TRANSFUSION PRACTICES Assessment of education and computerized decision support interventions for improving transfusion practice Jeffrey M. Rothschild, Siobhan McGurk, Melissa Honour, Linh Lu, Aubre A. McClendon, Priya Srivastava, W. Hallowell Churchill, Richard M. Kaufman, Jerry Avorn, E. Francis Cook, and David W. Bates BACKGROUND: Overuse of blood products is common, but prior efforts to improve transfusion deci- sions have met with limited success. STUDY DESIGN AND METHODS: This study exam- ines transfusion practices before and after a conven- tional educational intervention followed by a randomized controlled trial of a decision support (DS) intervention with computerized physician order entry (CPOE) for red blood cell, platelet, and fresh-frozen plasma orders. The study was conducted in an academic medical center between April 2003 and June 2004. Orders originating from units not using CPOE with DS (e.g., the emer- gency department) were excluded. Junior housestaff were randomly assigned into a control group and an intervention group who received DS for transfusion orders. Transfusion orders were initially classified according to guideline rules as DS-agree or DS- disagree. Chart reviews assessed inappropriateness for all DS-disagree orders and a sample of DS-agree orders. The total of inappropriate transfusion orders included chart review confirmed DS-disagree orders and DS-agree orders reclassified as inappropriate. RESULTS: The percentages of inappropriate nonemer- gent transfusion orders during the baseline phase for the entire staff and randomly assigned junior housestaff were 72.6 percent (2154/2967) and 71.9 percent (1259/ 1752) and improved after conventional education to 63.8 percent (1699/2663; p < 0.0001) and 63.3 percent (1263/1996; p < 0.0001), respectively. The percentage of inappropriate orders in the DS intervention group continued to improve (59.6%, 804/1350; p < 0.0001). Physicians accepted 14 percent (133/939) of new DS-recommended orders, especially recommendations to increase transfusion doses (73%). CONCLUSIONS: Education and computerized DS both decreased the percentage of inappropriate transfusions, although the residual amount of inappropriate transfu- sions remained high. T ransfusions of blood products are important, and sometimes life-saving, therapies for patients with a wide variety of illnesses. Blood products, however, are an expensive and limited resource. 1 Recent studies have found that more restrictive use of transfused red blood cells (RBCs) in critically ill patients 2 and other settings 3 may not only be safe, but also improve outcomes. Furthermore, the transfusion of blood products involves considerable risks. 4-6 Despite an increased awareness of these risks, the prescribing of inappropriate transfusions remains a significant problem. 7,8 The decision to order component blood products for hospitalized patients can be a complex process, 9,10 with much variability in transfusion practices. 11 Evidence- ABBREVIATIONS: CPOE = computerized physician order entry; DS = decision support; PT/INR = prothrombin time/ international normalized ratio. From the Division of General Medicine and Primary Care, the Department of Hematology, the Division of Transfusion Medi- cine and the Department of Pathology, and the Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massa- chusetts; Harvard Medical School, Boston, Massachusetts; and the Harvard School of Public Health, Boston, Massachusetts. Address reprint requests to: Jeffrey M. Rothschild, MD, MPH, Division of General Medicine, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120-1613; e-mail: jrothschild@partners.org. This study was presented in part at the 2004 Annual Meeting of the American Association of Blood Banks in Balti- more, MD. This study was funded by National Heart, Lung, and Blood Institute Grant RFA HL-01-011. Received for publication May 15, 2006; revision received July 18, 2006, and accepted July 21, 2006. doi: 10.1111/j.1537-2995.2007.01093.x TRANSFUSION 2007;47:228-239. 228 TRANSFUSION Volume 47, February 2007