Hospital of the University of Pennsylvania, United States
Background/Case Studies: Appropriate use of blood products is critical for optimizing patient outcomes, reducing hospital costs, and conserving donated resources. The Pediatric Critical Care Transfusion and Anemia Expertise Initiative (TAXI) guidelines provide important clinical guidance to avoid unnecessary red blood cell transfusion in the pediatric critical care setting. Clinical decision support (CDS) tools integrated into the electronic health record (HER) can promote adherence to transfusion guidelines, which is otherwise poor. Given the complexity of clinical scenarios requiring transfusions, iterative assessment and refinement of such CDS alerts is necessary.
Study
Design/Methods: An interruptive CDS alert was activated in our EHR on 01/2022 based on complex patient criteria defined in the TAXI guidelines. The alert fired when pRBCs were ordered outside of acceptable criteria. Providers were required to select predefined justification criteria and optionally provide free-text explanations before completing flagged orders. Post-implementation data collection include pRBC orders by pre-transfusion hemoglobin (Hb) values, percentage of alerts resulting in transfusion within 6 hours, proportion of acknowledgement reasons, and free text responses provided for alert override. Data from 552 fulfilled pRBC orders prior to implementation and 3,366 orders post-implementation were analyzed over three years (01/2022-01/2025).
Results/Findings: Following alert implementation, pRBC orders placed for patients with Hb levels < 7 g/dL increased from 37% to 42%, and orders for patients with Hb between 7–9 g/dL decreased from 47.5% to 42.5% (Figure A). Of 2,450 fired alerts, there was a 17% rate of transfusion avoidance within 6 hours of alert firing (Figure A). There was a 1.7% rate of alert acceptance, defined by removal of transfusion order within the alert, with the most common override acknowledgement reason being ‘not applicable’ followed by ‘active bleeding’. Provider feedback (n=631 comments) indicated misclassification due to hemoglobin values from point of care devices, priming for apheresis or dialysis, or goal hemoglobin values greater than 7.
Conclusions: The CDS alert demonstrated potential in reducing inappropriate transfusion orders but highlighted limitations in its current design due to lack of integration from point of care device results and exclusion of common reasons for transfusion outside of guidance. Iterative refinements informed by provider feedback will improve specificity and minimize interruptions in appropriate care delivery, with the goal of optimizing criteria sensitivity while maintaining adherence to best practices in blood product utilization within the PICU.
