Restrictive Transfusion Strategy and Clinical Decision Support Practices for Reducing RBC Transfusion Overuse

A Laboratory Medicine Best Practice Systematic Review and Meta-Analysis

James H. Derzon, PhD; Nicole Clarke, MPH; Aaron Alford, PhD; Irwin Gross, MD; Aryeh Shander, MD; Robert Thurer, MD


Am J Clin Pathol. 2019;152(5):544-557. 

In This Article

Abstract and Introduction


Objectives: Assess support for the effectiveness of two separate practices, restrictive transfusion strategy and computerized physician order entry/clinical decision support (CPOE/CDS) tools, in decreasing RBC transfusions in adult surgical and nonsurgical patients.

Methods: Following the Centers for Disease Control and Prevention Laboratory Medicine Best Practice (LMBP) Systematic Review (A-6) method, studies were assessed for quality and evidence of effectiveness in reducing the percentage of patients transfused and/or units of blood transfused.

Results: Twenty-five studies on restrictive transfusion practice and seven studies on CPOE/CDS practice met LMBP inclusion criteria. The overall strength of the body of evidence of effectiveness for restrictive transfusion strategy and CPOE/CDS was rated as high.

Conclusions: Based on these procedures, adherence to an institutional restrictive transfusion strategy and use of CPOE/CDS tools for hemoglobin alerts or reminders of the institution's restrictive transfusion policies are effective in reducing RBC transfusion overuse.


Nearly 12.5 million RBC units (approximately 36,000 units per day) are transfused each year in the United States,[1] with RBCs being the most common blood component transfused. According to the Agency for Healthcare Research and Quality, blood transfusions occurred in 10% of all hospital stays that included a procedure.[2] Although RBC transfusion has decreased in recent years, the American Medical Association and The Joint Commission (TJC) identified RBC transfusion as one of the five most overused procedures in hospitals at the National Summit on Overuse.[3,4]

Transfusions increased 134% between 1997 and 2011, and although rates have decreased,[5] as many as 50% or more RBC transfusions are likely unnecessary.[6–9] The rate of RBC transfusion in the United States is more than 25% higher than in other developed countries (eg, Canada, the United Kingdom, and the Netherlands).[10] Techniques such as computerized physician order entry/clinical decision support (CPOE/CDS) alerts based on laboratory hemoglobin (Hb) values are a current focus for monitoring AABB guideline compliance.[11]

The AABB has collaborated with TJC to help hospitals reduce overuse of RBC transfusion and improve patient outcomes by implementing patient blood management programs and voluntary certification to monitor progress on transfusion practices.[12,13] AABB provides recommendations for the target Hb levels for RBC transfusion among hospitalized adult patients who are hemodynamically stable with various preexisting disease conditions and symptom considerations.[14,15]

This review summarizes the effectiveness of two independent interventions, restrictive transfusion strategy and CPOE/CDS, to reduce RBC transfusion overuse as measured by decreases in the proportion of patients transfused and number of RBC units transfused in surgical and nonsurgical adult patients. Based on these reviews, findings are translated into two evidence-based practice recommendations.