Measure ID

Percentage of pediatric surgical cases with a blood transfusion that have a hemoglobin or hematocrit value documented prior to transfusion.

Measure Type
Measure Time Period

Up to 36 hours prior to the first transfusion during the case


Patients  ≥ 6 months to 18 years of age who receive a transfusion of red blood cells intraoperatively

  • ASA 6
  • Patients < 6 months and ≥ 18 years of age
  • Cardiac Procedures
  • Obstetric Procedures
  • Massive Transfusion or blood loss: Defined as volume of 40mL/kg
  • Cases where the ‘Measure End Time’ precedes ‘Measure Start Time’ will be excluded and marked 'invalid'
Success Criteria

Documentation of hemoglobin and/or hematocrit within 90 minutes prior to each blood transfusion volume ≥ 15mL/kg

Other Measure Details
  • Documentation of a Hgb/Hct value must be present within 90 minutes before each transfused volume of 15mL/Kg.
  • Exceptions
    • If the Hgb/Hct was  < 8/24 within 36 hours of the first transfusion, 15mL/kg may be transfused without a lab check 
    • If the most recent hgb/hct drawn before the first transfusion is ≤ 5/16, a volume of ≤ 30mL/kg can be administered without a lab check
Provider Attribution

Provider(s) who administered blood product

MPOG Concept Used

Blood Products

  • 10489   Packed Red Blood Cells- Autologous
  • 10490   Packed Red Blood Cells- Homologous
  • 10492   Whole Blood- Homologous
  • 10616   Packed Red Blood Cells- Unknown Type
  • 10617   Whole Blood- Unknown Type
  • 10618   Categorized Note- Blood Products
  • 10499   EBL

Point of Care Testing 

  • 3415     POC-Blood gas-Hct measured
  • 3435     POC- hematocrit spun
  • 3440     POC- Coulter counter- Hemoglobin
  • 3450     POC- Coulter counter- Hematocrit
  • 5081     POC- Blood gas- Hemoglobin

Formal Labs

  • 5005     Formal lab- Hemoglobin
  • 5006     Formal lab- Hematocrit
  • 5038     Formal lab- Blood gas- Hct measured
  • 5080     Formal lab- Blood gas- Hemoglobin
Measure Authors

 Measure Author


 Meridith Wade, MSN, RN

 University of Michigan

 Jay Jeong

 University of Michigan

 MPOG Pediatric Subcommittee



Measure Reviewer(s)
Next Review: 2025
 Date Reviewed  Reviewer  Institution  Summary  QC Vote






Published Date: 04/2022
 Date  Criteria  Revision