This article appears in the March 2013 issue of HealthLeaders magazine.
What simple shift in acute care practice can reduce patients' adverse events, cut lengths of stay, drop hospital costs by millions of dollars a year, and even prevent mortality? Not to mention save a precious human resource that may become more scarce within the next decade?
Look no further than patient blood management and a significant shift in blood transfusion service operations.
By reducing the point at which doctors initiate transfusion, called the hemoglobin trigger, from 8 g/dl to 7 in stable medical or surgical patients, and by not transfusing patients who don't really require it or not transfusing more than needed, healthcare leaders are finding significant savings without any negative effect on patient outcomes.
"Here we are, almost seven years down the road from our base year in 2006, and we're now spending half as much on blood acquisition, even though our patient volume and our patient acuity have increased," says Irwin Gross, MD, medical director of transfusion services and patient blood management at 411-bed Eastern Maine Medical Center in Bangor.
The 58% reduction in units purchased means that instead of $3.5 million a year, the hospital and its Level II trauma center serving 400,000 people as far as the Canadian border, spends only $1.6 million buying blood. Since 2006, Gross says, the hospital has spent $8 million less on blood acquisition, and that doesn't count the associated expenses of typing and cross-matching products inside the hospital.
Those savings also don't include the avoided costs of caring for patients with potentially fatal adverse outcomes resulting from transfusions, such as transfusion-related acute lung injury, transfusion-associated circulatory overload, or hemolysis. Gross estimates the cumulative risk of such events is at least 1% of patients who receive a transfusion.
"What we do know is that when we transfuse less, lengths of stay go down, hospital-acquired infection rates go down," Gross says. "Cases of new onset of acute renal failure and peri-surgical acute myocardial infarction rates are lower now that we have patient blood management."
These PBM savings are especially notable given that EMMC's pretransfusion hemoglobin trigger points were already comparatively low, an average of 8 g/dl, Gross says, "quite conservative relative to what others were doing; we didn't think we were overtransfusing."
"I think what's going to happen fairly soon is that the rest of the country is going to catch on," he says.
Gross, former president of the EMMC medical staff, recognized the problem while reading peer-reviewed studies showing "that risks of transfusion had been underestimated, underreported, and underrecognized, and that the evidence for benefit, except in settings of acute blood loss, really wasn't there. We had misinterpreted the literature." Yet the practice persisted throughout the country from a time "when a hemoglobin of 10 g/dl was felt to be an appropriate transfusion trigger."
Changing the transfusion mind-set, he says, was much more than just telling doctors to hold back before deciding to transfuse. "It was also about working across disciplines to make sure patients rarely get into a situation where they need to be considered for a transfusion—even something as seemingly insignificant as minimizing phlebotomy blood loss for lab testing" when it isn't really necessary.
What is increasingly clear is how variable each hospital's blood transfusion practices are, even down to each surgeon, regardless of specialty.
Healthcare improvement alliance Premier last year announced an analysis of blood use variation among 464 hospitals. It found that if all 464 had implemented blood protocols similar to those in the top performing 25%, the bottom 75% could save 802,000 units and $165 million could be saved a year without a decline in patient outcomes.
Executives with both the AABB and America's Blood Centers, which represent blood banks and transfusion professionals, agree that too much blood is wasted.
"Doctors often give patients blood just because they look a little anemic in the belief that if they 'pink up,' they'll do better," says Jim MacPherson, CEO of America's Blood Centers, whose members operate 600 donor centers for 3,500 North American hospitals. Unnecessary use, he says, is estimated to be between 10% and 50%. "Easily it's 10%, and probably closer to 20%."
Blood is getting so tough for blood banks to collect and hospitals to process that "we see disaster coming in a few years in terms of our ability to supply blood," says MacPherson. First, as people age, their medical conditions or medications, such as blood thinners, may disqualify them from donating. "In the mid-'90s, 60% of the U.S. population was eligible to be a donor, but today that's less than 40%," he says.
Demand is increasing because there are more uses for blood products. And as more people receive insurance coverage starting next year, more will be eligible for procedures, such as hip and knee replacements, that use more blood.
James AuBuchon, MD, CEO of the Puget Sound Blood Center and an AABB past president, points out that "most physicians have had incredibly poor, insufficient training in transfusion medicine." That's because until relatively recently there's been a lack of evidence-based safe protocols in blood transfusion. The AABB published its Red Blood Cell Transfusion: A Clinical Practice Guideline in the March 2012 issue of the Annals of Internal Medicine, recommending a "restrictive transfusion strategy" of 7-8 g/dl in stable patients.
A lurking, highly controversial issue in recent publications suggests that transfused patients mysteriously have poorer outcomes than similar groups of patients who don't get blood. There may be something else going on when blood from one person courses through another person's body.
"That's been a very difficult subject to wrestle across the goal line of truth, because patients who need transfusions are usually sicker," AuBuchon says. "Whether transfusion is causing a poorer outcome is unknown. But there is certainly concern that maybe there is a causal link." It may be, he adds, that older units of blood cause poorer outcomes than fresher ones. Federally funded studies are under way.
Across the country, some hospitals are showing how it can be done.
At 700-bed Texas Health Harris Methodist Hospital in Fort Worth, Laboratory Medical Director Patricia Fenderson, MD, PhD, says the hospital has saved increasing amounts every year since 2007, when she realized doctors were often transfusing patients at hemoglobin levels of 9 g/dl or higher. Now she's gotten doctors to hold back.
"In the fourth quarter of 2007, we had 400 episodes of transfusions in patients with a hemoglobin of greater than or equal to 9 g/dl, but in the third quarter of this year, there were just slightly over 100, and most of those were done because the patients were actively bleeding."
Joseph Prosser, MD, Texas Health Harris Methodist's chief medical officer, credits Fenderson for "determining that our blood usage seemed to be outside of national standards ... particularly on elective orthopedic cases."
The savings, they say, are probably much greater than the cost of the blood itself. The complex process of typing, cross-matching, and administering the blood within the hospital raises costs from about $200 paid to the blood bank to more than $1,000.
"More importantly, blood is dangerous if used inappropriately. It's an immune modulator, it increases the risk of infection, it can cause transfusion-related acute lung injuries, and certainly has historically transmitted other diseases," Prosser says.
"We've really had a tremendous improvement in the awareness and respect for use of blood at this hospital," he adds. "Every unit you don't transfuse when it's not needed protects the patient."
Fenderson says her strategy was to just show doctors how their ordering practices varied. She'd patiently explain that times had changed from when more blood was considered better. It wasn't always easy getting physicians to change their practice, she says.
"To say the least, I had some not too pleasant phone calls a few times. They would say, 'Who are you to question my ordering practices?' I tried to explain blood transfusions are really just liquid organ transplants, and just as you wouldn't perform a solid organ transplant because 'it wouldn't hurt,' you shouldn't be transfusing patients, especially when the benefits don't outweigh the risks."
Michael Handler, MD, vice president of medical affairs and chief medical officer for 122-bed SSM St. Joseph Hospital West in Lake St. Louis, Mo., one of seven SSM network hospitals, says the facility started monitoring blood usage in 2004, specifically looking at patients and anemia in two ways.
First, he says, presurgical autologous blood donations were actually making patients anemic and more at risk of needing a blood transfusion during their surgery because they didn't have a chance to build up their own.
"We ended up wasting a lot of product," he says.
They also looked more carefully at patient blood levels prior to surgery in case they were anemic. In addition, the hospital reduced the amount of blood kept on hand because many units that had expired use dates had to be destroyed.
SSM formed a task force across the six-hospital network and focused on physicians' use of blood during cardiac, bowel, and orthopedic surgeries and gastrointestinal hemorrhage, and tried to reduce "massive transfusions."
"We look for patterns, anything that looks inappropriate," Handler says.
The bottom line, he says, is that "we've reduced our costs by 33% since 2004," from $10 for blood per patient day to $6.78, or more than $1.4 million between 2005 and 2011, "even with increases in blood product costs."
"Bargains like this don't come along every day," says the AABB's AuBuchon. "Healthcare executives have a wonderful opportunity to improve patient care and reduce their costs simultaneously" with better management of a therapy that is precious and very expensive.
Reprint HLR0313-9
This article appears in the March 2013 issue of HealthLeaders magazine.