Once thought of as a way to treat Jehovah's Witnesses, whose religious beliefs don't allow transfusions, blood management programs are growing in number and scope in U.S. hospitals.
Sherri Ozawa, R.N., clinical director of the Institute for Patient Blood Management at Englewood (N.J.) Hospital and Medical Center, put the current number at about 100, although she adds that without established national criteria on what qualifies as a blood management program, the exact number is hard to pinpoint.
"I'm aware of about 100 active programs and I'm aware of at least a couple hundred more in development," says Ozawa, also a board member for the Society for the Advancement of Blood Management. In 1994, when Englewood's program began, there were fewer than 10 programs, she says.
The programs have evolved from a way to treat a small subset of the population for whom transfusions aren't an option to a way for hospitals to evaluate what they're spending on blood, examine outcomes after transfusions and explore whether some transfusions are unnecessary.
Benefits beyond reducing the cost of blood
What's widely agreed upon is that the programs can save money. The cost of a red blood cell transfusion, when you include such factors as obtaining consent, screening, lab work, education and treating short-term side effects, can be $522 to $1,183 per unit, according to a study published in the April 2010 issue of the journal Transfusion. Considering that about 15 million units of red cells are transfused every year in the United States, according to the AABB (formerly the American Association of Blood Banks), costs mount quickly.
Of those 15 million units, "90 percent-plus are given to stable, non-bleeding patients," Ozawa says.
That's where limiting transfusions achieves the biggest clinical and financial gains — not from the gunshots or car accidents. "Most [blood] is given in predicted, elective or nonemergency situations," she says.
At MedStar Georgetown University Hospital, which brought the first blood management program to the Washington, D.C., area in January 2011, orthopedic surgeon Mark Zawadsky, M.D., says reducing the number of transfusions can mean significant savings.
Georgetown had averaged about 1,200 units of blood a month. "If you look at even a 10 percent reduction, ... it's about $750,000 a year they end up saving," he notes.
But beyond the financial benefits, reducing the number of transfusions is just good medicine, proponents say. Englewood has gained an international reputation for being the pioneer in offering surgeries without transfusions as the standard of care for all patients.
Studies show that clinical benefits include shorter length of stay, faster wound healing, fewer readmissions and lower infection rates.
Those who cite risks involved with transfusion aren't questioning the overall safety of the blood supply. By all accounts it is safer than ever. But there are risks any time blood is transfused, during and after surgery. The number of adverse effects from transfusions — complications requiring any therapeutic or diagnostic intervention — was 60,110, or 1 in 394 transfusions for 2009, the most recent data available from the National Blood Collection and Utilization Survey.
Techniques can be used on most patients
Georgetown's program initially answered a need because there was a large population of Jehovah's Witnesses requesting bloodless surgery and that option wasn't available in the D.C. area. The program has expanded to a wider population, and Zawadsky says about 10 percent of the patients requesting bloodless surgeries are outside the Witness community.
Blood management at Georgetown and in other programs comes in three parts: before, during and after surgery. Iron supplements and bone marrow stimulation help beef up the body's production of red blood cells. Blood collection is minimized by taking the smallest amount possible to get lab results. Body temperature is held steady and blood pressure lowered to reduce blood flow. Fluid can be injected into the blood to dilute it and minimize red cell loss. After surgery, medications can help blood clot and increase blood volume.
"What we're finding is that all of those principles apply to the general population as well. ... You use a lot of these same techniques across the board on most patients," Zawadsky says.
Being overly aggressive with transfusions has created other problems, Zawadsky says, such as fluid overload, cardiac failure and higher infection rates.
In addition, a patient's immune system seems to be dampened down with introduction to foreign blood cells. "It's not an allergic reaction, but it does have an effect on a patient's ability to fight off infection," he says.
Blood management has attracted the attention of the Joint Commission and AABB, the association for advancing transfusions and cellular therapies. The Joint Commission developed a list of patient blood management performance measures, which are available in the organization's reserve library.
AABB published transfusion guidelines in March in the Annals of Internal Medicine noting that doctors aren't consistent when deciding when to transfuse. Among other recommendations, AABB recommended lowering the hemoglobin level, which typically triggers a decision to transfuse to 7 to 8 g/dl instead of 10 g/dl in stable patients.
Jonathan Waters, M.D., chief and professor of anesthesiology at Ma-gee-Womens Hospital of the University of Pittsburgh Medical Center, says uniform guidelines are key as more hospitals consider blood management. Even within the same hospital system, he says, doctors have widely varied practices on transfusion.
At the University of Pittsburgh, "we have about 40 surgeons who do total hip replacements, but the range of transfusions between surgeons ranges from one surgeon who transfuses none of his patients to a different surgeon who transfuses 90 percent of his patients."
The hospital has a six-point blood management plan and the No. 1 item in the plan is to get better compliance with evidence-based transfusion guidelines, Waters says.
What keeps hospitals from doing this?
If there's wide agreement that blood management programs help hospitals evaluate how they use blood, why aren't more of the nation's 5,700 hospitals starting them? Inertia and inconvenience are two big reasons, Waters says. "Medicine is fairly entrenched in tradition. We tend to do things the way we were taught."
It also adds time for the medical staff in making sure a patient is not anemic before surgery, he adds.
"A lot of people don't want to take that time," Waters says. "It's a big mindset change to say why is that patient anemic?" Fixing the mechanism that made the patient anemic takes longer and many hospitals really don't have the systems in place to investigate the problem."
Richard Benjamin, M.D., chief medical officer of the American Red Cross, says he agrees there's reluctance to change long-standing medical tradition when it comes to restricting transfusions. He's also not convinced blood management programs save money.
To do them properly, he says, hospitals may need to purchase an IT system that can crunch the data and tell administrators who is using the blood and whether the use is appropriate.
Hospitals also need to add anemia clinics, he says, and even if they are willing to spend the money, the decision to start blood management can take years.
However, Benjamin says, the reason to start a blood management program should not be based on the bottom line or fear that blood isn't safe. Blood used incorrectly can harm, and blood used correctly can be life-saving, he stresses, and starting a blood management program just to save money is a dangerous approach.
"There are consultants out there who go to hospitals and say you should be doing patient blood management because it will save you money. Or you should be doing patient blood management because blood is bad, dangerous and kills patients. I don't subscribe to either of those," Benjamin says. "If you do this properly, you can conserve resources, you can treat patients better, the outcomes are likely to be better.
— Marcia Frellick is a freelance writer living in Chicago.
Techniques and medications before, during and after surgery can reduce blood loss and the need for transfusion. Here are some typical techniques doctors in these programs use:
- Managing diet: Patients are instructed to eat foods high in iron with supplements to help absorb the iron.
- Introducing hematopoietic agents: Patients take iron supplements and other medications to boost red blood cell production.
- Microsampling: Staff take the smallest amount of blood possible to get lab results and group blood draws together.
- Keeping body temperature normal: When patients have a below-normal body temperature, they are more likely to lose blood.
- Keeping blood pressure low: Hypotensive anesthesia lowers blood pressure, which results in slower blood loss.
- Using "cell-saver" machines: The patient's own blood lost in surgery can be captured, cleaned and returned to the body.
- Using Harmonic scalpel: This tool uses vibration and friction to cut and cause clotting at virtually the same time.
- Using "closed system hemodilution": Blood is drawn, and in its place the patient gets an equal amount of intravenous fluid. This way, the volume is the same, but the blood lost in surgery is less concentrated. At the end of the surgery, the more concentrated blood is returned to the patient's body.
- Prescribing blood builders: Doctors may prescribe medications to increase blood volume and red blood cell production.
- Using hyperbaric oxygen chamber: This technology may be used to maintain blood oxygen levels.