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Less Blood Testing for Some Surgeries Safe, Cost Effective

 |  By cclark@healthleadersmedia.com  
   May 23, 2013

The ordering and testing of blood for surgery that rarely requires blood transfusions is expensive and "overutilized" by hospitals, researchers say. At Johns Hopkins alone, more appropriate blood ordering practices could save $200,000 a year.



Photo: montuno cc-by-sa-2.0

For hospitals looking to lower costs anywhere they can, Johns Hopkins researchers have identified a longstanding procedure worthy of a closer look: the unnecessary crossing and typing of blood for surgeries that almost never require transfusions.

"A lot of effort in transfusion medicine has gone toward understanding the transfusion itself and controlling the use of transfused blood," says Steven Frank, MD, associate professor of anesthesiology and critical care medicine at Johns Hopkins Medical Institutions. "But our new paper focuses on the ordering and testing of blood, which is expensive and time consuming and which we think is overutilized, especially for these cases that are rarely if ever transfused."

In fact, he adds, "there's a lot of unnecessary blood ordering for (surgery) cases." At Johns Hopkins alone, more appropriate blood ordering practices could save $200,000 a year, as well as improve patient safety, he says.

For example, Johns Hopkins can save $47 for a type and screen and $52 for a type and cross per unit, often done multiple times for the same unit when it is ordered but not used for a variety of patients.

"And while that may be a small fraction of the hospital's costs, in this day—when we're looking to get the most value from our healthcare system—we're looking at cost-benefits and every penny counts," says Frank, lead author of the paper with colleagues at Johns Hopkins and Brigham and Women's Hospital, in this week's issue of the journal Anesthesiology.

Frank's project used electronic records to examine blood utilization data for 53,526 patients who underwent 1,632 procedures at Johns Hopkins between January, 2010 and March, 2012. The algorithm has not yet been tested in clinical practice yet, however.

The team first looked at those cases that had a type and screen and/or a type and cross for donated units, and then calculated how many times the patients those units were prepared for actually required a transfusion.

Take, for example, thyroid surgeries. According to the "unique" algorithm Frank and his colleagues developed, only two in 1,000 such procedures at Johns Hopkins required the use of blood. Even in those few cases, no patient would die on the table for lack of blood because so called "emergency release" type O blood can be used instead.

Rarely, however, a patient transfused with O blood develops an adverse reaction. But that only happens in about one per thousand cases of emergency release units transfused. "This type of reaction is usually mild, slower in onset (4-21 days), associated with a mild increase in bilirubin, and often [goes] undetected," the authors said in the article.

Frank says that other hospitals—especially those that don't have electronic anesthesia record systems yet—can customize the Johns Hopkins algorithm to determine the likelihood any particular procedure within their own organization might require blood, and plan more appropriately, even to particular surgeons' practices and history.

Johns Hopkins was able to do this, he says, because three years ago it installed an AIMS, or Anesthesiology Information Management System, that computerizes anesthesia medical records.

"We gave up paper records, and since we did, we've been able to track blood utilization more accurately and easily for every single patient and procedure and their blood requirements, and also whether the blood was ordered for that case or not," he says.

"Unless you have the data, you don't know. You might think transfusion is rare, but how rare? These computerized records have given us the real numbers."

Half of the hospitals in the United States still do their anesthesia records on paper, he notes.

At Johns Hopkins, it wasn't that much of a surprise that blood was ordered but rarely used for thyroid surgeries. But the data on transfusion frequency for other types of procedures revealed unexpected information. For example, surgeries involving the breast, such as lumpectomy or mastectomy, require a transfusion in only one per 1,000 cases.

Frank, whose paper in March documented how blood units that stay in inventory between 21 and the maximum shelf life of 42 days is less viable and may be unsafe compared to blood used in the first three weeks, says there's another cost of ordering units of blood that aren't needed his paper didn't include. And that's inefficiency of moving units of blood in and out of inventory.

"Let's say units of blood are taken out of inventory today for 24 hours (for testing for use in a patient) but not used, then two days later, and then two days after that. That blood is aging on the shelf, set aside and when it finally does get used, it's been stored for more than three weeks. We think by then the quality of red cells is decreased," because they lose the ability to deliver oxygen.

Frank says it's not just avoiding unnecessary ordering of blood typing and crossing that the Johns Hopkins algorithm might help, but also in making sure that enough blood is ordered when it should be, and not overlooked—an important patient safety issue, he says.

Alparslan Turan, M.D. of the Cleveland Clinic and others wrote in an accompanying editorial that the algorithm is "a novel and largely objective method for determining operation and institution-specific maximum blood order guidelines, that is recommendations for type-and-screen or the crossmatching of units for particular procedure classes."

They raised the question, however, of effectiveness. "How effective it is in clinical practice remains to be described. We hope these investigators will later report how difficult it was to implement their system, how well it worked in practice, and the resulting cost savings."

Asked if he thinks hospitals will not make the effort because the dollars might not seem that large, Frank says that once the hospital sees the waste and inefficiency, it will move fast to change practice.

"What will happen is that hospitals [and their labs] will focus on necessary blood orders and get then done faster. Right now, unnecessary orders are not triaged, so you may have a blood order for an aortic aneurysm that definitely needs blood, but it's waiting behind three thyroidectomies and delays the preparation because the bank staff is overwhelmed with these unnecessary blood orders."

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