Improving Red Blood Cell Transfusion Practices in the ICU: A Quality Improvement Initiative

Introduction: Red blood cell (RBC) transfusions in critically ill patients are common but often overused, exposing patients to unnecessary risks without clear clinical benefit. Evidence-based guidelines recommend restrictive transfusion strategies, including single-unit transfusions and transfusion thresholds of hemoglobin (Hgb) < 7 g/dL. Despite these recommendations, practice variation persists. This quality improvement project aimed to enhance compliance with RBC transfusion best practices in the intensive care units (ICUs) at our institution by implementing a multifaceted educational and performance feedback intervention.


Methods: In April 2025, a multidisciplinary intervention was launched targeting ICU faculty, fellows, and nursing staff. The intervention included: Education on RBC transfusion guidelines, weekly email communications summarizing team metrics with three primary goals (≥91% of transfusions being single-unit, ≥79% of transfusions given for Hgb < 7 g/dL, < 4% of transfusions given for Hgb ≥ 8 g/dL), and monthly distribution of both team and individual compliance reports. Outcomes from the post-intervention period (April–June 2025) were compared to a baseline period (April–June 2024). Key metrics included number of RBC units transfused, percentage of single-unit transfusions, transfusions given for Hgb < 7 g/dL, and transfusions given for Hgb ≥ 8 g/dL. Exclusions included patients on ECMO, those meeting massive transfusion criteria, cases of active bleeding, and transfusions administered in the operating room.


Results: RBC transfusions decreased from 141 units to 100 units. The proportion of single-unit transfusions increased from 84% to 91% (p = 0.0001), transfusions for Hgb < 7 g/dL increased from 74% to 81% (p = 0.0002), and transfusions for Hgb ≥ 8 g/dL decreased from 9% to 7% (p = 0.09).


Conclusions: This targeted quality improvement initiative significantly improved adherence to evidence-based transfusion practices in the ICU, resulting in reduced overall RBC utilization, increased compliance with single-unit transfusions, and improved alignment with transfusion thresholds. Regular education, real-time performance feedback, and transparent communication with ICU teams were key drivers of success and sustainability.