title: Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts.
abstract: BACKGROUND
  Best practice alerts (BPAs) provide clinical decision support (CDS) at the point of care to reduce unnecessary blood product transfusions, yet substantial transfusions continue outside of recommended guidelines.
  
  
  OBJECTIVE
  To understand why providers order blood transfusions outside of recommended guidelines despite interruptive alerts.
  
  
  METHODS
  Retrospective review.
  
  
  METHODS
  Tertiary care hospital.
  
  
  METHODS
  Inpatient healthcare providers.
  
  
  METHODS
  Provider-BPA interaction data were collected from January 2011 to August 2012 from the hospital electronic medical record.
  
  
  METHODS
  Provider (free-text) responses to blood transfusion BPA prompts were independently reviewed and categorized by 2 licensed physicians, with agreement assessed by χ(2) analysis and kappa scoring.
  
  
  RESULTS
  Rationale for overriding blood transfusion BPAs was highly diverse, acute bleeding being the most common (>34%), followed by protocolized behaviors on specialty services (up to 26%), to "symptomatic" anemia (11%-12%). Many providers transfused in anticipation of surgical or procedural intervention (10%-15%) or imminent hospital discharge (2%-5%). Resident physicians represented the majority (55%) of providers interacting with BPAs.
  
  
  CONCLUSIONS
  Providers interacting with BPAs (primarily residents and midlevel providers) often do not have the negotiating power to change ordering behavior. Protocolized behaviors, unlikely to be influenced by BPAs, are among the most commonly cited reasons for transfusing outside of guidelines. Symptomatic anemia is a common, albeit subjective, indication cited for blood transfusion. With a wide swath of individually uncommon rationales for transfusion behavior, secondary use of electronic medical record databases and integrated CDS tools are important to efficiently analyze common practice behaviors.
authors.affiliation: Department of Medicine, Stanford University Medical Center, Stanford, California.
authors.forename: Jonathan H
authors.initials: JH
authors.lastname: Chen
authors.forename: Daniel Z
authors.initials: DZ
authors.lastname: Fang
authors.forename: Lawrence
authors.initials: L
authors.lastname: Tim Goodnough
authors.forename: Kambria H
authors.initials: KH
authors.lastname: Evans
authors.forename: Martina
authors.initials: M
authors.lastname: Lee Porter
authors.forename: Lisa
authors.initials: L
authors.lastname: Shieh
mesh_terms: D001803:Blood Transfusion / Q000191:economics / Q000592:standards*; D057286:Electronic Health Records / Q000191:economics / Q000592:standards*; D006282:Health Personnel / Q000592:standards; D006801:Humans; D050316:Medical Order Entry Systems / Q000191:economics / Q000592:standards*; D010820:Physicians / Q000592:standards*; D017410:Practice Guidelines as Topic / Q000592:standards*; D012189:Retrospective Studies