D156 Task 1 Practice Problem Analysis Example

Practice Problem Analysis: Red Blood Cell Transfusions Given Above Evidence-Based Thresholds on the Medical and Surgical Services of a 350-Bed Community Hospital

Student Name

Leavitt School of Health, Western Governors University

D156: Business Case Analysis for Healthcare Improvement, Task 1

Course Instructor

Month Day, Year

Practice Problem Analysis: Red Blood Cell Transfusions Given Above Evidence-Based Thresholds on the Medical and Surgical Services of a 350-Bed Community Hospital

The Problem

The composite 350-bed community hospital transfuses more red blood cells than peer hospitals of its size, and a large share of those transfusions are given to stable patients whose hemoglobin is above the thresholds recommended by current guidelines. The problem is bounded here to adult inpatients on the medical and general surgical services, which account for 71% of red cell units issued by the blood bank, and excludes the intensive care unit, cardiac surgery, oncology, obstetrics and patients with active bleeding, where decisions follow separate protocols.

Evidence From Internal Reporting

The blood bank's transfusion report for the past 12 months shows 2,146 red cell units given to 1,183 patients on the two services. A review of the electronic record found that 41% of those units were given when the most recent hemoglobin was 8 g/dL or higher, and 58% of transfusion orders were for two units at once rather than a single unit followed by reassessment. The hospital's internal target, set by its transfusion committee two years ago, was that no more than 20% of units would be given above 8 g/dL; the rate has not moved below 38% in any month since. Monthly figures ranged from 36% to 45% with no downward trend.

The external benchmark is clear. International guidelines based on 45 randomized trials with more than 20,000 adult participants recommend a restrictive strategy for hospitalized adults who are hemodynamically stable, considering transfusion when hemoglobin is below 7 g/dL, with thresholds of 7.5 g/dL in cardiac surgery and 8 g/dL for orthopedic surgery or preexisting cardiovascular disease; restrictive thresholds did not adversely affect patient-important outcomes for most populations (Carson et al., 2023).

Contributing Factors

Contributing factors were traced using a cause-and-effect (fishbone) analysis with a working group of two hospitalists, a surgeon, two charge nurses, the blood bank supervisor and a pharmacist, supplemented by review of 40 randomly selected transfusions above 8 g/dL. The main causes were grouped as follows.

Methods: the transfusion order set in the electronic record defaults to two units and asks for no indication or hemoglobin value. Transfusions are often ordered overnight by covering clinicians who do not know the patient. People: many clinicians trained when a threshold of 10 g/dL was common, and some surgeons believe patients recover faster with higher hemoglobin. Nurses sometimes prompt a transfusion when a morning hemoglobin falls, even without symptoms. Environment and culture: no one reviews transfusion appropriateness in real time, and the transfusion committee's retrospective audits are reported months later with no feedback to individual clinicians. Measurement: the hospital tracks units issued but not appropriateness by clinician or service, so no one sees their own pattern.

In the 40-case review, 29 transfusions had no documented symptom or sign of anemia, 22 were two-unit orders and 17 were ordered overnight by covering clinicians.

Cost Picture

Costs were built in parts, each with its source. Acquisition cost per red cell unit: $215, from the blood supplier's current contract. Administration cost per unit, including nursing time, tubing, testing and blood bank processing: estimated at $310 from the hospital's cost accounting department using an activity-based approach; published estimates of total cost per unit are higher once all activities are counted, which makes this figure conservative. Total cost per unit: $525. Units given above 8 g/dL on the two services last year: about 880 (41% of 2,146). Estimated cost of these potentially avoidable transfusions: about $462,000 a year.

Costs that are harder to price add to the case. Every transfusion carries risks, including transfusion-associated circulatory overload and transfusion reactions, and each adverse event adds length of stay and treatment. Blood is also a limited community resource; units transfused unnecessarily are units not available elsewhere during shortages.

Evidence That the Problem Can Be Changed

Other hospitals have reduced unnecessary transfusion substantially. An academic medical center that combined clinician education with a real-time best practice alert at the moment of ordering cut the share of transfusions given to patients with hemoglobin above 8 g/dL from 60% to below 30% and reduced annual red cell transfusions by 24%, saving an estimated $6.4 million in blood acquisition costs over four years, despite rising patient volumes and case mix complexity (Goodnough & Shah, 2014). The hospital has the same electronic record capability, which suggests a similar approach is feasible. In that program's detailed report, education alone produced only a modest fall in out-of-guideline transfusions, while adding decision support at the point of ordering brought the rate down to 35% and then below 30% (Goodnough et al., 2014), a pattern that argues against relying on education by itself here.

Why It Matters to the Organization

The problem touches three of the hospital's strategic priorities. Quality: the hospital's strategic plan commits to reducing harm, and every avoidable transfusion is an avoidable exposure to risk. Financial sustainability: the hospital operates on a thin margin, and blood product spending is one of the few supply costs driven directly by clinical decisions the hospital can influence. Stewardship: the regional blood supplier has asked hospitals to reduce avoidable use during recurrent shortages, and the hospital's reputation with its community depends partly on being a responsible user of donated blood. Nurses have a direct stake as well, since they administer, monitor and document every unit and are often the first to recognize a transfusion reaction or fluid overload. Framing the problem this way connects a clinical practice issue to goals leadership already owns, which is the starting point for a business case.

Problem Statement

On the medical and general surgical services, 41% of red cell units are transfused to stable adult inpatients with hemoglobin of 8 g/dL or higher, against an internal target of 20% and a guideline threshold of 7 to 8 g/dL, costing an estimated $462,000 a year in avoidable transfusion costs and exposing patients to unnecessary risk. The problem is driven by a two-unit default order set, the absence of real-time decision support and feedback, and outdated practice habits. The business case that follows will propose and price an intervention to address these causes.

References

Carson, J. L., Stanworth, S. J., Guyatt, G., Valentine, S., Dennis, J., Bakhtary, S., Cohn, C. S., Dubon, A., Grossman, B. J., Gupta, G. K., Hess, A. S., Jacobson, J. L., Kaplan, L. J., Lin, Y., Metcalf, R. A., Murphy, C. H., Pavenski, K., Prochaska, M. T., Raval, J. S., . . . Pagano, M. B. (2023). Red blood cell transfusion: 2023 AABB international guidelines. JAMA, 330(19), 1892-1902. https://doi.org/10.1001/jama.2023.12914

Goodnough, L. T., & Shah, N. (2014). The next chapter in patient blood management: Real-time clinical decision support. American Journal of Clinical Pathology, 142(6), 741-747. https://doi.org/10.1309/AJCP4W5CCFOZUJFU

Goodnough, L. T., Shieh, L., Hadhazy, E., Cheng, N., Khari, P., & Maggio, P. (2014). Improved blood utilization using real-time clinical decision support. Transfusion, 54(5), 1358-1365. https://doi.org/10.1111/trf.12445