736 - Is Introducing Guidelines Sufficient to See Practice Change? Assessing the Impact of a pRBC Transfusion Guideline

Publication Number: 1713.736

Micha Thompson, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, United States; Lauren A. Sanlorenzo, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, United States; Sandhya S.. Brachio, Columbia University Vagelos College of Physicians and Surgeons, 622 W. 168th St, PH17, NY, United States

Background: Clinical practice guidelines (CPGs) are a mainstay of evidence based medicine to inform decision-making while reducing bias and standardizing approach. Adherence to guidelines is often mixed, impeding their intended effect. Our level IV NICU recently developed a guideline to provide transfusion thresholds for anemia of prematurity and guidance around feeding during transfusion to maximize patient benefit, optimize resources, and limit adverse effects.

Objective: This study evaluated baseline transfusion practices and assessed practice changes with CPG introduction.

Design/Methods: Data were retrospectively reviewed February 2020 - December 2024 with CPG introduction August 2023. Our primary outcome was proportion of transfusions adherent to guidelines. Transfusions were analyzed in groups of 10 to assess rate of adherence over time. Data collected for each transfusion included demographics (Table 1) and potential adverse effects (additional IV access, complications like IV infiltrates, feeding disturbances, and exposure to extra diuretics). Inclusion criteria mirrored the scope of the CPG: gestational age 22-30 weeks, corrected age < 37 weeks, and clinically stable.

Results: Of 1,374 transfusions, 404 met inclusion criteria. Demographics were similar though the post-guidelines cohort were younger with smaller birthweights (Table 1). After CPG introduction in Block 27 there was a modest centerline shift from 45% to 63% due to an astronomical point in Block 31, and a narrowing of control limits (Figure 1). We noted a shift Block 16-24 prior to introduction; we did not change the centerline as no intervention occurred to explain a change in practice. Most frequent adverse effects of transfusions were additional IV insertion and feeding disturbances. Feeding disturbances significantly decreased after guideline implementation (Figure 2). Two clinical scenarios had notable low adherence to guidelines: pre-operative (5/15, 33%) and pre-extubation (3/11, 27%).

Conclusion(s): Through this retrospective work we found that the introduction of guidelines has the potential to influence practice given the modest shift in our centerline. There was variability in feeding practices pre-guidelines and due to new CPG targeted guidance, we saw a significant decrease in feeding disturbances. However, our overall results demonstrate that the sole introduction of guidelines is insufficient to see meaningful practice change, necessitating intentional prospective quality improvement work. There was particular variability in adherence in pre-operative and pre-extubation care, demonstrating specific areas for future PDSA cycles.

Table 1
Demographics for transfusion events before and after guideline introduction. Asterisk signifies statistical difference, p <0.05.

Figure 1
1. Control chart demonstrating adherence to guidelines for every 10 transfusion events. UCL = upper control limit; LCL = lower control limit; CL = centerline; pRBC = packed red blood cell

Figure 2
Control chart demonstrating percentage of feeding disturbances per 10 transfusion events. Feeding disturbance defined as cessation of feeds due solely to transfusion. pRBC = packed red blood cell