Variability in adherence to goal-directed transfusion protocols and inter-physician variability: an odd phenomenon

Introduction On May 15, 2019, we implemented an institutional goal-directed transfusion protocol based on thromboelastography (TEG) for cardiac surgeries in an effort to eliminate unjustifiably high non-RBC blood product usage [1]. Standardization of care delivery attenuates inter-provider variability and improves clinical, operational and financial outcomes for patients and the healthcare system [2,3]. The objective of this prospective single-center study is to describe overall guideline adherence and inter-physician variability to protocol adherence. Methods We prospectively collected transfusion data on all consecutive cardiac surgeries performed between May 2019 and January 2020. Based on our transfusion guideline recommendations, we calculated the observed to expected (O:E) transfusion of fresh frozen plasma (FFP), platelet, and cryoprecipitate for all 6 cardiac surgeons and 8 anesthesiologists on staff; O:E 1 refer to under-transfusion, adequate-transfusion, and over-transfusion per guideline recommendations, respectively. Descriptive data is described as percentages, means and standard deviations. Results Between May 2019 and January 2020, we collected 128 cases. Protocol adherence (O:E = 1) was 57% after adjusting to surgeons, and 65% after adjusting for anesthesiologists. Over-transfusion (O:E >1) is most common for FFP followed by platelets, and the variability is pronounced especially amongst surgeons, when stratified by specialty. Under-transfusion (O:E Discussion Herein, we observe two important phenomena related to implementing an institutional goal-directed transfusion protocol for cardiac surgery; 1. Despite an agreed-upon protocol, close to 30% of surgeons and anesthesiologists deviate, and 2. Despite efforts at standardization, inter-physician variability in care delivery remains. Future work will be directed at identifying barriers to physician adherence to recommended guidelines as they relate our institutional transfusion practices [3].