"Transfusion indication RBC (PBM-02)": gap analysis of a Joint Commission Patient Blood Management Performance Measure at a community hospital.

Background: The Joint Commission accredits health care organisations in the USA as a prerequisite for licensure. In 2011, TJC published seven Patient Blood Management Performance Measures to improve the safety and quality of care. These Measures will provide hospital-specific information about clinical performance.

Materials And Methods: Of the seven TJC PBM Performance Measures, we decided to evaluate PBM-02, "Transfusion indication RBC", at our hospital. Blood transfusion orders were collected from May 2 to August 2, 2011 and the data analysed.

Results: Of the 724 consecutive red blood cell transfusion orders, 694 (96%) documented both clinical indication and pre-transfusion haemoglobin/haematocrit results. The leading transfusion indication (47% of total) was "high risk patients with pre-transfusion Hb of <9 g/dL". The majority (72%) of non-actively bleeding patients received a single unit of blood as recommended by our transfusion guidelines. However, 70% of these patients went on to receive additional units and 21% of the initial orders were placed for two or more units. Patients with active bleeding and special circumstances accounted for 17% and 4% of the transfusions, respectively. Our blood utilisation did not change by introducing the single-unit transfusion policy.

Discussion: The majority (96%) of the transfusion orders met The Joint Commission criteria by providing both transfusion indication and pre-transfusion Hb and/or Hct values. Our transfusion guidelines recommend single-unit red blood cell transfusions with reassessment of the patient after each transfusion for need to receive more blood. Although most (72%) initial orders followed our transfusion guidelines, 70% of patients who received a single unit initially went on to receive more blood (some in excess of 10 units). Our objective data may be helpful in evaluating blood ordering practices at our hospital and in identifying specific clinical services for review.