title: Why do four NICUs using identical RBC transfusion guidelines have different gestational age-adjusted RBC transfusion rates?
abstract: OBJECTIVE
  To compare neonatal red blood cell (RBC) transfusion rates in four large Intermountain Healthcare NICUs, all of which adhere to the same RBC transfusion guidelines.
  
  
  METHODS
  This retrospective analysis was part of a transfusion-management quality-improvement project. De-identified data included RBC transfusions, clinical and laboratory findings, the anemia-prevention strategies in place in each NICU, and specific costs and outcomes.
  
  
  RESULTS
  Of 2389 NICU RBC transfusions given during the 4-year period studied, 98.9 ± 2.1% (mean ± S.D.) were compliant with our transfusion guidelines, with no difference in compliance between any of the four NICUs. However, RBC transfusion rates varied widely between the four, with averages ranging from 4.6 transfusions/1000 NICU days to 21.7/1000 NICU days (P < 0.00001). Gestational age-adjusted transfusion rates were correspondingly discordant (P < 0.00001). The lower-transfusing NICUs had written anemia-preventing guidelines, such as umbilical cord milking at very low birth weight delivery, use of cord blood for admission laboratory studies, and darbepoetin dosing for selected neonates. Rates of Bell stage ⩾ 2 necrotizing enterocolitis and grade ⩾ 3 intraventricular hemorrhage were lowest in the two lower-transfusing NICUs (P < 0.0002 and P < 0.0016). Average pharmacy costs for darbepoetin were $84/dose, with an average pharmacy cost of $269 per transfusion averted. With a cost of $900/RBC transfusion, the anemia-preventing strategies resulted in an estimated cost savings to Intermountain Healthcare of about $6970 per 1000 NICU days, or about $282,300 annually.
  
  
  CONCLUSIONS
  Using transfusion guidelines has been shown previously to reduce practice variability, lower transfusion rates and diminish transfusion costs. Based on our present findings, we maintain that even when transfusion guidelines are in place and adhered to rigorously, RBC transfusion rates are reduced further if anemia-preventing strategies are also in place.
authors.affiliation: The Women and Newborn's Clinical Program, Salt Lake City, UT, USA.
authors.forename: E
authors.initials: E
authors.lastname: Henry
authors.affiliation: The Women and Newborn's Clinical Program, Salt Lake City, UT, USA.
authors.forename: R D
authors.initials: RD
authors.lastname: Christensen
authors.affiliation: The Women and Newborn's Clinical Program, Salt Lake City, UT, USA.
authors.forename: M J
authors.initials: MJ
authors.lastname: Sheffield
authors.affiliation: The Women and Newborn's Clinical Program, Salt Lake City, UT, USA.
authors.forename: L D
authors.identifier: 0000000229083597
authors.initials: LD
authors.lastname: Eggert
authors.affiliation: The Women and Newborn's Clinical Program, Salt Lake City, UT, USA.
authors.forename: P D
authors.initials: PD
authors.lastname: Carroll
authors.affiliation: The Women and Newborn's Clinical Program, Salt Lake City, UT, USA.
authors.forename: S D
authors.initials: SD
authors.lastname: Minton
authors.affiliation: The Women and Newborn's Clinical Program, Salt Lake City, UT, USA.
authors.forename: D K
authors.initials: DK
authors.lastname: Lambert
authors.affiliation: The Transfusion Medicine Program, Intermountain Healthcare, Salt Lake City, UT, USA.
authors.forename: S J
authors.identifier: 0000000176802569
authors.initials: SJ
authors.lastname: Ilstrup
mesh_terms: D000740:Anemia / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D002543:Cerebral Hemorrhage / Q000150:complications; D017046:Cost Savings / Q000379:methods; D020345:Enterocolitis, Necrotizing / Q000150:complications; D017707:Erythrocyte Transfusion / Q000191:economics / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D005865:Gestational Age; D019983:Guideline Adherence / Q000592:standards / Q000706:statistics & numerical data; D006801:Humans; D007231:Infant, Newborn; D007235:Infant, Premature, Diseases / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D007363:Intensive Care Units, Neonatal / Q000706:statistics & numerical data; D015931:Intensive Care, Neonatal / Q000379:methods / Q000592:standards; D008297:Male; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000706:statistics & numerical data; D058996:Quality Improvement; D012189:Retrospective Studies; D014481:United States