Background Blood transfusions though life‐saving are not entirely benign. They are the most overused procedure in the hospital and have been under scrutiny by the ‘Choosing Wisely campaign’. The strict adoption of restrictive transfusion guidelines could improve patient outcomes while reducing cost. Objectives In this study, we evaluate adherence to restrictive transfusion guidelines, along with hospital mortality and length of stay (LOS) in transfusion events with a pre‐transfusion haemoglobin (Hb) ≥7 g/dl. Additionally, we evaluated associated costs accrued due to unnecessary transfusions. Methods We conducted a retrospective observational study in a 64‐bed medical intensive care unit (MICU) of an academic medical centre involving all adult patients (N = 957) requiring packed red blood cell transfusion between January 2015 and December 2015. Results In total, 3140 units were transfused with a mean pre‐transfusion Hb of 6.75 ± 0.86 g/dl. Nine hundred forty‐four (30%) transfusion events occurred with a pre‐transfusion Hb ≥7 g/dl, and 385 (12.3%) of these occurred in patients without hypotension, tachycardia, use of vasopressors, or coronary artery disease. Forgoing them could have led to a savings of approximately 0.3 million dollars. Transfusion events with pre‐transfusion Hb ≥7 g/dl were associated with an increased mortality in patients with acute blood loss (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.11–3.88; p = 0.02) and LOS in patients with chronic blood loss (β1.8.26, 95% CI 4.09–12.43; p < 0.01). Conclusion A subset of anaemic patients in the MICU still receive red blood cell transfusions against restrictive guidelines offering hospitals the potential for effective intervention that has both economic and clinical implications.

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