Marjon Borgert

186 Chapter 8 We implemented the transfusion bundle in the ICU nursing teams. Vlaar et al. showed that most often, it is the nurse who points out the need for transfusion. 4 Therefore, the use of the transfusion bundle by nurses might have had an important e ect on reducing inappropriate transfusions. In the literature, care bundles are often evaluated by measuring the e ect of the bundle by using compliance levels. These compliance levels are often calculated by using bundle checklists. 6 In this study, we were primarily interested in the reduction of the number of inappropriate RBC transfusions. For this we assessed per transfusion if this was based on lower pre-transfusion Hb levels than the patients individual preset Hb thresholds. Our results showed a signi cant reduction in the number of inappropriate transfusions. Remarkably, compliance-levels of the whole bundle remained low during the study period. It is known that the reported levels of bundle compliance are widely variable between studies. 22 Thismight, for example, be due to theway compliancewas calculated or the number of bundle interventions included. In our study, we have calculated bundle compliance by using the all-or-none approach. This means that if one of the bundle interventions was not performed, the whole bundle was considered as non-compliant. It may also be possible that the bundle interventions were actually performed without using the bundle checklist. The use of paper-based bundle checklists could have in uenced this e ect and may have led to a documentation burden. 23,24 However, the intention of care bundles is not to use them as checklists but to improve habits and processes and to internalize the bundle interventions. 25 The latter might be true in our study. This might be due to an increased awareness of the risks of RBC transfusion due to the implementation of the transfusion bundle. In our study, we have examined whether transfusions were based on lower pre- transfusion Hb levels than the preset Hb threshold per individual patient. We have not assessed whether the pre-set threshold was considered adequate for each individual patient according to the transfusion guideline. Interestingly, our results show that in most cases, restrictive Hb thresholds were used as stated in the transfusion guideline. 16 Hébert et al. showed that in most critically ill patients the Hb threshold can be safely lowered without in uencing clinical outcomes negatively. 1 To further improve the e ect of the transfusion bundle, the preset thresholds could be reviewed and discussed by peers. This might have an e ect in lowering the preset Hb thresholds for more patients. Using the transfusion bundle on these preset Hb levels may lead to a larger reduction of inappropriate transfusions. However, to sustain the implementation e ect for appropriate transfusions, real-time clinical decision support systems for ordering blood