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Validation of a New Method to Automatically Select Cases With Intraoperative Red Blood Cell Transfusion for Audit

Dexter, Franklin MD, PhD*; Epstein, Richard H. MD; Ledolter, Johannes PhD; Dasovich, Susan M. MD§; Herman, Jay H. MD; Maga, Joni M. MD; Schwenk, Eric S. MD#

doi: 10.1213/ANE.0000000000002502
Research Report: PDF Only

BACKGROUND: Hospitals review allogeneic red blood cell (RBC) transfusions for appropriateness. Audit criteria have been published that apply to 5 common procedures. We expanded on this work to study the management decision of selecting which cases involving transfusion of at least 1 RBC unit to audit (review) among all surgical procedures, including those previously studied.

METHODS: This retrospective, observational study included 400,000 cases among 1891 different procedures over an 11-year period. There were 12,616 cases with RBC transfusion. We studied the proportions of cases that would be audited based on criteria of nadir hemoglobin (Hb) greater than the hospital’s selected transfusion threshold, or absent Hb or missing estimated blood loss (EBL) among procedures with median EBL <500 mL. This threshold EBL was selected because it is approximately the volume removed during the donation of a single unit of whole blood at a blood bank. Missing EBL is important to the audit decision for cases in which the procedures’ median EBL is <500 mL because, without an indication of the extent of bleeding, there are insufficient data to assume that there was sufficient blood loss to justify the transfusion.

RESULTS: Most cases (>50%) that would be audited and most cases (>50%) with transfusion were among procedures with median EBL <500 mL (P < .0001). Among cases with transfusion and nadir Hb >9 g/dL, the procedure’s median EBL was <500 mL for 3.0 times more cases than for procedures having a median EBL ≥500 mL. A greater percentage of cases would be recommended for audit based on missing values for Hb and/or EBL than based on exceeding the Hb threshold among cases of procedures with median EBL ≥500 mL (P < .0001). There were 3.7 times as many cases with transfusion that had missing values for Hb and/or EBL than had a nadir Hb >9 g/dL and median EBL for the procedure ≥500 mL.

CONCLUSIONS: An automated process to select cases for audit of intraoperative transfusion of RBC needs to consider the median EBL of the procedure, whether the nadir Hb is below the hospital’s Hb transfusion threshold for surgical cases, and the absence of either a Hb or entry of the EBL for the case. This conclusion applies to all surgical cases and procedures.

From the *Division of Management Consulting, Department of Anesthesia, University of Iowa, Iowa City, Iowa; Department of Anesthesiology, Pain Management and Perioperative Medicine, University of Miami, Miami, Florida; Departments of Management Science and §Pathology, University of Iowa, Iowa City, Iowa; Department of Pathology, Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Anesthesiology, University of Miami, Miami, Florida; and #Department of Anesthesiology, Thomas Jefferson University, Philadelphia, Pennsylvania.

Accepted for publication August 24, 2017.

Funding: Departmental funds.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Reprints will not be available from the authors.

Address correspondence to Franklin Dexter, MD, PhD, Division of Management Consulting, Department of Anesthesia, University of Iowa, 200 Hawkins Dr, 6-JCP, Iowa City, IA 52242. Address e-mail to

© 2018 International Anesthesia Research Society
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