Murphy David J, Pronovost Peter J, Lehmann Christoph U, Gurses Ayse P, Whitman Glenn J R, Needham Dale M, Berenholtz Sean M
Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Emory University, Atlanta, Georgia.
Transfusion. 2014 Oct;54(10 Pt 2):2658-67. doi: 10.1111/trf.12718. Epub 2014 May 21.
Despite evidence supporting restrictive red blood cell (RBC) transfusion thresholds and the associated clinical practice guidelines, clinical practice has been slow to change in the intensive care unit (ICU). Our aim was to identify barriers to conservative transfusion practice adherence.
A mixed-methods study involving observation of prescriber (i.e., physicians, physician assistants, nurse practitioners) and bedside nurse daily bedside rounds, provider survey, and medical record abstraction was conducted in one cardiac surgical ICU (CSICU) and one surgical ICU (SICU) in an academic hospital in Baltimore, Maryland.
Of 52 patient encounters observed during bedside rounds, 38 (73%) involved patients without evidence of active bleeding or cardiac ischemia. Surveys were completed by 52 (93%) of the 56 providers participating in rounds. Prescribers in the CSICU and SICU (87 and 90%, respectively) indicated the ideal pretransfusion hemoglobin (Hb) to be not more than 7 g/dL in nonbleeding and/or nonischemic patients compared to a minority of nurses (8% [p = 0.002] and 42% [p = 0.015], respectively). Prescribers and nurses in both ICUs overestimated the typical pretransfusion Hb in their units (CSICU, p < 0.001; SICU, p = 0.019). During rounds, providers infrequently explicitly discussed Hb monitoring or transfusion thresholds (33%) despite most (60%) reporting significant variation in transfusion thresholds between individual prescribers.
Our study identified several provider and system barriers to evidence-based transfusion practices including knowledge differences, overly optimistic estimates of current practice, and heterogeneous transfusion practice in each ICU. Further work is necessary to develop targeted interventions to improve evidence-based RBC transfusion practices.
尽管有证据支持限制性红细胞（RBC）输血阈值及相关临床实践指南，但重症监护病房（ICU）的临床实践变化缓慢。我们的目的是确定妨碍坚持保守输血实践的障碍。
在马里兰州巴尔的摩一家学术医院的一个心脏外科重症监护病房（CSICU）和一个外科重症监护病房（SICU）进行了一项混合方法研究，包括观察开医嘱者（即医生、医师助理、执业护士）和床边护士的每日床边查房、提供者调查以及病历摘要。
在床边查房期间观察的52次患者会诊中，38次（73%）涉及无活动性出血或心脏缺血证据的患者。参与查房的56名提供者中有52名（93%）完成了调查。CSICU和SICU的开医嘱者（分别为87%和90%）表示，对于无出血和/或无缺血的患者，理想的输血前血红蛋白（Hb）不超过7 g/dL，而少数护士（分别为8% [p = 0.002]和42% [p = 0.015]）持不同意见。两个ICU的开医嘱者和护士都高估了各自科室典型的输血前Hb水平（CSICU，p < 0.001；SICU，p = 0.019）。查房期间，尽管大多数（60%）报告个体开医嘱者之间的输血阈值存在显著差异，但提供者很少明确讨论Hb监测或输血阈值（33%）。
我们的研究确定了几个妨碍循证输血实践的提供者和系统障碍，包括知识差异、对当前实践过于乐观的估计以及每个ICU中输血实践的异质性。有必要开展进一步工作以制定有针对性的干预措施，以改善循证红细胞输血实践。
