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Release Notes:
Measure Information Form
Version 2010A1

Measure Information Form

Measure Set: Blood Management(BM)

Set Measure ID: BM-02

Performance Measure Name: RBC Transfusion Indication

Description: The total number of red blood cell (RBC) transfusion events that had a pre-transfusion hemoglobin (hgb) or hematocrit (hct) and clinical indication documentation from a sample of patients who received RBCs.

Rationale: Improvement of the safety and quality of care that a hospital provides includes the review of the use of blood and blood products. Despite current evidence and best practice guidelines, clinical practice regarding when to transfuse varies among physicians and institutions even though most would agree that blood products should only be given when the benefits outweigh the harm. Many advocate that transfusion decisions should be based on a clinical assessment and not on laboratory values alone to avoid inappropriate over-or-under transfusion. Measuring whether an “indication for transfusion” and a pre-transfusion laboratory value was documented may improve the utilization of blood components. In addition, implementing such a process may simplify the hospital’s review for appropriateness of the transfusion when auditing records for accreditation and regulatory agencies. In a study by Friedman and Ebrahim, there was a significant correlation between red blood cell transfusions that lacked documentation of the clinical necessity for transfusion and justification of the transfusion.

Type of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Number of RBC transfusion events with pre-transfusion hemoglobin or hematocrit and clinical indication documented
Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Denominator Statement: Number of red blood cell unit transfusion events evaluated

Included Populations:
  • Discharges with an ICD-9-CM Principal or Other Procedure Codes for transfusion as defined in Appendix A, Tables 9.2-9.6.
  • The first three RBCs transfusion events per patient after hospital arrival

Excluded Populations:

  • Patients less than 4 months of age

Data Elements:

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-9-CM codes; therefore, coding practices may require evaluation to ensure consistency. If ICD-9-CM codes are not present, alternative methods of identifying patients who received blood transfusions may be required.

Measure Analysis Suggestions: Hospitals may want to use the data to further evaluate the process for determining the need for blood products based on the clinical indications and correlating it with the pre-transfusion value that was documented. This information may assist hospitals to determine if the patients were transfused appropriately or if efforts should be directed toward additional documentation efforts for monitoring blood product usage. Data may be grouped by service designation or by blood products to identify specific areas for staff review.

Sampling: Yes. for additional information see the Population and Sampling Specifications Section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

  • Friedman MT, Ebrahim A. Adequacy of physician documentation of red blood cell transfusion and correlation with assessment of transfusion appropriateness. Arch Pathol Lab Med. 2006;130: 474-79.
  • Corwin HL, Parsonnet KC, Gettinger A. RBC transfusion in the ICU: is there a reason? Chest. 1995;108: 767-771.
  • Tobin SN, Campbell DA, Boyce NW. Durability of response to a targeted intervention to modify clinician transfusion practices in a major teaching hospital. MJA. 2001;174:445-448.
  • Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care. Crit Care Med 2009 Vol.37, No.12.

Measure Algorithm:

Attach file

Related Topics

Measure Information Form BM-02
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)