Appropriate transfusions in the ICU: Can midlevel providers help improve compliance?
Sengupta R, Small BL, Smoot T, Lopez-Plaza I, and DiGiovine B. Appropriate transfusions in the ICU: Can midlevel providers help improve compliance? Am J Respir Crit Care Med 2015; 191
American Journal of Respiratory & Critical Care Medicine
Introduction/Rationale: Intensive Care Units struggle to comply with a number of quality indicators. This may be especially true in academic ICUs where a new resident group starts every month. As such, we were interested to see if there were any differences in compliance with quality indicators in our Medical ICUs with residents as the primary care providers as compared to ICUs with mid-levels as the primary providers. Many critically ill patients can tolerate hemoglobin levels as low at 7g/dl with similar clinical outcomes to those with higher transfusion thresholds. Thus, we chose compliance with a restrictive transfusion strategy as our quality indicator as recent data suggests it reduces cardiac events, re-bleeding, bacterial infections, and total mortality. Methods: Patients were admitted to the ICUs “randomly” so that there was no expected differences in the severity of illness or admitting diagnoses between the different ICU teams. A retrospective review of blood transfusions over a four month period in the medical ICU was conducted using data abstracted from our electronic medical record. The date, time and number of pRBC transfusions that occurred were recorded. Transfusions were determined to be appropriate if they were ordered for Hg<7g/dL, and inappropriate for Hg ≥7g/dl. Results: Over four months, 131 patients received 209 total transfusions. It was found that 51.67% of these transfusions were deemed appropriate according to the above-mentioned standard. We found that on the MICU service operated strictly by physician assistants (PAs), 68% of their transfusions ordered were appropriate, compared to 48% on the resident teaching service (p=0.018). Discussion: In general, we find that standardized recommendations are followed 50% of the time. Such was the case in our medical intensive care units. Interestingly, we did find that compliance with this standard was better when working with a small group of midlevel providers as compared to a large group of rotating residents. The next phase of this study will be to investigate the factors that lead to higher compliance in the midlevel service, and also to implement a series of interventions in the resident-operated ICUs with the hope of seeing a reduction in the number of unnecessary pRBC transfusions in critically ill patients. (Table Presented).