Blood transfusions are considered a critical part of patient care. The College of American Pathologists estimates that 44,000 units of blood are used every day by hospitals and emergency care centers to treat patients.
Recent evidence-based clinical studies have found that many blood transfusions are unnecessary and can lead to a higher risk of infection, disease, morbidity and mortality. Historically, physicians have transfused when a patient’s hemoglobin concentration level was at 10 grams per deciliter (g/dl). Research now indicates the transfusion threshold may be safely lowered in stable, non-bleeding patients to 7 g/dl or, under certain circumstances, to 8 g/dl. (Normal levels for women are 12–16 g/dl, and 14–18 g/dl for men.)
“The vantage point has always been myopic,” explains Angie Mitchell, former director of Nursing Services for HealthTrust. “If a patient’s hemoglobin level dropped to 10 g/dl, he or she got blood. But we really need to look at the big picture. There are too many risks to a patient’s health to give an unnecessary blood transfusion.”
Today, more hospitals and healthcare systems are making great strides to educate physicians and nurses about the importance of appropriate blood management and blood product utilization at their facilities. Technology is the key to success. Computer-based dashboards, notifications and monitoring systems have helped make the implementation of blood management programs a reality.
HCA HealthONE: Developing a Measurement System
When the clinical team from the Continental Division of HCA—which includes six Denver-area acute care hospitals in the HealthONE system and two acute care hospitals in Wichita, Kansas—first set out to launch a patient blood management initiative in 2012, they were transfusing approximately 9,000 units of blood each quarter.
“New clinical evidence suggested that we could transfuse at lower hemoglobin levels, but we needed to develop a context for appropriate blood use,” explains Rob Campbell, PharmD, vice president of Resource Management at HCA HealthONE. “We knew the first thing we had to do was develop a system to measure excellent care.”
The award-winning HCA Continental Blood Stewardship team compiled evidence and shared it with physicians, and began building stewardship teams at each hospital. Team members developed a Web-based dashboard that monitored transfusions that individual physicians were ordering and implemented lower hemoglobin triggers. Despite adding more trauma centers since 2012, the Continental Division reduced the number of transfusions to approximately 5,000 units per quarter.
“It was eye-opening for everyone to learn that blood could actually harm patients,” Campbell says. “We needed to make sure we used a transfusion only when it was helpful.”
Medical representatives from each facility in the Continental Division attended an educational summit focused on best practices for blood management. There, they found out what was working at other facilities and shared success stories.
“We did this as a team,” says Chief Medical Officer Gary Winfield., M.D. “We wanted to create a firm sense of, ‘We’re in this together.’ ”
Joint Commission Recommendations
In 2011, the Joint Commission released six recommendations for developing appropriate blood management programs.
1 Develop a toolkit of clinical educational materials for physicians. Include the risks and benefits of transfusion and the best practices and guidelines supported by clinical evidence.
2 Expand education on appropriate alternatives to transfusion. Identify subject matter experts to provide guidance
3 Advocate for accountability to organizational standards and periodic assessments.
4 Create a standard for performance metrics and data collection. Measure the transfusion practices of physicians as part of ongoing practice evaluations.
5 Develop an informed consent process for transfusions that communicates the risks and benefits.
6 Identify research priorities to close evidence gaps in what constitutes optimal transfusion practices.
St. David’s South Austin Medical Center: Sharing Data to Compel Change
The Blood Utilization Task Force at St. David’s South Austin Medical Center in Austin, Texas, has seen similar results since starting a blood management initiative in 2011. At launch, 19 percent of transfusions were being performed on inpatients with a hemoglobin concentration level higher than 8 g/dl.
“We compiled a spreadsheet each month and looked at transfusions where hemoglobin concentration levels were 8 g/dl or more,” explains Albert Gros, M.D., chief medical officer at St. David’s South Austin Medical Center. “It contained the names of doctors and their patients’ pre-transfusion hemoglobin level, post-transfusion hemoglobin level and clinical condition. We showed physicians these data at every department meeting.”
The strategy was effective. By December 2012, only 3 percent of transfusions were higher than 8 g/dl. The following month, the task force implemented a new trigger: 7 g/dl of hemoglobin or less. In one year, they again reduced the number of transfusions—this time from 35 percent to 15 percent.
In 2011, when adjusted patient days numbered 94,000, St. David’s South Austin Medical Center transfused about 7,000 units of blood. By the end of 2014, when the tally was 117,000, it transfused only around 4,900 units.
“Our patient load has grown, but the number of units of blood transfused has decreased dramatically,” Gros says. “More important, though, we feel like we’re now delivering better medical care to our patients.”
Trinity Health: Implementing Evidence-based Transfusion Guidelines
The Clinical and Care Optimization teams at Michigan-based Trinity Health started its blood utilization program in late 2014 to unify the use of evidence-based red blood cell transfusions across the system. Driven by clinical data, team leaders standardized evidence-based transfusion guidelines for their system of more than 80 hospitals and 120 continuing care facilities.
“We’ve made an effort to take the most current medical literature and incorporate it into our decision-making process for all of our physicians as they consider red blood cell transfusions for their patients,” explains Robert Moser, M.D., chief of pathology and chief medical informatics officer for Trinity’s St. Francis Medical Center in Trenton, New Jersey.
Modeled after the CPOE Reducing Inappropriate Transfusions (CRIT) Collaborative—a Stanford University-based approach to blood management in pediatrics—the Trinity Health team worked with its IT department to implement a guidance system in the blood ordering process. Trinity Health is now the largest health system represented in the CRIT Collaborative.
“We hardwired those evidence-based transfusion guidelines into our computerized blood ordering set,” says Jeffry Komins, M.D., chief medical officer of the Trinity Health East Group and clinical lead of the multidisciplinary Steering Team. “If a physician were to order blood inappropriately, a screen would pop up to remind that physician of the system’s evidence-based guidelines for blood transfusions.”
The Trinity Health team developed educational tools, posters and presentations about appropriate blood use, and distributed systemwide the most recent medical research and literature addressing the use of blood transfusions in specific medical specialties.
Following this implementation phase, Trinity Health formed a Care Optimization Team, led by Moser. Each Trinity Health hospital has two representatives on the Care Optimization Team, a physician or clinician plus the blood bank supervisor. Hospital representatives meet regularly to discuss the successes and challenges of patient blood management and share best practices.
“We’ve produce a daily, detailed report that covers all the transfusion-ordering practices for every hospital in our system,” Moser explains. “Each morning, I receive several emails with transfusion reports. I can see who has ordered transfusions, why they were ordered, how many units were ordered, whether a patient met the right threshold and any necessary patient identifiers.”
Centura Health: Harnessing Technology
Before becoming chief medical officer of HCA’s Physician Services Group, Christopher Ott, M.D., was chief medical officer of the Mountain and North Denver Operating Group of Centura Health. The blood utilization team at Centura Health implemented a program to help physicians monitor how many transfusions they were ordering.
“Old habits are hard to break,” Ott explains. “If you learned during your training to transfuse at a given level, use blood products in particular ratios and for certain diagnoses, and have done so for years, it can be difficult to adopt a new practice. In order to disrupt reflexive ordering, the IT system is utilized to prompt a consideration of each blood product order and require a reason for transfusing outside of the data-supported range.”
If a physician logs in to the computer ordering system to order red blood cells and the patient doesn’t meet the right threshold, then a notification alerts the physician.
The system helped Centura reduce its overall use of blood products by 40 to 60 percent while significantly decreasing the risk of patient harm, Ott adds.
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