Red blood cell transfusion: 2016 clinical practice guidelines from AABB

C linical practice guidelines are designed to help clinicians with an educational resource that summarizes the best available medical evidence and the best treatment recommendations. In 2004, the AABB Board of Directors identified development of clinical practice guidelines as a strategic priority to help improve patient care by supporting appropriate transfusion practices and charged the Clinical Transfusion Medicine Committee (CTMC) with preparing these guidelines. The CTMC aims to develop guidelines that physicians can use to ensure proper use of blood components and transfusion service directors can use to develop local transfusion practices that are evidence based. The Institute of Medicine describes clinical practice guidelines as “statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.” Due to the growing importance of guidelines in medical practice, the Institute of Medicine in 2011 developed standards for drafting clinical practice guidelines. The key components include having an explicit development process that is transparent to minimize bias, distortion, and conflicts of interest; involving a multidisciplinary panel; basing the decisions on a rigorous systematic review of the evidence; summarizing the evidence in terms of the risks and benefits for each recommendation; including gaps of knowledge; and providing a rating of the evidence and strength of each recommendation. AABB follows these standards in its generation of transfusion clinical practice guidelines. To assist in the transparent development of guidelines and grading strength of recommendations, in 2000 a group of individuals formed the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group. This group created the GRADE methodology that assists with the standardization of terms used to describe the quality of data, standardization of terms used to describe strength of recommendations, and a standardized summary presentation of findings and recommendations. The GRADE methodology also promotes explicit description of processes used to conduct the systematic review of literature and generation of recommendations. GRADE also allows for generation of recommendations when consensus is not achieved. The GRADE methodology recommends that a group is formed, the clinical questions are formulated, a systematic review of the literature is performed, and then evidence-based guidelines are developed following the explicit step-by-step methodology of the GRADE system. The GRADE methodology has become the worldwide standard for developing guidelines and AABB has endorsed using GRADE methodology for all guidelines drafted by the association. AABB has drafted clinical practice guidelines for plasma, platelet (PLT), and RBC transfusion. The AABB Board supported publication of these guidelines in journals with a more general medical audience, such as JAMA and Annals of Internal Medicine, so the guidelines can have broader impact on the individuals who are most often ordering transfusions. Overall, AABB’s guidelines have been well received. The original RBC transfusion guideline has been cited more than 500 times in less than 4 years and the PLT transfusion guideline was the number one manuscript downloaded from the Annals of Internal Medicine journal website in 2015 (>60,000 times). In addition, a recent study performed completely independent of AABB (and not including any former or current guideline panel members) evaluated the methodologic quality and rigor of development of RBC transfusion guidelines from 13 organizations using the AGREE II instrument (Appraisal of