Amid rising blood costs and mounting safety concerns about transfusions, hospitals are adopting stricter measures to manage their blood supplies.A growing number of hospitals are developing guidelines for when transfusions are necessary, and they are making sure doctors are in compliance. Institutions also are increasingly checking patients for anemia before surgery and treating them with iron or red-blood-cell-boosting drugs to cut down on transfusions in the operating room.
A machine that recirculates blood during surgery reduces the need for transfusions.
Patients are feeling the impact. Some hospitals are eliminating the practice of having patients donate their own blood weeks before surgery, which can trigger anemia. Instead, they are recycling patients' own blood by collecting it in the operating room for immediate re-infusion during or after surgery. And in intensive-care units, nurses are sharply reducing the amount of blood they draw daily from patients for testing, which can make patients so anemic they require a transfusion.
Mike Witka, a financial consultant for the Roman Catholic archdiocese in Indianapolis, hoped to avoid a blood transfusion during surgery to replace both his knees last year. His orthopedic surgeon at St. Vincent Indianapolis Hospital, Jeffery Pierson, prescribed the drug Procrit to treat a mild case of anemia before surgery. During the operation, Dr. Pierson collected Mr. Witka's own blood so it could be re-infused into the patient. "I was pretty leery of getting a blood transfusion with all the horror stories you hear from hospitals," says Mr. Witka. "This seemed like a common-sense approach."
"Doctors have traditionally thought blood was absolutely safe, and don't see why they should withhold it from patients. But the modern view is that when we give blood unnecessarily we cause measurable harm to patients," says Timothy Hannon, medical director of the blood-management program at St. Vincent Indianapolis, owned by Ascension Health. "We have to be sure we are giving the right dose of blood to the right patient at the right time, and make much smarter use of blood products."
To be sure, blood transfusions save lives in surgery and trauma cases and help cancer patients recover from the ravages of chemotherapy. Hospitals say the new blood-management programs won't reject requests for blood if the doctor's medical judgment says it is necessary. Instead, the programs aim to make doctors stop and think about whether a transfusion is medically appropriate.
The nonprofit Joint Commission, the leading hospital-accreditation group, assembled a task force of blood-management experts. The group has developed a 19-point program that the Commission may adopt to help hospitals determine if they are properly managing their blood supplies and safely administering blood to patients. Meanwhile, the Society for the Advancement of Blood Management, a professional group, is launching an awareness campaign for medical professionals and consumers next week. It has a brochure (available at www.sabm.org) with questions patients should ask before agreeing to a transfusion, including what risks are involved and what options are available to minimize blood loss during surgery.
The cost of a unit of blood has more than doubled over the past decade, and hospitals spend an estimated $25 billion to buy, process and transfuse about 30 million units a year. Safety also is an issue: A growing body of evidence shows that donated blood causes changes in the recipient's immune system that result in higher rates of infections, complications and even death. A study published Tuesday in the journal Chest found that blood stored for 29 days or more, nearly two weeks less than the current standard for blood storage, is associated with a higher infection rate in patients receiving transfusions with the blood. Other risks: mislabeled specimens and the possible bacterial contamination of stored blood.
AIDS Fears Abate
Two decades ago, doctors were reluctant to give transfusions because of the threat of contracting viruses such as AIDS and hepatitis C. Since then, tighter screening has reduced infectious-disease threats, and doctors have become more liberal in their use of donated blood on the assumption that it can't hurt, and might help patients.
But as new concerns emerged in recent years about complications from donated blood, medical groups sought to limit the use of transfusions. These efforts have had limited success, partly because hospitals weren't enforcing the measures. Doctors themselves often aren't aware of the guidelines or ignore them in favor of their own prescribing habits, and hospital staff aren't always trained to recognize signs of complications from donated blood, medical experts say.
"It used to be if a doctor ordered blood in the hospital we would just give it to him," says Michael Waldrum, chief executive of University of Alabama at Birmingham Hospital. "Now we have systems in place to make them justify their access to blood."
Dr. Waldrum says the 1,000-bed hospital cut the demand on its blood supply by 11% since adopting last year a pilot blood-management program sponsored by the Red Cross. He says the hospital noticed wide variation in the blood-prescribing habits of its doctors. It conducted educational sessions on strategies to reduce use, such as checking hemoglobin levels to make sure a transfusion is necessary and drawing less blood from ICU patients.
The Red Cross, which supplies about half the blood to American hospitals, is offering 100 hospital clients the services of Strategic Healthcare Group, a blood-management consulting firm founded by St. Vincent's Dr. Hannon. "Blood management is a win-win for everyone because it focuses hospitals on providing better patient care while conserving a precious resource," says Richard Benjamin, Red Cross chief medical officer.
St. Vincent, which has had a blood-management program in place since 2001, has cut its rate of hospital transfusions since that time by over 30%, resulting in savings of more than $4 million a year.
Baylor University Medical Center at Dallas has gradually reduced the use of almost all blood donated by patients prior to their having joint surgery. A high percentage of this blood ended up being thrown away because it wasn't needed, says David J. Ballard, chief quality officer at Baylor and a co-chairman of the Joint Commission task force. At the same time, patients who pre-donated their own blood sometimes became anemic, and later needed not only their own blood but transfusions of additional units of donor blood. Instead, the hospital has increased the practice of recycling a patient's own blood during surgery.
Fewer Donors
Blood conservation isn't a new idea -- it has been used to avoid massive transfusions in cardiac-surgery patients and in military field hospitals for years. "Bloodless surgery" programs were developed in the 1970s for some religious groups who shun donated blood.
The latest efforts to manage blood supplies come amid a shrinking pool of potential donors. Tighter screening for infectious disease and other potential complications have reduced the donor pool to about 37% of Americans, a study last year showed. That's down sharply from the more than 60% long considered the level of potential donors. The American Association of Blood Banks, which says only about 10% of the population donates blood at any one time, warns that new donor restrictions and an aging population could further narrow the number of donors.
Blood Use Declines
The University of Pittsburgh Medical Center, which has 16 hospitals in Western Pennsylvania and spends about $122 million a year on its blood labs, began a program to lower blood use at its flagship Presbyterian Hospital in 2002. By 2005 the amount of blood provided per hospital admission dropped by 18%, resulting in savings of about $1.8 million a year, says Ed Corona, corporate director of laboratory services. He says the program is being adopted system-wide.
Jonathan Waters, head of the UPMC's blood-management program and another co-chairman of the Joint Commission task force, says doctors sometimes fail to evaluate patients before surgery to detect any pre-operative anemia that could be treated with drugs or intravenous iron. He says about half of elderly joint-replacement patients are anemic and need a blood transfusion. "It's very simple to check a patient's hemoglobin level when they are scheduling surgery, but often surgeons don't do it," Dr. Waters says. "It requires a paradigm shift in how we practice medicine." Hemoglobin is responsible for transporting oxygen to organs.
