Measure Abbreviation
TRAN-01
Data Collection Method

This measure is calculated based on data extracted from the electronic medical record combined with administrative data sources such as professional fee and discharge diagnoses data.  This measure is explicitly not based on provider self-attestation.

Measure Type
Process
Description

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

Measure Time Period

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

Inclusions

All surgical patients receiving anesthetics who receive a transfusion of red blood cells.

Exclusions
  • Massive Transfusion: Transfusion of 4 or more units of blood. Note for sites that document transfusions in ml instead of units: ASPIRE will default to 350ml/unit.
  • EBL ≥ 2000 ml
  • Patients < 2 years of age 
  • Patients <12 years old undergoing a cardiac procedure (CPT: 00560, 00561, 00562, 00563, 00567, 00580).
  • Patients <12 years old where either transfused PRBC or EBL was greater than 30cc/kg.
  • Burn cases (CPT Codes 01951, 01952, 01953)
  • ASA 5 & 6
  • Obstetric Non-Operative Procedures (CPT: 01958, 01960, 01967)
  • Obstetric Non-Operative Procedures with procedure text: “Labor Epidural”
  • Exclude patients undergoing cesarean section (CPT: 01961, 01968, 01962, 01963, 01969) with an EBL > 1500cc.
  • Exclude patients undergoing cesarean section (CPT: 01961, 01968, 01962, 01963, 01969) with a HR>110, SBP<85, DBP<45, or O2Sat <95%.
  • Exclude postpartum hemorrhage cases (ICD-10 code: O72.0, O72.1, O72.2, O72.3)
Success
  • Documentation of hemoglobin and/or hematocrit prior to blood transfusion
  • Considerations:
    • For the first unit of transfusion, a hemoglobin or hematocrit of any value should be checked in a time period of 0 to 90 minutes before the transfusion, or the most recent documented hemoglobin or hematocrit of less than 8/24 should be within 36 hours of the transfusion.
    • If the last hemoglobin or hematocrit drawn before the first transfusion is ≤ 5/16, a second unit could be administered without rechecking hemoglobin/hematocrit.
    • If multiple units are administered, documentation of a hemoglobin or hematocrit value must be present within 90 minutes before each administration.
    • For pediatric cases (patients < 12 years old): Pre-transfusion hemoglobin/hematocrit required before the first unit and an additional recheck after 15cc/kg of PRBCs have been administered.
    • For cardiopulmonary bypass cases, all transfusions administered between cardiopulmonary bypass start and end will not be included for determining measure results for the case.
Other Measure Build Details
  • Cardiopulmonary bypass (CPB) start/end times defined as follows:
    • Measure will first determine CPB start and end times using the first time associated with one of the following notes and the last time associated with one of the following notes:
      • 50047    Perfusion – Retrograde Arterial Prime/Venous Antegrade Prime Performed (Yes/No)
      • 50399    Cardiopulmonary bypass -- aortic clamp on/off note
      • 50401    Cardiopulmonary bypass vent on - note
      • 50402    Cardiopulmonary bypass vent off - note
      • 50403    Cardiopulmonary bypass vent on detail
      • 50404    Cardiopulmonary bypass vent off detail
      • 50405    Cardiopulmonary bypass rewarm - note
      • 50407    Cardiopulmonary bypass systemic cooling initiated
      • 50409    Cardiopulmonary bypass (full/partial/left-heart) terminated
      • 50410    Cardiopulmonary bypass initiated (full/partial/left-heart)
      • 50411    Cardiopulmonary bypass -- ventilator turned off
      • 50412    Cardiopulmonary bypass -- perfusion start
      • 50413    Cardiopulmonary bypass -- perfusion end
      • 50415    Cardiopulmonary bypass -- aortic crossclamp off
      • 50416    Cardiopulmonary bypass -- crossclamp and circulatory arrest time totals
      • 50417    Cardiopulmonary bypass -- Access cannula removed note
      • 50419    Cardiopulmonary bypass -- Aortic crossclamp removal requiring therapy
      • 50420    Cardiopulmonary bypass -- Isoflurane vaporizer turned on
      • 50421    Cardiopulmonary bypass -- Arterial cannula inserted note
      • 50422    Cardiopulmonary bypass -- Arterial cannula insertion site detail
      • 50424    Cardiopulmonary bypass -- Blood pressure lowered note
      • 50425    Cardiopulmonary bypass -- Blood pressure lowered therapy detail
      • 50426    Cardiopulmonary bypass -- Ice off head
      • 50427    Cardiopulmonary bypass -- Ice on head
      • 50428    Cardiopulmonary bypass - cardioplegia start
      • 50429    Cardiopulmonary bypass - cardioplegia stop
      • 50647    Cardiopulmonary bypass - Aprotinin test dose performed
      • 50714    Cardiopulmonary bypass - Full/partial/left-heart bypass start / stop event
      • 50766    Cardiopulmonary bypass -- Circulatory arrest start
      • 50767    Cardiopulmonary bypass -- Circulatory arrest stop
    • Finally, if there are no intraoperative notes available, the measure will review physiologic data mapped to the following variables to determine start and end times as follows:
      • At least one of these two cardiac indictors are met:
        • Systolic Blood Pressure (MPOG Concept: 3030) - Diastolic Blood Pressure (MPOG Concept: 3035) < 20 or Pulse (MPOG Concept: 3005) ≤ 5
      • At least one of these two pulmonary indicators are met:
        • Respiratory Rate (MPOG Concept: 3580) ≤ 2 or End Tidal CO2 (MPOG Concepts: 3235, 3236) ≤ 5
  • Transfusion is defined as:
    • Packed Red Blood Cells-Autologous, Homologous, Unknown Type
    • Whole Blood-Homologous, Unknown Type                          
    • Categorized Note- Blood Products
  • Hematocrit/hemoglobin are defined as:
    • POC - Blood gas-Hct measured,  Hemoglobin
    • POC – Hematocrit spun
    • POC – Coulter counter – Hematocrit, Hemoglobin
    • Formal lab – Hematocrit,  Hemoglobin
    • Formal lab - Blood gas - Hct measured, Hemoglobin
Responsible Provider

Provider(s) who administered blood product

Threshold
90%
MPOG Concept IDs Required

Blood Product MPOG Concept IDs

Point of Care Testing MPOG Concept IDs

Formal Lab MPOG Concept IDs

EBL MPOG Concept ID

10489

Packed Red Blood Cells- Autologous

3415

POC-Blood gas-Hct measured

5005

Formal lab- Hemoglobin

10499

EBL

10490

Packed Red Blood Cells- Homologous

3435

POC- hematocrit spun

5006

Formal lab- Hematocrit

 

10492

Whole Blood- Homologous

3440

POC- Coulter counter- Hemoglobin

5038

Formal lab- Blood gas- Hct measured

 

10616

Packed Red Blood Cells- Unknown Type

3450

POC- Coulter counter- Hematocrit

5080

Formal lab- Blood gas- Hemoglobin

10617

Whole Blood- Unknown Type

5081

POC- Blood gas- Hemoglobin

10618

Categorized Note- Blood Products

Data Diagnostics Affected
  • Percentage of Inpatient Cases with Documented Blood Loss
  • Percentage of Cases with Documented Blood Transfusions
  • Percentage of Fluids with a Meaningful Fluid Mapping
  • Percentage of Labs Mapped to a Meaningful Lab Mapping
  • Percentage of Cases with a Lab Drawn During Anesthesia
  • Percentage of Cases with Point of Care Hematocrit Labs
  • Percentage of Cases with Point of Care Hemoglobin Labs
  • Percentage of Cases with any Staff Tracking
  • Percentage of Anesthesia Provider Sign-Ins that are Timed
Rationale

The American Association of Blood Banks (AABB) recommends a transfusion threshold of hemoglobin concentration less than or equal to 8 g/dL or when patient is symptomatic (chest pain, orthostatic hypotension, tachcardia unresponsive to fluid resuscitation, or congestive heart failure).1,2 Furthermore, blood transfusions in non-cardiac surgery have been associated with increased risk of 30-day mortality and morbidity.3

Although the literature is not conclusive on the exact hemoglobin concentration that requires transfusion, the evidence is clear that use of fewer RBC transfusions reduces cost and risk for adverse effects of transfusion, and that transfusion for hemoglobin values greater than 10 g/dL is usually not indicated.

TRAN 01 is a process measure focused on measuring hemoglobin or hematocrit prior to transfusion. The rationale for this measure is that the decision to transfuse should include knowledge of the hemoglobin value before administration of blood.  Because the literature is not absolutely conclusive on a specific hemoglobin threshold for transfusion, TRAN 01 does not include the actual hemoglobin value as part of the measure.

Risk Adjustment

Not applicable

References

1. Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Annals of internal medicine. 2012;157(1):49-58.

2. Carson JL, Guyatt G, Heddle NM, et al. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. Jama. 2016;316(19):2025-2035.

3. Glance LG, Dick AW, Mukamel DB, et al. Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology. 2011;114(2):283-292.