Transfusion Audit

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Active?: legacy
Program: CC
Requestor: Unknown/legacy
Collection start: 2007-11-01
Collection end: 2008-01-31

Legacy only, see below for details


  • to audit the appropriateness of RBC transfusion practices in the ICU.

Audit Dates

  • Random audits


  • STB (May 1.04 to Jun 30.05) SICU & MICU
  • HSC (Jan to Jun 30.05) SICU & MICU


  • all ICU's in City of Winnipeg (exclude CCU & IICU) (Nov 1.07 to Jan 31.08)

Data can be found on: X:\CCMDB_Special_Projects\Transfusion\2004_2005_TRANSFUSION

Amendments to transfusion collection process guidelines:

  1. October 31.07 1400 hrs – record the date and time of transfusion not date and time Hgb level
  2. Nov 1.07 1400 hrs – item 3 – drop of Hgb 30 G/L within 24 hrs
  • Instead of recording the date and time of the Hgb level, you will be recording the date and time that each unit of packed cell (PC) was given to a patient. Every unit of PC that a patient receives should have a reason why it was given. (Reason is the items 1-5 listed below).
  • You DO NOT need to record the date and time of Hbg level. Just record the closest Hgb LEVEL PRIOR to each unit of PC transfused.
  • If two or more units of PC are ordered to be given consecutively in a row and there is no Hgb level drawn between each unit of PC’s, record the same Hgb level that you used for the first PC transfused and in the comment section for the second PC transfused type: same Hgb.
  • This data needs to be completed as soon as possible for all patients, not only those who are being sent, since the data is sent for all patients every time data is sent.

APPROPRIATE Transfusion if following Criteria is met:

1. HGB < 70 G/L NOTE: If you don’t have a serum Hgb level then you can use an ABG Hgb level. Since blood gas results correlate reasonably well with a formal CBC, transfusion with a blood gas Hgb <70g/L should be considered appropriate.


2. HGB > 71 G/L + Acute Coronary Syndrome (ACS), (within last 3 months)

  • except for patients who have had a complete revascularization (CABG)

3. HGB > 71 G/L + Active bleeding

  • (decrease of HGB of > 30 G/L within 24 hrs OR >= 3 units PC)

4. HGB > 71 G/L + Septic Shock

  • resuscitative phase (within 1st 24 hrs)

5. INAPPROPRIATE Transfusion if:

   If criteria 1 to 4 above not met


How to prioritize your selection if “two reasons” for the transfusion of a unit of Packed Cells exist at the same time. IF patient meets the following two criteria at the same time:

  • (1) Hgb 70 or less +
  • (2) ACS
    • Then choose item 1. Hgb 70 or less as the reason for transfusion.
  • (1) Hgb 70 or less +
  • (3) Active bleed
    • Then choose item 1. Hgb 70 or less as the reason for transfusion.
  • (1) Hgb 70 or less +
  • (4) Septic Shock
    • Then choose item 1. Hgb 70 or less as the reason for transfusion.

More RULES.....

  • Hgb 71 or more +
    • 2. ACS +
    • 3. Active bleed.

If both DX, then choose 3. Active bleed

  • Hgb 71 or more +
    • 2. ACS +
    • 4. Septic shock.

If both DX, then choose 4. Septic Shock

  • Hgb 71 or more +
    • 3. Active bleed +
    • 4. Septic Shock

If both DX, then choose 3. Active bleed

Dec 7.07 @1400 hrs UPDATE: Collection GUIDE

1. HGB not done for PC’s hung simultaneously A.If two or more PC’s are hung at the same time (simultaneously)enter the time that each PC's was hung five minutes apart into the PDA. B.In the TRANSFUSION COMMENTS section, type the following: two units hung at once for the same HGB.

  • reason: inconsistency with this process & hard to spot duplicate entries. Some are entering exactly the same time for each PC others are entering one or two minutes apart etc. When you send your files in each Wednesday, all the data in the TMP file is sent into us repeatedly. Our processes staff sifts out the duplicates, however when PC date and time is exactly the same for one or more PC, we are not sure if it is a duplicate entry or in fact a PC that was given simultaneously.
  • All transfusion data are needed every week for reporting purpose.

2. HBG not repeated between units that are not given simultaneously:

  • When a HGB is not repeated between units of PC’s that are hung during the course of a day or so, then for the subsequent PC’s that are hung, please type into your TRANSFUSION COMMENTS the following: Hbg not repeated between units.

3. Quality checking the total number of PC transfusion with LAB data

  • For all patients admitted on Nov 1.07 and discharged on for before Feb 3.08 the total number of PC’s transfused should equal to total number of PC tallied in your Lab data. Please make sure you do this cross check before you send in files. (ACCESS takes care of this data integrity check now).