Evaluating the Appropriateness of Red Blood Cell Transfusions: the Limitations of Retrospective Medical Record Reviews

Abstract

Only 68% of post-operative transfusion events on the day of surgery and 35% of transfusion events on days after surgery were accompanied by documentation of blood loss and/or change in vital signs. Symptoms were recorded in only 10% of post-operative transfusion events. The rationale for transfusion was recorded in only 16% of post-operative transfusion events on the day of surgery, in 27% on post-operative days and in 95% of intra-operative transfusions. The documentation of rationale was not different for transfusion events involving autologous blood (31%) or allogeneic blood (32%). This study provided information on transfusion practices. Single unit transfusions occurred in only 47 and 34% of patients receiving autologous and allogeneic blood, respectively. Only 19% of patients transfused with more than one allogeneic blood units, were clinically reassessed between blood units, compared to 34% of patients receiving more than one autologous blood unit. We conclude that retrospective chart reviews are limited by inadequate documentation and may not be the optimal source of information to determine the appropriateness of a transfusion. Improved methods (e.g. prospective reviews, or other system-level data collection methods) are needed for QI programs to influence practice. Despite its limitations, the information obtained suggests that current practice could be improved.

A retrospective one-year single-centre survey of obstetric red cell transfusions

“…Audit of compliance with a transfusion trigger is possible in well-controlled circumstances, but is less reliable where there are widely varying clinical factors, or when decisions to transfuse are made during a dynamic state of blood loss. Audet et al 20 highlighted problems with accuracy of retrospective record review. The clinical indication may not be recorded and the timing of decision related to laboratory results may be difficult to ascertain.…”

Retrospective analysis of transfusion outcomes in pregnant patients at a tertiary obstetric center

“…The lack of adequate documentation to assess the appropriateness of transfusion has been similarly reported by Friedman et al and Audet et al in non-obstetric patients, with 49% and 32% of RBC transfusions respectively being associated with suboptimal chart documentation. 17,18 The costs and risks associated with transfusion merit better justification for its use in an obstetric setting, although differences in physician training and attitudes can contribute towards inconsistent transfusion practices. 3,19 These factors may also have contributed towards the differences in recognition and management of postpartum anemia by different physicians in our study.…”

Evaluating Appropriateness of Treatment for Crohn’s Disease: Feasibility of an Explicit Approach

“…While some studies found medical records to be of limited use in assessing the appropriate management of care [18, 19], other studies succeeded in determining a significant proportion of appropriateness of care [20,21,22,23]. This underscores the fact that the feasibility of using the medical records for evaluating the appropriateness of care may not be generalizable to other settings and other disease entities or procedures and needs to be validated for each setting.…”