Clinical Decision Support for Pediatric Blood Product Prescriptions

Abstract

Since the beginning of the 20th century, blood products have been used to effectively treat life-threatening conditions. Over time, we have come to appreciate the many benefits along with significant risks inherent to blood product transfusions. As such, recommendations for the safe and effective use of blood products have evolved over time. Current evidence supports the use of restrictive transfusion strategies that can avoid the risks of unnecessary transfusions. In spite of good evidence, there is a considerable amount of variability in transfusion practices across providers. Clinical decision support (CDS) is an effective tool capable of increasing adherence to evidence-based practices. CDS has been used successfully to improve adherence to transfusion guidelines. Pediatric literature demonstrates strong evidence for the use of CDS to improve appropriateness of red blood cell and plasma transfusion utilization. Further studies in more diverse settings with more standardized reporting are needed to provide more clarity around the effectiveness of CDS in blood product prescriptions.

Keywords

clinical decision support - computerized physician order entry - red blood cell - platelets - plasma - transfusions - pediatrics

• References

• 1 Starr DP. Blood, an Epic History of Medicine and Commerce. 1st ed. New York: Alfred A. Knopf; 1998: 8 , 441
• 2 Adams ES. A critical appraisal of “transfusion strategies for patients in pediatric intensive care units” by Lacroix J, Hebert PC, Hutchison, et al (N Engl J Med 2007; 356:1609-1619). Pediatr Crit Care Med 2009; 10 (3) 393-396
• 3 Tinmouth A, Fergusson D, Yee IC, Hébert PC ; ABLE Investigators; Canadian Critical Care Trials Group. Clinical consequences of red cell storage in the critically ill. Transfusion 2006; 46 (11) 2014-2027
• 4 Elward AM, Fraser VJ. Risk factors for nosocomial primary bloodstream infection in pediatric intensive care unit patients: a 2-year prospective cohort study. Infect Control Hosp Epidemiol 2006; 27 (6) 553-560
• 5 Schmidt P, Kopsa H, Balcke P , et al. Increased renal-graft survival after repeated blood-transfusions. Lancet 1977; 2 (8031) 242
• 6 Reeves BC, Murphy GJ. Increased mortality, morbidity, and cost associated with red blood cell transfusion after cardiac surgery. Curr Opin Cardiol 2008; 23 (6) 607-612
• 7 Popovsky MA. Pulmonary consequences of transfusion: TRALI and TACO. Transfus Apheresis Sci 2006; 34 (3) 243-244
• 8 Laverdière C, Gauvin F, Hébert PC , et al; Canadian Critical Care Trials Group. Survey on transfusion practices of pediatric intensivists. Pediatr Crit Care Med 2002; 3 (4) 335-340
• 9 Spinella PC, Dressler A, Tucci M , et al; Pediatric Acute Lung Injury and Sepsis Investigators Network. Survey of transfusion policies at US and Canadian children's hospitals in 2008 and 2009. Transfusion 2010; 50 (11) 2328-2335
• 10 Bahadur S, Sethi N, Pahuja S, Pathak C, Jain M. Audit of pediatric transfusion practices in a tertiary care hospital. Indian J Pediatr 2015; 82 (4) 333-339
• 11 Hibbs SP, Nielsen ND, Brunskill S , et al. The impact of electronic decision support on transfusion practice: a systematic review. Transfus Med Rev 2015; 29 (1) 14-23
• 12 Standardization of Blood Utilization Practices Could Improve Opportunity for Improved Outcomes, Reduced Costs. Premiere Healthcare Alliance; 2012: 1-7
• 13 Lacroix J, Hébert PC, Hutchison JS , et al; TRIPICU Investigators; Canadian Critical Care Trials Group; Pediatric Acute Lung Injury and Sepsis Investigators Network. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med 2007; 356 (16) 1609-1619
• 14 Carson JL, Terrin ML, Noveck H , et al; FOCUS Investigators. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 2011; 365 (26) 2453-2462
• 15 Hébert PC, Wells G, Blajchman MA , et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999; 340 (6) 409-417
• 16 Lightdale JR, Randolph AG, Tran CM , et al. Impact of a conservative red blood cell transfusion strategy in children undergoing hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2012; 18 (5) 813-817
• 17 Pattakos G, Koch CG, Brizzio ME , et al. Outcome of patients who refuse transfusion after cardiac surgery: a natural experiment with severe blood conservation. Arch Intern Med 2012; 172 (15) 1154-1160
• 18 Kumar A, Mhaskar R, Grossman BJ , et al; AABB Platelet Transfusion Guidelines Panel. Platelet transfusion: a systematic review of the clinical evidence. Transfusion 2015; 55 (5) 1116-1127 , quiz 1115
• 19 Roback JD, Caldwell S, Carson J , et al; American Association for the Study of Liver; American Academy of Pediatrics; United States Army; American Society of Anesthesiology; American Society of Hematology. Evidence-based practice guidelines for plasma transfusion. Transfusion 2010; 50 (6) 1227-1239
• 20 Du Pont-Thibodeau GLJ, Ducruet T, Tucci M. Survey on red cell transfusion practice pattern of pediatric intensivists. Pediatr Crit Care Med 2012; 13: 716-717
• 21 Institute of Medicine (U.S.). Committee on Quality of Health Care in America. Crossing the Quality Chasm: a New Health System for the 21st Century. Washington, DC: National Academy Press; 2001: 337
• 22 Bates DW, Kuperman GJ, Wang S , et al. Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. J Am Med Inform Assoc 2003; 10 (6) 523-530
• 23 US National Library of Medicine. N.I.o.H. Medline Citation Counts by Year of Publication. 2013; Available at: www.nlm.nih.gov/bsd/medline_cit_counts_yr_pub.htm
• 24 Bastian H, Glasziou P, Chalmers I. Seventy-five trials and eleven systematic reviews a day: how will we ever keep up?. PLoS Med 2010; 7 (9) e1000326
• 25 Berenholtz S, Pronovost PJ. Barriers to translating evidence into practice. Curr Opin Crit Care 2003; 9 (4) 321-325
• 26 Cabana MD, Rand CS, Powe NR , et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282 (15) 1458-1465
• 27 Haynes B, Haines A. Barriers and bridges to evidence based clinical practice. BMJ 1998; 317 (7153) 273-276
• 28 Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. JAMA 1998; 280 (15) 1339-1346
• 29 Williams CN, Bratton SL, Hirshberg EL. Computerized decision support in adult and pediatric critical care. World J Crit Care Med 2013; 2 (4) 21-28
• 30 Roshanov PS, Fernandes N, Wilczynski JM , et al. Features of effective computerised clinical decision support systems: meta-regression of 162 randomised trials. BMJ 2013; 346: f657
• 31 Adams ES, Longhurst CA, Pageler N, Widen E, Franzon D, Cornfield DN. Computerized physician order entry with decision support decreases blood transfusions in children. Pediatrics 2011; 127 (5) e1112-e1119
• 32 Baer VL, Henry E, Lambert DK , et al. Implementing a program to improve compliance with neonatal intensive care unit transfusion guidelines was accompanied by a reduction in transfusion rate: a pre-post analysis within a multihospital health care system. Transfusion 2011; 51 (2) 264-269
• 33 Petäjä J, Andersson S, Syrjälä M. A simple automatized audit system for following and managing practices of platelet and plasma transfusions in a neonatal intensive care unit. Transfus Med 2004; 14 (4) 281-288
• 34 McCrory MC, Strouse JJ, Takemoto CM, Easley RB. Computerized physician order entry improves compliance with a manual exchange transfusion protocol in the pediatric intensive care unit. J Pediatr Hematol Oncol 2014; 36 (2) 143-147
• 35 Adams ES. CPOE Reducing Inappropriate Transfusions. 2015; Available at: http://med.stanford.edu/crit