Experts: Hospitals can improve care, save health care dollars by cracking down on unnecessary blood transfusions

Comprehensive blood conservation efforts can deliver big dividends in terms of safety, efficiency

While blood transfusions are often essential in the care of trauma patients, several prominent health care organizations recognize that too often providers are ordering blood transfusions when they are not medically necessary. This drives up costs and exposes patients to unnecessary risks, according to experts. And it also essentially wastes precious blood supplies.

The American Medical Association’s Physician consortium for Performance Improvement and The Joint commission recently highlighted blood transfusions as one of five treatments that are overused at a National Summit on Overuse, which was held in September in chicago, IL. (See more on the National Summit on Overuse, below.)

Also, the Advisory committee on Blood Safety and Availability for the Department of Health and Human Services in Washington, Dc, has called for new standards, both for when transfusions are needed as well as strategies to conserve blood products.

According to the American Red Cross, between 1994 and 2008, blood use rose by 40% in the United States. The agency says that more than 14 million units of red blood cells are used every year in this country. This amounts to about 49 units of blood for every 1000 patients — much more than in many other countries. However, parts of the United States continue to experience shortages of blood, and it is difficult for blood banks to keep up with the demand, according to agency officials.

Nonetheless, with education and technological tools, it is clear that hospitals that focus on this issue can reduce the amount of blood they transfuse without negatively impacting patient care, and potentially save health care dollars in the process.

Take note of new evidence

Numerous studies in recent years have highlighted the problem of overuse. For example, in a study published earlier this year in the journal Anesthesiology, researchers found wide variation among surgeons and anesthesiologists regarding when they order transfusions.1

The researchers reviewed the electronic anesthesia records of more than 48,000 surgical patients at Johns Hopkins Hospital in Baltimore, mD, during the 18 months between February of 2010 and August of 2011. Overall, about 3,000 patients received transfusions during surgery, but the patients undergoing cardiac procedures received blood at much lower trigger points than patients having other types of surgery.

For example, patients who were having surgery for pancreatic cancer, orthopedic issues, or aortic aneurisms often received blood when their hemoglobin was at or even above 10 grams per deciliter, even though lower hemoglobin thresholds of 7 or 8 have been shown to be safe.

Also, the amount of blood transfused did not appear to be based on how sick the patients were or how much blood is typically lost during the specific type of surgery, according to Steven Frank, MD, the lead author of study and director, Perioperative Blood management Services, Department of Anesthesiology/Critical Care Medicine at John Hopkins Medical Institutions.

“A lot of this has to do with a tradition in practice being handed down for generations of doctors that the hemoglobin level has to be maintained at 10 or higher,” notes Frank. “In the last 15 years, there have been eight publications supporting lower hemoglobin triggers of 7 or 8, showing the same outcomes as a hemoglobin trigger of 10, even in older, sicker patients. People have been slow to change their practices and accept the lower hemoglobin triggers.”

Also contributing to the problem, says Frank, are general guidelines governing when a surgical patient should receive blood that are too vague with respect to hemoglobin levels that fall between 7 and 10 grams per deciliter.

Consider transfusion risks, costs

Frank points out that it costs the American Red Cross about $1,100 to obtain, test, store, and transport a unit of blood. Providers pay $278 for the blood and Medicare pays $180, he says. And there are consequences beyond cost to consider. “Blood transfusion is not without risk, even though HIV and hepatitis are much lower risks than they used to be because there is better testing,” he says.

For example, there can be an allergic reaction to a transfusion; there is a risk for a transfusion-related lung injury, which occurs in one out of every 5,000 patients; and about one in every 100 patients experiences transfusion-associated cardiac overload, explains Frank. “If you are not going to [improve the outcome] by transfusing blood, then there is no reason to transfuse beyond the recommended thresholds,” he says.

However, of particular importance to the ED, the lower hemoglobin triggers don’t always apply to actively bleeding patients, such as patients who are brought to the ED following traumatic injuries from a car accident or a gun shot wound. “It is like having a hole in the gas tank. You are losing blood, so if you want to stay ahead of the game you are going to have to give blood to actively bleeding patients because you know their hemoglobin is going to drop,” he says. “But you don’t have to give it above a hemoglobin of 10; you can still tolerate the newly accepted lower hemoglobin levels.”

It is not easy to change provider practice, but Frank advises clinical leaders to make sure providers are aware of the latest research, supporting lower hemoglobin triggers for blood transfusions. “I would show practitioners the four published guidelines and the four randomized trials that all support hemoglobin triggers of 7 or 8, and try to dispose of the traditional teaching that hemoglobin needs to be above 10,” he says.

Further, Frank points out there is good evidence that electronic notifications or alerts that are integrated into the electronic order sets that most hospitals now use can lead to significant improvements in compliance with the new, lower hemoglobin triggers. In fact, Johns Hopkins Hospital has just implemented this type of intervention.

“We have a recommended threshold for transfusion, and if the hemoglobin is above 8, the provider will get a message in the electronic order noting that this transfusion may be outside of recommended guidelines,” explains Frank. “Then the provider will have to submit a specific reason why he or she is giving blood to the patient.”

While it is too early to tabulate the results from this intervention at Johns Hopkins, Frank notes one published study that showed that a similar approach decreased the blood transfusion rate by 12%.2

Provider education is key

One hospital that has already made great strides in limiting unnecessary use of blood products is Eastern Maine Medical Center in Bangor, ME. “Our medical director approached the administration in the summer of 2006 with the concept of a blood management and conservation program,” explains Tiffany Nelson, RN, BSN, coordinator of EMMC’s Patient Blood Management Program.

The program included a proposal to decrease blood acquisition costs and improve quality of care, she explains.

One of the first interventions involved implementing a computerized physician order entry system for blood product ordering that is similar to what Frank describes. The system not only alerts providers if they are deviating from evidence-based guidelines, it also tracks how much blood each provider uses. “Provider report cards are given to each service, showing specific provider transfusion rates in comparison to his or her peers,” explains Nelson.

The program includes a comprehensive education program aimed at bringing both nurses and physicians up to speed on the latest blood transfusion recommendations, as well as steps that can be taken to reduce the need for blood. For example, patients are checked for anemia prior to elective surgeries so that they can be treated for the condition beforehand, thereby reducing the need for transfusions.

The hospital has also taken steps to reduce the amount of blood that is drawn for laboratory tests, and to limit the number of repeat transfusions that physicians can order for a specific patient without testing to make sure the added blood is necessary.

The results of the program have been dramatic. The hospital now gives blood to just over half as many patients as it used to, and it has reportedly saved more than $5 million in blood costs without any added risks to patients.

Reference

  1. Frank S, Savage W, Rothschild J, et al. Variability in blood and blood component utilization as assessed by an anesthesia information management system. Anesthesiology 2012;117: 99-106.
  2. Yazer M, Waters J. How do I implement a hospital-based blood management program? Transfusion 2012;52: 1640-1645.

Sources

  • Steven Frank, MD, Director, Perioperative Blood Management Services, Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, MD. E-mail: sfrank3@jhmi.edu.
  • Tiffany Nelson, RN, BSN, Coordinator, Patient Blood Management Program, Eastern Maine Medical Center, Bangor, ME. E-mail: tnelson@emh.org.

The Joint Commission, AMA seek to raise awareness of five treatments that are overused

Treatments can be life-saving, but they also often come along with risks, not to mention costs, so it is important to make sure providers only prescribe tests, procedures, or medicines when they are indicated, based on evidence-based guidelines. In fact, this issue is so important that the American Medical Association’s Physician consortium for Performance improvement (PcPi) and The Joint Commission co-sponsored the National Summit on Overuse to discuss methods for improving both the quality and safety of patient care.

The meeting, which was held on September 24, 2012, in chicago, iL, included representatives from physician organizations, medical specialties, government agencies, research institutions, and patient groups to build consensus on ways to minimize the overuse of five treatments that are commonly used, but not always necessary, including:

  • heart vessel stents;
  • blood transfusions;
  • ear tubes for brief periods of fluid behind the eardrum;
  • antibiotics for viral upper respiratory infections; and
  • early scheduled births without medical need.

During the summit, participants reviewed the existing literature about the five treatments, and discussed ways to raise awareness about their overuse among both health professionals and patients. they also developed recommendations for improving appropriate use of the treatments and minimizing the potential risk to patients. these included the creation of educational tools, the dissemination of leading practices, standardized reporting of data, and better alignment of existing guidelines.

Mark Chassin, MD, FACP, MPP, MPH, president, The Joint Commission, noted that the overuse of medical tests, treatments, and procedures is a serious quality and patient safety concern. “Our aim is to help improve safety for patients by raising awareness about the inappropriate indications for these procedures and treatments,” he says. “Widespread and effective dissemination of this important information will help physicians and patients make informed decisions and avoid overuse.”

Excerpts from the conference are available at www.jointcommission.org/podcast.aspx?categoryiD=12&F_aLL=y.