Improve outcomes, reduce costs with a patient blood management program

A patient blood management (PBM) program can save hospitals money and improve patient outcomes, while reserving blood products for those patients who need them most, providing this and other insights are Patricia Ford, MD and Tammy Germini, MT (ASCP) in a recent webinar. “Business Unusual: Unlocking Strategic Ways to Manage Blood Supply and Improve Patient Care” was hosted by the American College of Healthcare Executives. Dr Ford is clinical professor of medicine at the University of Pennsylvania School of Medicine and medical advisor in comprehensive patient blood management for Accumen. Ms Germini is executive director of health systems operations at Quest Diagnostics.

“In the United States, we're transfusing 21 million blood components to approximately 8 million patients annually,” Germini says, “contributing to $6-7 billion in annual costs,” and those costs are rising rapidly.

According to a study by The Joint Commission, up to 40% of blood transfusions are unnecessary, making red cell transfusion one of the top 5 most overused procedures in hospital medicine. That overuse amounts to $1.9 billion in costs, plus an additional $6.1 billion in avoidable adverse events from the transfusions.

Transfusion “is really a liquid transplant,” says Ford. Adverse events are common, and can include the risk of rebleeding, increased hospital stay, and mortality. All of these can be reduced with an appropriate PBM program. Minimizing transfusion is recommended by over a half dozen medical societies, including the Society of Hospital Medicine and the American Society of Hematology.

One of the foundations of PBM is recognition and prompt treatment of anemia, noted Ford. “This is one of the largest preventable public health and health economic burdens worldwide, and transfusion has always been our default approach.” Anemia is especially common in women, affecting more than one-third of women under age 50. Pre-operative patients with anemia have a higher rate of infection, higher risk of kidney damage, longer hospital stays, and higher mortality. In Ford’s institution, they are developing a pathway to bring all pre-operative patients with anemia to the anemia clinic, “to optimize and improve their condition before they go to surgery.”

Bleeding management is another critical part of PBM. It includes measures to reduce surgical time and improve surgical technique, and possibly the use of prophylactic antifibrinolytics. Point-of-care testing in the operating theater can help determine the cause of any excess bleeding, leading to specific treatment rather than simply increasing transfusion.

There is also an important role for minimizing iatrogenic blood loss through phlebotomy, Dr. Ford says. “Anemia secondary to phlebotomy blood loss accounts for 40% of red blood cell transfusions in the ICU,” a situation that can be addressed through focused attention on reducing blood lost to phlebotomy, such as ordering fewer tests, using pediatric tubes for the draw, and minimizing wastage in a central line.

Education is key for changing institutional behavior, says Dr. Ford. Her team has built into the electronic records system a “stop” to require input of a reason for transfusion when the hemoglobin is above 7 grams per deciliter, the usual ceiling for transfusion. “We will never stop a doctor from ordering a transfusion,” she emphasizes, but the requirement for a reason “makes people really think, ‘Do I need to give this blood transfusion?’” The team saw a decline in transfusion by 10% within 6 months from this simple step. The PBM team also collaborates with surgeons, administrators, and other personnel to promote adoption of policies to further reduce the volume of blood transfused, such as using 1 unit, rather than 2 units, as the default.

Data collection and feedback are also central components of a successful PBM program, Dr. Ford says. “I started out by meeting with our Chiefs, our executives, and our leadership to really get buy-in for this program. And then together we identified what it is that we want from this program.” Together, they quickly recognized that they wanted data analysis, metrics, and benchmarks, “because we want quality improvement.”

In a meta-analysis of 17 studies, researchers found that a PBM program led to a 39% reduction in transfusions, shorter hospital stays, fewer complications, and increased survival. Along with cost savings, “those are the major drivers that lead a hospital or a health system to embark on establishing patient blood management as their standard of care,” Dr. Ford says.