TRANSFUSION PRACTICE IN MEDICAL PATIENTS

Objective: Blood transfusion raises serious issues of safety and economics. We therefore examined blood usage and its characteristics in medical inpatients, given the relative scarcity of existing data. Design: During a 1-year period, transfusion episodes on two medical services were reviewed by five specialists for justifiability on the basis of generally agreed on guidelines. Setting: The study was conducted at two institutions, a municipal teaching hospital where house staff deliver care and a community hospital where patients are under the direct care of private physicians. Patients: Four hundred thirty-eight randomly selected transfusion episodes on the medical services of the two institutions were reviewed. Main Outcome Measures: The prevalence of unjustifiable transfusions based only on the information available to the managing physician at the time of transfusion. Results: Eighteen percent of the 438 randomly selected transfusion episodes were viewed as not justifiable by at least four of five reviewers; another 17% were classified as equivocal because two or three reviewers judged them to be not justifiable. The most striking observation was the greater prevalence of nonjustifiable transfusion episodes at the community hospital (26% vs 16% at the teaching institution; P=.0121). Other observations included a tendency for physicians to prescribe transfusions by the numbers (at least 11% of nonjustifiable transfusions) and to overtransfuse. The routineness with which transfusion was viewed by managing physicians was also identifiable by the absence of written transfusion notes in 39% of all episodes reviewed, which incidentally raises questions about the adequacy of the medical chart's documentary functions today. Conclusions: The rate of nonjustifiable or equivocal transfusion on medical services may be as high as 35%. Reliance on numbers rather than clinical status seems to be a major problem. Education is obviously a critical issue and should also target private practitioners, who seemed to perform less well than physicians in training. Transfusion guidelines that use specific hematocrit values also need to be reexamined.