholds (33%) despite most (60%) reporting significant variation in transfusion thresholds between individual prescribers.

Conclusions Our study identified several provider and system barriers to evidence-based transfusion practices including knowledge differences, overly optimistic estimates of current practice, and heterogeneous transfusion practice in each ICU. Further work is necessary to develop targeted interventions to improve evidence-based RBC transfusion practices.

Original languageEnglish (US)
Pages (from-to)2658-2667
Number of pages10
JournalTransfusion
Volume54
Issue number1
DOIs
StatePublished - Oct 1 2014
Externally publishedYes

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Erythrocyte Transfusion
Evidence-Based Practice
Critical Care
Intensive Care Units
Hemoglobins
Nurses
Physician Assistants
Baltimore
Nurse Practitioners
Practice Guidelines
Medical Records
Ischemia
Observation
Hemorrhage
Physicians
Surveys and Questionnaires

ASJC Scopus subject areas

  • Hematology
  • Immunology
  • Immunology and Allergy
  • Medicine(all)

Cite this

Red blood cell transfusion practices in two surgical intensive care units : A mixed methods assessment of barriers to evidence-based practice. / Murphy, David J.; Pronovost, Peter J.; Lehmann, Christoph U.; Gurses, Ayse P.; Whitman, Glenn J R; Needham, Dale M.; Berenholtz, Sean M.

In: Transfusion, Vol. 54, No. 1, 01.10.2014, p. 2658-2667.

Research output: Contribution to journalArticle

Murphy, David J. ; Pronovost, Peter J. ; Lehmann, Christoph U. ; Gurses, Ayse P. ; Whitman, Glenn J R ; Needham, Dale M. ; Berenholtz, Sean M. / Red blood cell transfusion practices in two surgical intensive care units : A mixed methods assessment of barriers to evidence-based practice. In: Transfusion. 2014 ; Vol. 54, No. 1. pp. 2658-2667.
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abstract = "Background Despite evidence supporting restrictive red blood cell (RBC) transfusion thresholds and the associated clinical practice guidelines, clinical practice has been slow to change in the intensive care unit (ICU). Our aim was to identify barriers to conservative transfusion practice adherence.Study Design and Methods A mixed-methods study involving observation of prescriber (i.e., physicians, physician assistants, nurse practitioners) and bedside nurse daily bedside rounds, provider survey, and medical record abstraction was conducted in one cardiac surgical ICU (CSICU) and one surgical ICU (SICU) in an academic hospital in Baltimore, Maryland.Results Of 52 patient encounters observed during bedside rounds, 38 (73{\%}) involved patients without evidence of active bleeding or cardiac ischemia. Surveys were completed by 52 (93{\%}) of the 56 providers participating in rounds. Prescribers in the CSICU and SICU (87 and 90{\%}, respectively) indicated the ideal pretransfusion hemoglobin (Hb) to be not more than 7 g/dL in nonbleeding and/or nonischemic patients compared to a minority of nurses (8{\%} [p = 0.002] and 42{\%} [p = 0.015], respectively). Prescribers and nurses in both ICUs overestimated the typical pretransfusion Hb in their units (CSICU, p < 0.001; SICU, p = 0.019). During rounds, providers infrequently explicitly discussed Hb monitoring or transfusion thresholds (33{\%}) despite most (60{\%}) reporting significant variation in transfusion thresholds between individual prescribers.Conclusions Our study identified several provider and system barriers to evidence-based transfusion practices including knowledge differences, overly optimistic estimates of current practice, and heterogeneous transfusion practice in each ICU. Further work is necessary to develop targeted interventions to improve evidence-based RBC transfusion practices.",
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N2 - Background Despite evidence supporting restrictive red blood cell (RBC) transfusion thresholds and the associated clinical practice guidelines, clinical practice has been slow to change in the intensive care unit (ICU). Our aim was to identify barriers to conservative transfusion practice adherence.Study Design and Methods A mixed-methods study involving observation of prescriber (i.e., physicians, physician assistants, nurse practitioners) and bedside nurse daily bedside rounds, provider survey, and medical record abstraction was conducted in one cardiac surgical ICU (CSICU) and one surgical ICU (SICU) in an academic hospital in Baltimore, Maryland.Results Of 52 patient encounters observed during bedside rounds, 38 (73%) involved patients without evidence of active bleeding or cardiac ischemia. Surveys were completed by 52 (93%) of the 56 providers participating in rounds. Prescribers in the CSICU and SICU (87 and 90%, respectively) indicated the ideal pretransfusion hemoglobin (Hb) to be not more than 7 g/dL in nonbleeding and/or nonischemic patients compared to a minority of nurses (8% [p = 0.002] and 42% [p = 0.015], respectively). Prescribers and nurses in both ICUs overestimated the typical pretransfusion Hb in their units (CSICU, p < 0.001; SICU, p = 0.019). During rounds, providers infrequently explicitly discussed Hb monitoring or transfusion thresholds (33%) despite most (60%) reporting significant variation in transfusion thresholds between individual prescribers.Conclusions Our study identified several provider and system barriers to evidence-based transfusion practices including knowledge differences, overly optimistic estimates of current practice, and heterogeneous transfusion practice in each ICU. Further work is necessary to develop targeted interventions to improve evidence-based RBC transfusion practices.

AB - Background Despite evidence supporting restrictive red blood cell (RBC) transfusion thresholds and the associated clinical practice guidelines, clinical practice has been slow to change in the intensive care unit (ICU). Our aim was to identify barriers to conservative transfusion practice adherence.Study Design and Methods A mixed-methods study involving observation of prescriber (i.e., physicians, physician assistants, nurse practitioners) and bedside nurse daily bedside rounds, provider survey, and medical record abstraction was conducted in one cardiac surgical ICU (CSICU) and one surgical ICU (SICU) in an academic hospital in Baltimore, Maryland.Results Of 52 patient encounters observed during bedside rounds, 38 (73%) involved patients without evidence of active bleeding or cardiac ischemia. Surveys were completed by 52 (93%) of the 56 providers participating in rounds. Prescribers in the CSICU and SICU (87 and 90%, respectively) indicated the ideal pretransfusion hemoglobin (Hb) to be not more than 7 g/dL in nonbleeding and/or nonischemic patients compared to a minority of nurses (8% [p = 0.002] and 42% [p = 0.015], respectively). Prescribers and nurses in both ICUs overestimated the typical pretransfusion Hb in their units (CSICU, p < 0.001; SICU, p = 0.019). During rounds, providers infrequently explicitly discussed Hb monitoring or transfusion thresholds (33%) despite most (60%) reporting significant variation in transfusion thresholds between individual prescribers.Conclusions Our study identified several provider and system barriers to evidence-based transfusion practices including knowledge differences, overly optimistic estimates of current practice, and heterogeneous transfusion practice in each ICU. Further work is necessary to develop targeted interventions to improve evidence-based RBC transfusion practices.

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