Laboratory QA
Improving Appropriateness of Blood Utilization
Through Prospective Review of Requests for
Blood Products: The Role of Pathology Residents
as Consultants
Lindsey Haldiman, DO,1* Hamid Zia, MD,1 Gurmukh Singh, MD, PhD, MBA1
Lab Med Summer 2014;45:264-271
DOI: 10.1309/LMSKRN7ND12ZOORW
ABSTRACT
Objective: To evaluate the effectiveness of prospective review of
orders for fresh-frozen plasma (FFP) and platelets in reducing blood-
product use, and of the effectiveness of preparing pathology residents
to serve as clinical consultants.
Design: At our 572-bed tertiary-care hospital, we developed
guidelines for the use of blood products in collaboration with a
variety of departments. For patients whose condition(s) met generally
accepted criteria, we identified trigger points to allow for quick release
by blood bank staff of blood products. For patients whose condition(s)
did not meet the applicable criteria, the on-call pathology resident
reviewed the medical record of that patient to determine whether there
were any extenuating circumstances; consulted with the ordering
physician and attending pathologist, as needed; and advised the house
staff on appropriate use of blood products. We evaluated the change in
Because of reimbursement issues and ever-greater
understanding of the perils of overuse of healthcare
resources, there is an increasing trend toward curtailing
healthcare costs in hospitals across the United States.1
Clinical pathologists often find themselves under
increasing scrutiny from hospital administrators to trim
laboratory expenses while simultaneously increasing
their output and improving patient outcomes. Blood
transfusion therapy is the second-largest expense2 in the
clinical laboratory, and may account for up to 50% of the
Abbreviations
RBC, red blood cell; FFP, fresh frozen plasma; EMR, electronic medical
record; TJC, The Joint Commission; PCC, prothrombin complex
concentrate; SvO2, mixed venous oxygen saturation.
Department of Pathology, University of Missouri–Kansas City
1
*To whom correspondence should be addressed.
E-mail: lindsey.haldiman@tmcmed.org
264 Lab Medicine  Summer 2014  |  Volume 45, Number 3 www.labmedicine.com
use of blood products between the years 2009 and 2012 to assess the
effectiveness of the program.
Results: We observed a decrease of 38.8% and 31.4% in the use of
FFP and platelets, respectively (29.7% and 21.1%, respectively, when
normalized for the number of discharges). If projected to the national
level, this improvement would translate to an annual cost reduction of
approximately $130 million.
Conclusions: Prospective review of orders for blood products can
significantly improve use of these products, thereby reducing risk to
patients and avoiding unnecessary healthcare costs. The involvement
of pathology residents in the prospective review process provides an
excellent opportunity for their training as laboratory consultants.
Keywords: fresh frozen plasma, appropriateness of utilization, clinical
pathology consultation, patient safety
total laboratory budget.3,4 Wide variations exist in blood-
product use in different healthcare systems, and even
among different hospitals in the same system.1 There is an
important opportunity to make laboratory operations lean
and efficient by optimizing and standardizing blood use.
Currently, at least 15 different blood products and blood
components are available for transfusion.
Blood products are used worldwide; 13,785,000 whole
blood/packed red blood cell (RBC) units were transfused in
the United States in 2011.5 Blood transfusions have saved
many lives and are an integral part of patient care. However,
the availability of blood products and variations in the
frequency of transfusions have raised concern regarding
the overuse of transfusion therapy.6-8 The literature
suggests more favorable patient outcomes in adult and
pediatric patient populations when a more judicious and
restrictive, rather than liberal, use of blood transfusion
therapy is observed.9-13 The validity and usefulness of
restrictive transfusion practice in neonates has been
widely debated,10-13 with a benefit from a more liberal

approach suggested in the results of some randomized
trials, whereas the results of others trials failed to show
any benefit from such an approach. Transfusing whole
blood or blood products into a patient is not a benign
procedure, due to the circumstances that necessitate blood
transfusion and due to the hazards associated with blood
transfusion itself.7,14-16 Many adverse reactions can occur
with transfusion of blood and blood products, including
death.17-30 Therefore, it is important to weigh the risks versus
the benefits when considering blood-transfusion therapy.
Several attempts have been made by our peer institutions
to optimize blood use in transfusion medicine. These
attempts involved the patient blood management
approach, modifications regarding computerized order
entry by physicians, and prospective or concurrent
review of physician orders by blood bank personnel
and/or transfusion medicine specialists.31 However, a
silent transfusion epidemic continues. We implemented
a prospective review of requests for blood products in
our tertiary-care, Level I trauma hospital, that resulted in
significant reduction in the use of blood products from
2009 through 2012. Herein, we discuss our experience
and success in improving the appropriateness of blood
product use based on our examination of prospective and
concurrent review of requests for blood products.
Materials and Methods
We designed this study to monitor the effects of
implementation of guidelines for prospective review
of orders for fresh frozen plasma (FFP), platelets, and
cryoprecipitate from 2009 through 2012. We distributed, to
physicians and other relevant healthcare staff, guidelines
for appropriate use of RBCs; however, we only reviewed
the use of these products retrospectively over the study
period. Herein, we present evidence that prospective
review of orders for FFP and platelets can result in
significant decrease of use of such products, which
yields reduction in risk to patients, the fringe benefit of
cost reduction, and the important dividend of preparing
pathology residents for their role as clinical consultants.
We developed guidelines for the use of blood products
under the auspices of the Transfusion Committee, in
collaboration with the anesthesia, hematology/oncology,
emergency, and trauma departments, to aid in the
proper selection and use of blood and blood products.
Trigger points were identified to allow for quick release
www.labmedicine.com Summer 2014  |  Volume 45, Number 3  Lab Medicine 265
Laboratory QA
of products for patients whose conditions met generally
accepted criteria for transfusion with particular blood
products. Blood bank staff members were educated on
applying these guidelines. If the condition(s) of a given
patient met the criteria established in the guidelines,
the product(s) was (were) automatically approved
and issued to the patient. If the condition(s) of the
patient did not meet the criteria for the ordered blood
component—usually FFP and platelets—as established
in the guidelines, the blood bank technologist contacted
the on-call pathology resident with the full name and
medical-record number of the patient in question, as well
as the contact information for the ordering physician. This
process was in effect 24 hours per day. The pathology
resident was then able to consult the electronic medical
record (EMR) database, remotely if needed, to access the
medical record of that patient to understand why the units
may have been ordered, whether they were indicated,
and whether any extenuating clinical circumstances were
relevant. If the requested blood components did not
seem necessary for the patient, the pathology resident
contacted the ordering physician to discuss the reason
for ordering those units. The pathology resident could, if
necessary, discuss with the physician reasons why the
units ordered may not be beneficial for the patient, along
with alternative approaches. In many cases, the advice
given by the pathology resident resulted in the physician
canceling the order or using a different product.
One of the common changes we observed was a shift
from FFP to cryoprecipitate in patients with bleeding
associated with uremia. In circumstances in which the
pathology resident determined that the blood product
ordered was inappropriate and there were no extenuating
circumstances, the pathology resident consulted with
the on-call pathologist and then approved the request or
suggested a consultation with the ordering attending and
pathology attending physicians. In most circumstances, the
pathology resident approved the orders, and the ordering
attending physician needed to decide whether he or she
still wanted the blood product administered to the patient.
The residents and the attending pathologist discussed
call issues every Friday morning during the weekly
clinical pathology conference that included all residents.
These discussions provided continuing education on
blood-product use and provided first-year residents
with exposure to expected calls. The on-call attending
pathologists were always available to the on-call pathology
residents if any questions about blood product orders
arose during their scheduled call times.
Laboratory QA

Hematocrit level of ≤21% or hemoglobin level of ≤7 g/dL (the change to this indication is still in process)*

Hematocrit level ≤24% or hemoglobin level ≤8 g/dL in a patient with coronary artery disease and unstable angina
and/or myocardial infarction and/or cardiogenic shock, patients undergoing radiotherapy (as much as 10 g/dL
may be allowed in patients undergoing radiotherapy)

Rapid blood loss approaching loss of 30% of blood volume and/or not responding to appropriate volume resuscitation,
or ongoing blood loss

The patient has been determined to have normovolemia, and there is evidence to support the need for increased
oxygen-carrying capacity, as witnessed by (please indicate):

• Tachycardia and/or hypotension not corrected by adequate volume replacement only

• Sepsis and/or systemic inflammatory reaction syndrome (SIRS)

• Mixed venous oxygen saturation (SvO2) of <70%

• Other—please specify: ___________________________

*This has now been implemented

Figure 1
Indications for acceptable use of red blood cell transfusion.

• Abnormal coagulation-study results and significant hemorrhage

• Prophylactic use of fresh frozen plasma before a procedure: international normalized ratio (INR) >2.0; INR >1.7 with bleeding

• Emergent reversal of hemorrhage caused by warfarin sodium (recommended to use prothrombin complex concentrate [PCC])

• Research protocol/plasmapheresis/other—please specify: __________________

Figure 2
Indications for acceptable use of fresh frozen plasma transfusion.

We established the guidelines for RBC transfusion with
the criteria of a hemoglobin level of 8 gm/dL or less and
a hematocrit level of 24% or less as a trigger point for
acceptable transfusion (we are in the process of revising
this trigger point downward to 7.0 gm/dL). We also
deemed rapidly dropping hemoglobin levels and obvious
hemorrhage to be triggers for acceptable transfusion.
A full list of RBC-use guidelines are given in Figure 1.
At the end of each month, we retrospectively assessed
RBC transfusions. The attending pathologist reviewed for
appropriateness, taking into consideration any extenuating
circumstances, any cases in which RBC units were
transfused but the condition(s) of the patient did not meet
the set criteria.
We set prospective review guidelines for the use of FFP
primarily based on the international normalized ratio (INR)
(Figure 2). We granted automatic approval of FFP units
for patients with an INR of 1.7 or greater. Transfusion of
FFP units ordered for an individual with an INR of less
than 1.7 but greater than 1.5 required the approval of
the on-call pathology resident. Transfusion of FFP units
ordered for patients with an INR of 1.5 or less required
consultation between the ordering attending physician
and the on-call pathology resident.
We carried out a similar prospective review process for
platelet transfusions; guidelines for automatic approval of
platelet units were established (Figure 3). Transfusion of

266 Lab Medicine  Summer 2014  |  Volume 45, Number 3 www.labmedicine.com

 Laboratory QA

Platelet count of ≤10,000/µL (prophylactic transfusion)

Platelet count of ≤20,000/µL and signs of hemorrhagic diathesis (petechiae and/or mucosal bleeding)

Platelet count of ≤50,000/µL in a patient with (please indicate):

• Active hemorrhage

• Invasive procedure (recent, in progress, and/or planned)—please specify:

________________________________________________________________________

Platelet count of ≤10,000/µL before neurological, middle-ear, or ophthalmic operations

Platelet dysfunction, as documented by—please specify: _______________________

Research protocol/other—please specify: ___________________________________

Figure 3
Indications for acceptable use of platelet transfusion.

 Fibrinogen <100 mg/dL in surgery or trauma patient

Figure 4
 Fibrinogen <200 mg/dL in a patient with CNS pathology or procedure
Approval guidelines for blood bank staff for cryoprecipitate.
 Bleeding in von Willebrand’s disease

 Uremic patient with bleeding, not responsive to DDAVP

any platelet units ordered for a patient whose condition
did not meet these criteria required approval by the on-call
pathology resident and, if needed, consultation with the
attending pathologist.
Guidelines for automatic approval of cryoprecipitate by the
blood-bank staff are shown in Figure 4. We addressed
variations from these guidelines in the same manner as
described for FFP.
We collected data on the number of RBC units, FFP,
platelets and cryoprecipitate transfused from the year
2009 through 2012. We also gathered data on the number
of discharges for each of these years and adjusted
the usage rates to normalize the data for the number
of patients treated. Changes in usage of each blood
component were calculated.
Our medical center uses EMR software from Cerner
Corporation (Kansas City, MO).
urban, tertiary-care hospital serving a large population of
uninsured patients. It is a Level I trauma center, but does
not offer open heart surgery. The study was approved
by the Institutional Review Board of the University of
Missouri–Kansas City School of Medicine and the Privacy
Board of Truman Medical Centers, Kansas City, Missouri.
Results
We observed an overall decrease in the number of units
transfused for each blood product we reviewed; this
decrease reached nearly 40% for FFP usage. However,
we also discovered that the number of discharges had
decreased; the decreases in discharges did not correlate
with the 38. 8% and 31.4% decreases in FFP and platelet
use, respectively. Data normalized for discharges is
presented in Table 1 as number of products transfused
per 1000 patients discharged per year.

The study was conducted at a 2-campus medical center Estimates of cost savings for the decrease in blood
in Kansas City, Missouri. The medical center is a 572-bed, product use were limited to the cost of FFP and platelets.

www.labmedicine.com Summer 2014  |  Volume 45, Number 3  Lab Medicine 267

Laboratory QA
Table 1. Annual Blood-Component Use From
2009 Through 2012 and Total Change as a
Function of Discharge of 1000 Hospital Patientsa
Year RBCs FFP Plts Cryo Total
2009 235.8 66.7 23.7 6.0 332.2
2010 217.8 61.5 28.2 5.4 312.9
2011 232.6 47.1 22.1 5.8 307.6
2012 244.6 46.9 18.7 6.2 316.4
Change +3.7% -29.7% -21.1% +3.5% -4.8%
from 2009
to 2012 a
RBCs, red blood cells; FFP, fresh frozen plasma; Plts, platelets; Cryo, cryoprecipitate.
a
Data on the discharge of 1000 hospital patients is an indicator of the number of
patients treated.
We did not consider technical time, reagents for typing,
crossmatching, storage, delivery, or nursing costs
associated with the administration of blood products.
Blood components are a significant cost to the hospital
and the patient. Table 2 shows the cost per blood
component at our institution and the savings to the
institution after implementation of the resident consultation
plan. If extrapolated to overall health care expenditures
in the United States, the approximate annual reduction in
the cost of blood products would be approximately $130
million. Including the ancillary costs of blood transfusions
in this estimate produces a greater saving.
Shander et al 32 used an activity-based costing model,
previously developed at the Cost of Blood Consensus
Conference, to determine the comprehensive cost of
supplying RBC transfusions to patients. This model takes
into account acquisition costs, all process steps, and all
indirect and direct costs in 4 different hospitals in the
United States. The total per unit costs varied among the 4
hospitals, from $522.45 to $1183.32 per patient. Previous
findings from several different studies had estimated a per
unit RBC cost between $332 and $717 per patient, which
may be a significant underestimate.32
Discussion
The Joint Commission (TJC), which accredits qualified
health care organizations, requires that hospital personnel
review the appropriateness of all transfusions and attempt
268 Lab Medicine  Summer 2014  |  Volume 45, Number 3 www.labmedicine.com
Table 2. Net Reduction in Costs for Individual
Blood Components in our Institution From
2009 Through 2012a,b
Variable FFP Plts
Cost per unit $59.88 $539.68
Difference in no. of units 349 100
transfused in 2012
compared with 2009
Decrease in cost in 2012 $20,898.12 $53,968.00
FFP, fresh frozen plasma; Plts, platelets.
Our institution is an 572-bed inner-city, safety-net, tertiary-care hospital. It is a
Level I trauma center but does not offer open heart surgery.
b
If one were to extrapolate the data herein to the overall healthcare systems in the
United States, this would translate to a national savings of approximately $130
million annually.
to correct transfusion practices that do not adhere to
standard practice. Evaluation of the appropriate use of
blood and blood products is a quality assurance metric
for transfusion services. Laboratory personnel may
evaluate blood utilization prospectively, concurrently,
or retrospectively.33,34 Hospital transfusion committees
are instrumental in establishing criteria that ensure the
appropriate use and safety of blood products.35
During our 4-year study, we observed no meaningful
change in the use of RBCs and cryoprecipitate. The
decline in the use of FFP and platelets that we observed
was remarkable in that each category experienced greater
than 20% decline in normalized (per patient) use. The
absence of change in RBC use probably reflects the lack
of prospective review. Although use of RBCs generally
met the criteria for transfusion on retrospective review, as
previously reported,36 there is evidence that patients are
often given excessive amounts of transfused products
once transfusion is initiated.36
The increase in cryoprecipitate use that we observed may
be a random event. However, because we encouraged
the use of cryoprecipitate in lieu of FFP in some
circumstances, this increase may have resulted from
positive intervention and may have been partly responsible
for the reduction in FFP use.
Implementation of prospective review is neither easy nor
painless, although the process can have a significant
impact on the use of blood components and is important
in preparing pathology residents to serve as consultants
to their clinical colleagues. The process of prospective

review requires a number of steps to be successful. The first
challenge is developing guidelines for automatic approval by
blood bank staff for release of blood and blood products,
as well as trigger points for review by pathology residents
and the requirement for consultation. Consultations with
the departments of hematology/oncology, anesthesia, and
surgery, under the auspices of the Transfusion Committee
and approval by the Medical Executive Board, required
nearly 2 years of discussions and negotiations. The next
important issue was training and educating pathology
residents in transfusion medicine so they feel comfortable
and competent in discussing the issues with clinicians.
We bolstered the educational process by reviewing all
calls with the pathology residents on a weekly basis. A
commitment from the attending pathologists to be available
at all times was instrumental for providing consultative,
administrative, and emotional support in the frequently
unpleasant exchanges with medical and surgical house
staff. The understanding with the pathology residents was
that they will never be questioned, criticized, chastised, or
in any way made to feel unwelcome for calling the attending
pathologist for any of the prospective review issues.
Bringing about changes in the attitudes of, and practices
by, pathology residents took continuing reinforcement of
this nonpunitive understanding to encourage them to share
their acquired expertise in transfusion medicine and to
promote strong rapport with the attending pathologists.
Clinical house staff sometimes resisted the process for
getting approval for a treatment that they believed was
warranted. However, the transfusion service emphasized
that it was instituting a consultative process rather than
dictating their therapeutic options. The treating physician
was usually given the benefit of the doubt in borderline
cases. We discovered that a critical resource is the
availability—remotely if necessary—of the EMR database
to pathology residents so that they were apprised of the
clinical circumstances, which helped them suggest viable
alternatives to the use of blood or blood products. Often,
the understanding that the blood product will be available,
if and when needed, persuaded them to withdraw a request
that may have made to cover “just in case” scenarios.
Between the years 2007 and 2009, the Department of
Pathology promoted this initiative with clinical colleagues
through constant dialogue, periodically going on rounds
with the family medicine residency program, and offering an
elective course in laboratory medicine for medical students
and house staff; this process is active and ongoing.
Pathology residents played an active role in the consultation
process through collaborative dialogue with ordering
www.labmedicine.com Summer 2014  |  Volume 45, Number 3  Lab Medicine 269
Laboratory QA
physicians when those physicians initiated inappropriate
orders. We found anecdotally that regular communication
and discussion with ordering physicians leads to a better
overall understanding of blood components and their
uses. This, in turn, reduced future inappropriate orders
and unnecessary transfusions. We often observed that
even when we were liberal in the approval process, the
act of requiring consultation led to changes in behavior
that reduced the number of inappropriate orders for blood
products. However, we did not track the number of orders
and the outcomes of consultations. The process described
herein has been important in preparing our pathology
residents to be clinical consultants; their discussions with
other members of the house staff, attending physicians,
and other residents reinforced the learning process. This
process ensured that pathology residents became as well
informed as, if not better informed than, their colleagues
at the bedside. An added benefit from this continuous
consultation process was a change in introducing
prothrombin complex concentrate (PCC) as a more
appropriate therapy for patients with warfarin sodium
overdose and intracerebral bleeding.37
Blood and blood products usually constitute the second-
largest cost, after personnel costs, for departments of
pathology and laboratory medicine; reduction in the use of
blood components can measurably reduce the cost to the
laboratory and the hospital.2 In turn, this reduces the cost
to the patient and reduces the risk of adverse reactions
related to transfusions.
When pathology residents acted as consultants, this
prepared them to be competent blood bank consultants
in their future careers. By being involved in consultations
as residents, they gained an understanding of when and
in what situations transfusions of blood components are
appropriate. They also became familiar with the types of
conflicts that they may encounter when communicating
with and/or educating ordering physicians. Education is
the key to making changes in any institutional culture;
the more frequently and extensively residents are
exposed to this process, the more effective they will be
in their future careers.
To recapitulate the factors for success, the important
issues are as follows:
a) Availability of the EMR database, including remotely,
to pathology residents
b) Commitment by the pathology attending physicians to
provide education; training; and intellectual, adminis-
trative, and emotional support to pathology residents
Laboratory QA
c) Development of trigger points in consultation with
members of the medical staff
d) Establishment of the viability of the pathology depart-
ment as a source of clinical consulting advice
Conclusion
Prospective review of orders for blood products can
result in significant improvement in use of blood products,
thereby reducing risk to patients and avoiding unnecessary
costs to the healthcare system. Involvement of pathology
residents in prospective reviews provides an excellent
opportunity for their training as consultants. LM
Acknowledgments
The authors are grateful to Mr. Vu Pham, MT(ASCP) for
assistance in data collection.
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