Intended for healthcare professionals

Practice Practice Pointer

Reducing unnecessary red blood cell transfusion in hospitalised patients

BMJ 2021; 373 doi: (Published 06 April 2021) Cite this as: BMJ 2021;373:n830

Linked Editorial

Sustainable practice: what can I do?

  1. Nishila Mehta, medical student1 2,
  2. Michael F Murphy, professor and consultant haematologist3 4 5,
  3. Lawrie Kaplan, patient and family adviser6,
  4. Wendy Levinson, professor of medicine1 6
  1. 1Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  2. 2Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  3. 3Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  4. 4NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK
  5. 5Radcliffe Department of Medicine, University of Oxford, Oxford, UK
  6. 6Choosing Wisely Canada, Toronto, Ontario, Canada
  1. Correspondence to: W Levinson wendy.levinson{at}

What you need to know

  • Red blood cell (RBC) transfusions are frequently overused, and are associated with increased risk of patient harm and added healthcare costs, without conferring additional value

  • Evidence from clinical trials shows that restrictive transfusion strategies (transfusing one unit at a time, and using a lower haemoglobin threshold) do not increase morbidity or mortality among diverse populations of hospitalised patients

  • A variety of interventions are shown to reduce the rate of inappropriate RBC transfusions, including audit and feedback, clinician education, organisational policy change, and clinical decision support tools

Transfusion of red blood cells (RBC) is used to treat patients with severe anaemia or bleeding. Supplies of blood for transfusion need to be protected, as countries have experienced a decline in donation rates during the covid-19 pandemic.1 However, published international audits describe inappropriate rates of RBC transfusion of 22-57% in a variety of clinical settings, including hospitalised inpatients, operative units, and emergency departments.234 Unnecessary blood transfusions may expose patients to harms, including allergic, febrile, or haemolytic reactions; circulatory overload associated with transfusion (seen in up to 1-6% of transfused patients); and acute lung injury.5 These complications may occur without the transfusion adding any clinical benefit. Blood products are costly to collect and administer. Their overuse wastes a limited precious resource donated by the public.6

Conservative blood use, often referred to as “restrictive transfusion practice,” is recommended in stable, non-bleeding patients by the National Institute for Health and Care Excellence (NICE) and the Choosing Wisely campaigns in Canada, the UK, and the US.78910 Recommendations focus on two major clinical decision points: the haemoglobin concentration (Hb) at which blood transfusion is considered, and the number of RBC units administered at a time (table 1).

View this table:
Table 1

When to transfuse RBCs in the adult inpatient78 …

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