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Conserving blood: How hospitals are reducing blood transfusion rates
By Kathleen Louden
From the October ACP Hospitalist, copyright © 2008 by the American College of Physicians
Blood shortages, high blood acquisition costs and concerns about transfusion-related risks have generated growing interest among hospitals in finding ways to decrease use of blood therapy. For some organizations, the solution has been to create an integrated blood conservation program. Other hospitals are turning to bloodless medicine to meet the needs of patients with religious objections to blood transfusions. The need for better blood management could dramatically increase if future research confirms a recent study. An article in the March 20 New England Journal of Medicine reported that transfusions with blood stored longer than two weeks can lead to poorer outcomes after cardiac surgery than with newer blood.
“If we were to use blood less than 14 days old, you can imagine the impact on the blood supply,” said Ajay Kumar, ACP Member, a hospitalist and director of blood management at Cleveland Clinic.
Regional blood shortages already are a problem, especially in urban areas. In 2001, 57% of U.S. hospitals experienced a blood shortage, and nearly 13% canceled elective surgeries because of shortages, according to an American Hospital Association (AHA) survey performed that year.
In 2002, the AHA told a government advisory committee that “blood conservation efforts hold much promise” in mitigating shortages. Although the association does not track the number of hospitals that have programs in blood conservation, at least one company that helps hospitals develop integrated blood conservation programs has noted increased interest.
“More hospitals in large cities are creating such programs,” said Sharon Vernon, RN, vice president of education for Hemo Concepts, based in Old Bridge, N.J. Although blood shortages are more common on the coasts than in rural areas, any hospital can benefit from a blood conservation program, she said, adding, “It’s good medicine for all patients.”
Blood conservation boosts outcomes, cuts costs
Integrated blood conservation brings together approaches that conserve the patient’s own blood and limit the use of donor transfusions. Supporters say the approach improves clinical outcomes and reduces length of stay and the costs of care.
Studies show that blood transfusions lengthen the immunosuppression period, raise the risk of morbidity such as infection, and contribute to longer length of stay.
Studies show that blood transfusions lengthen the immunosuppression period, raise the risk of morbidity such as infection, and contribute to longer length of stay, Dr. Kumar said.
“Every pack of red blood cells (RBC) that you don’t transfuse decreases the risk to the patient,” said Tamara Doehner, ACP Member and a hospitalist at Methodist Hospital in Omaha, Neb.
Methodist Hospital started a blood conservation program in 2006 and saw a 4% decline in RBC use over the first year, Dr. Doehner said. Although they have not tracked cost savings from the program—enhanced patient safety is their focus, she said—Methodist likely is saving money because a unit of blood costs the hospital $250 plus processing costs.
Adding to the expense of blood transfusion, Medicare does not reimburse the first three units of blood a patient receives in a calendar year.
Strategies to success
For maximum benefit, a blood conservation program should integrate drugs, technologies and techniques. As well, it should involve an interdisciplinary clinical effort, with a team that includes transfusion specialists, surgeons, critical care specialists, nurses and pharmacists.
Hospitalists are also an important part of a blood conservation team, according to one leader in the field, because they can minimize unneeded blood draws and transfusions that can take a toll on patients.
“One greatly under-appreciated fact is that a critical care patient gives a lot of blood for tests—on average, one to two units in a hospitalization,” said L. Tim Goodnough, MD, a hematologist-oncologist and director of the transfusion service at Stanford University Medical Center. “You don’t want to set up the patient to become even more anemic.”
Besides making sure the tests they order are necessary and not repetitive, hospitalists can consider microsampling, in which tiny blood samples are taken for lab testing. Another important tactic is to use a low trigger for transfusion of red blood cells, a hemoglobin level that some authors define as less than 7 g/dL.
No universal transfusion trigger exists, and Dr. Kumar believes there should not be one. Physicians, he said, should judge the need for transfusion based not just on blood parameters but also on an individual patient’s clinical condition, such as cardiovascular status.
Also key to blood conservation is aggressive anemia management, especially in intensive care and perioperatively. Options to boost blood production that hospitalists can employ include iron replacement therapy as well as administration of vitamins B12 and C and folic acid and, in selected patients, erythropoietin (epoetin alfa).
Methods to minimize blood loss intraoperatively include clotting medications such as antifibrinolytics and surgical tools such as electrocautery and the harmonic scalpel. Two techniques that surgical teams may use for major surgical procedures are autologous blood recovery systems (Cell Saver), which collect, wash and recycle a patient’s blood during surgery, and acute normovolemic hemodilution. The latter method removes some of the patient’s RBCs immediately before surgery and replaces the blood cells with intravenous fluids to dilute the blood.
Autologous blood donation is used in selected patients, such as those with multiple antibodies, but generally has a limited role in blood conservation because it carries a higher risk to patients of perioperative anemia, and about 50% of the blood remains unused, Dr. Kumar said.
The technique also may not prevent an allogeneic transfusion if the patient needs more blood than he or she donated, said Randy Thomas, administrative director of the Center for Bloodless Medicine and Surgery at Abington (Pa.) Memorial Hospital. Furthermore, there often are better ways of preventing anemia, he said.
“If a patient’s [condition] can be optimized before surgery, why take out the blood and put it back?” he asked.
Kathleen Louden is a freelance health writer in Gurnee, Ill.
How to start a blood conservation program
Many hospitals which start an integrated blood conservation program find they already are performing some aspects of blood management.
“You generally don’t have to invest in a lot of new technology,” said Randy Thomas, administrative director of the Center for Bloodless Medicine and Surgery at Abington (Pa.) Memorial Hospital.
To begin a blood conservation program, hospitals do need a comprehensive plan, said Sharon Vernon, RN, vice president of education for Hemo Concepts of Old Bridge, N.J. Based on what Hemo Concepts does for its clients, she recommended that the plan include these components:
Gatekeeper/champion. Hire a full-time program coordinator responsible for implementing the program. Hemo Concepts prefers a clinician for this position.
Baseline data collection. Track donor transfusion rates, triggers and alternatives used; number of blood tests ordered and amount of blood taken for each test; medications used to decrease bleeding; infection and mortality rates; and other pertinent data.
Policies and procedures. A multidisciplinary team, under the direction of the program coordinator, should develop organization-wide standards, including transfusion alternatives and informed consent.
Education. The program coordinator should inform health care providers and patients about blood conservation as an option.
Evaluation. Compare outcomes against baseline data. It can take several years to fully implement a blood conservation program, Mr. Thomas said.
“You have to change physician practice,” he said. “The exciting part is physicians are offering patients an option that maybe they didn’t have in the past.”
Joint commission proposes assessing blood management
A Joint Commission Technical Advisory Panel has developed 19 candidate performance measures for assessing blood management in hospitals, including several involving blood conservation. The panel will review public comments about the proposed measures beginning in October and will select measures for detailed specification development.
“There’s hope … that we’ll end up with a set of measures that can support evidence-based decisionmaking and reduce unwarranted variation in blood management practice,” said David J. Ballard, FACP, MSPH, PhD, advisory panel co-chair and senior vice president and chief quality officer of Baylor Health Care System in Dallas.
Draft measures for blood conservation strategies include transfusion indication, measurement of preoperative hemoglobin level, blood salvage documentation and monitoring blood product wastage. However, recommendation of the final measures that would be included in the set will not likely be determined until 2010, if funding is secured, Dr. Ballard said.
Although the public comment period ended Aug. 29, Dr. Ballard said ACP members may have future opportunities to test the measures and provide feedback. Updated project information will be posted on The Joint Commission Blood Management Web site.
In brief: blood conservation
Experts suggest the following tactics for blood conservation:
- Reduced transfusion trigger
- Microsampling for blood draws
- Iron therapy
- Vitamins (B12, C, folic acid)
- Clotting medications
- Intraoperative autologous blood recovery/cell salvage
- Acute normovolemic hemodilution
- Harmonic scalpel
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