Improve patient outcomes, conserve health care resources and
reduce unnecessary health care cost. These are key goals of every
hospital administrator. “Patient blood management” is a highly
effective strategy to achieve these goals. Appropriate patient
blood management is a responsibility that requires strong
administrative leadership and commitment.
Approximately 16 million units of blood are donated each year in
the United States.(1) Less than 5 percent of the population
donates blood and the donor pool is shrinking causing at least
sporadic blood shortages. Many blood centers carry a three-day or
less inventory of blood. A recent International Consensus
Conference on Transfusion Outcomes (ICCTO) concluded that a
minimum of 40 percent, possibly as high as 60 percent, of all
transfusions are administered to stable non-bleeding patients and
90 percent of blood is given because of a low red cell count
without any significant symptoms.(2)
Improving Patient Outcomes
Clinical outcomes are better or unchanged when patients receive
fewer blood transfusions. A PubMed literature search produced
roughly 200 articles between April 2006 and April 2008 that
demonstrated improved patient outcomes when blood transfusion is
restricted. The ABC Trial(3) and the Transfusion Requirements In
Critical Care (TRICC) Trial(4) demonstrated lower infection
rates, lower mortality and shorter hospital stays associated with
reduced transfusion. Recent studies evaluating cardiac surgery
have linked transfusion to increased mortality, post-operative
infections, ischemic events (myocardial infarction, stroke and
renal complications), increased ICU and increased hospital length
of stay. These studies have also shown a blood dose-response
relationship linking increased blood exposure with adverse
Restrictive blood practices conflict with our general perception
that “Blood Saves Lives.” An editorial by Drs. Howard Corwin and
Jeffrey Carson states “Red cell transfusion should no longer be
regarded (by physicians) as ‘may help, will not hurt.’”(7)
Strategies to Reduce Transfusion
There are three strategies to improve transfusion practices:
Start with more blood; lose less blood; and salvage lost blood.
Patients can start with more blood by reducing anemia prior to
elective surgery through implementation of anemia clinics to
replete iron and other nutrients and build hemoglobin levels.
Lose-less strategies incorporate hemodilution and meticulous
control of patient bleeding, a relatively time-consuming activity
with high patient safety and financial benefits. Cell salvage may
return reclaimed lost blood to effectively reduce transfusion
requirements. These strategies are most effective when
coordinated by a blood conservation program that includes a
thoughtful team approach by physicians.
Administrative commitment to patient blood management is critical
to success. Leadership is required to bring about planning and
cooperation among physicians, nurses, pharmacy, laboratory,
surgical services and blood bank. Leadership will be required to
build physician champions, promote physician education and change
transfusion practice. Rational budgeting of modest upfront
expense is needed to reap nearly immediate hospital cost savings.
For instance, one unit of medically unnecessary blood likely
costs the institution $1,500 per unit not just for processing and
nursing administration, but for costs associated with treating
avoidable complications and increased hospital length of stay.
Effective blood management likely can reduce $3,000 in
unnecessary expense from each patient receiving blood.(8)
A successful blood conservation program will effectively
coordinate care and develop specific roles for hematologists,
surgeons, anesthesiologists, hospitalists, transfusion directors
and blood perfusionists. Comprehensive audits of hospital blood
use, funded by cost savings, are essential to measure the
effectiveness of improved transfusion protocols. Blood-use audits
should be objective to eliminate reviewer bias, standardized to
ensure that every chart, every physician and every hospital is
evaluated in similar fashion and uses comprehensive chart
Patient blood management is an evolving, dynamic medical
discipline. Reducing blood use cannot only dramatically improve
patient care and safety, but will substantially reduce hospital
length of stay and health care costs. Bloodless sprouting across
the country to meet patient desires for fewer blood transfusions,
better care and lower health care costs. Not only are centers of
bloodless medicine and bloodless surgery operating within
hospitals, but bloodless hospitals are now being established. In
2002, the Society for the
Advancement of Blood Management (SABM) was founded to
facilitate research, improve general awareness about modern
transfusion and blood conservation principles, and improve
transfusion practices in hopes of dramatically reducing or even
eliminating future blood transfusions. SABM is a resource for
hospitals wishing to improve bloodless patient care.
1. U.S. Dept of Health & Human Services. The 2007 Nationwide
Blood Collection and Utilization report.
2. Shander A, Fink A, Javidroozi M, et al. Appropriateness of
Allogeneic Red Blood Cell Transfusion: The International
Consensus Conference on Transfusion Outcomes. Transfusion
medicine reviews. 2011.
3. Vincent JL, Baron J-F, Reinhart K, et al. Anemia and blood
transfusion in critically ill patients. JAMA : the journal of
the American Medical Association. 2002;288(12):1499-507.
4. Hébert PC, Wells G, Blajchman MA, et al. A multicenter,
randomized, controlled clinical trial of transfusion requirements
in critical care. Transfusion Requirements in Critical Care
Investigators, Canadian Critical Care Trials Group. The New
England journal of medicine. 1999;340(6):409-17.
5. Koch CG, Li L, Duncan AI, et al. Morbidity and mortality risk
associated with red blood cell and blood-component transfusion in
isolated coronary artery bypass grafting. Critical care
6. Murphy GJ, Reeves BC, Rogers CA, et al. Increased mortality,
postoperative morbidity, and cost after red blood cell
transfusion in patients having cardiac surgery.
7. Corwin HL, Carson JL. Blood transfusion — when is more really
less? The New England journal of medicine.
8. Shander A, Hofmann A, Ozawa S, et al. Activity-based costs of
blood transfusions in surgical patients at four hospitals.