BLOOD MANAGEMENT Efficacy of education followed by computerized provider order entry with clinician decision support to reduce red blood cell utilization Gabriel S. Zuckerberg, 1 Andrew V. Scott, 1 Jack O. Wasey, 1 Elizabeth C. Wick, 2 Timothy M. Pawlik, 2 Paul M. Ness, 3 Nishant D. Patel, 2 Linda M.S. Resar, 4 and Steven M. Frank 1 BACKGROUND: Two necessary components of a patient blood management program are education regarding evidence-based transfusion guidelines and computerized provider order entry (CPOE) with clinician decision support (CDS). This study examines changes in red blood cell (RBC) utilization associated with each of these two interventions. STUDY DESIGN AND METHODS: We reviewed 5 years of blood utilization data (2009-2013) for 70,118 surgical patients from 10 different specialty services at a tertiary care academic medical center. Three distinct periods were compared: 1) before blood management, 2) education alone, and 3) education plus CPOE. Changes in RBC unit utilization were assessed over the three periods stratified by surgical service. Cost savings were estimated based on RBC acquisition costs. RESULTS: For all surgical services combined, RBC utilization decreased by 16.4% with education alone (p 5 0.001) and then changed very little (2.5% increase) after subsequent addition of CPOE (p 5 0.64). When we compared the period of education plus CPOE to the pre– blood management period, the overall decrease was 14.3% (p 5 0.008; 2102 fewer RBC units/year, or a cost avoidance of $462,440/year). Services with the highest massive transfusion rates (10 RBC units) exhibited the least reduction in RBC utilization. CONCLUSIONS: Adding CPOE with CDS after a successful education effort to promote evidence-based transfusion practice did not further reduce RBC utilization. These findings suggest that education is an important and effective component of a patient blood management program and that CPOE algorithms may serve to maintain compliance with evidence-based transfusion guidelines. B lood transfusion, the most commonly per- formed medical procedure in US hospitals, 1 has been identified by The Joint Commission as one of the top five most overused medical proce- dures. 2 This determination is based primarily on five recently published, large, randomized trials that showed that a restrictive hemoglobin (Hb) transfusion trigger (Hb 7-8 g/dL) provides either equivalent 3-5 or improved clini- cal outcomes 6,7 when compared to a liberal trigger (Hb 9- 10 g/dL). Improvements in hospitalwide transfusion prac- tices not only reduce transfusion-related costs substan- tially, 8 but can also decrease morbidity and improve patient outcomes. Patients who receive transfusions are known to be at increased risk for hospital-acquired infec- tions, 9,10 transfusion reactions, 11 a number of other adverse outcomes, 12-14 and even mortality. 14-17 Reducing unnecessary transfusions minimizes exposure to these risks, and risk reduction is a primary goal for patient blood management programs. ABBREVIATIONS: BPA 5 best practice alert; CDS 5 clinician decision support; CPOE 5 computerized provider order entry; OB/GYN 5 obstetrics/gynecology. From the 1 Department of Anesthesiology/Critical Care Medicine, the 2 Department of Surgery, the 3 Department of Pathology (Transfusion Medicine), and the 4 Department of Medicine (Hematology), Oncology & Institute for Cellular Engineering, Johns Hopkins Medical Institutions, Baltimore, Maryland. Address correspondence to: Steven M. Frank, MD, Depart- ment of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Zayed 6208, 1800 Orleans Street, Baltimore, MD 21287; e-mail: sfrank3@jhmi.edu. Received for publication September 13, 2014; revision received December 3, 2014; and accepted December 4, 2014. doi:10.1111/trf.13003 V C 2015 AABB TRANSFUSION 2015;55;1628–1636 1628 TRANSFUSION Volume 55, July 2015