How do I implement a more restrictive transfusion trigger of hemoglobin level of 7 g/dL at my hospital?

Background: The red blood cell (RBC) transfusion trigger is a major driver of transfusion practice and affects health care costs and in some instances patient outcomes. Reducing the transfusion threshold will decrease RBC utilization and hospital costs.

Study Design And Methods: The hospital transfusion committee, endorsed by the medical staff executive committee, developed an educational program for physicians, nurses, and blood bank staff focusing on the scientific basis for a transfusion trigger of hemoglobin (Hb) of 7 g/dL rather than 8 g/dL as well as a program to discourage the routine 2-unit RBC transfusion. RBC transfusion practice review was performed and those physicians transfusing outside of the new variables were questioned as to the necessity for the transfusion.

Results: A total of 4492 RBC units were saved and 662 patients were not transfused over the three fiscal years (FYs), 2010, 2011, and 2012, compared to 2009 baseline. Direct cost savings over 3 years with a transfusion trigger of Hb of 7 g/dL was $943,320. If activity-based costing is used, the savings may have reached as high as $5,314,036. The number of single-unit RBC transfusions increased steadily over the course of the study while the number of 2-unit transfusions remained relatively stable over the three FYs 2010 to 2012.

Conclusion: A Hb level of 7 g/dL is the transfusion threshold which is being adopted by many hospitals. Institutional culture change to a Hb level of 7 g/dL can be implemented with the right champion when endorsed by upper echelon medical leadership and hospital administration.