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 events.(5,6)
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 analytic techniques.
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 medicine. 2006;34(6):1608-16.
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. Circulation. 2007;116(22):2544-52.
7. Corwin HL, Carson JL. Blood transfusion — when is more really less? The New England journal of medicine. 2007;356(16):1667-9.
8. Shander A, Hofmann A, Ozawa S, et al. Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion. 2010;50(4):753-65.