Blood Stewards

The merits of establishing a blood management program

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By establishing a blood management program (BMP), a hospital can reduce costs, use resources more efficiently and improve patient outcomes. Successful BMPs require carefully developed protocols and dissemination of multidisciplinary education to all healthcare professionals who handle blood.

"Those of us who work in regional blood centers or hospital transfusion services need to be stewards of blood. We have to establish and monitor blood usage criteria and auditing trails to prove that blood is not being wasted, and alternatively being used for established evidence-based indications, where available," said Phillip J. DeChristopher, MD, PhD, medical director of transfusion medicine/blood bank/apheresis at Loyola University Health System and professor of pathology and medicine at Loyola University Stritch School of Medicine in Maywood, Ill.

The bottom line of a blood management program is appropriate patient care. To achieve this, DeChristopher suggests following the "rule of rights" or giving a patient the right blood component for the right indication at the right time.

Lowering Costs
Ordering and using less blood decreases a fairly expensive commodity within a healthcare system, explained Jack A. Hager, MS, MT(ASCP), SBB, CEO of American Red Cross National Testing Laboratory in Portland, Ore.; chair of the ASCP Council of Laboratory Professionals; and member of the American Society for Clinical Pathology (ASCP).

With a blood management program, the goal is to give patients no more than what they need. If a patient is symptomatically anemic and may require a red blood cell (RBC) transfusion, then the old standard was to order and administer 2 units of RBCs, DeChristopher explained. Current recommendation is to give 1 unit, then measure the outcome to reassess the patient.

"This approach improves patient care because it avoids donor exposure; reduces the demand for blood within an individual institution; and cuts costs in proportion," DeChristopher said.

To standardize the practice of conserving blood, North Shore-LIJ Health System has developed revised standards of practice for all hospitals and physicians, educated all personnel in transfusion pathways, established prospective monitoring at the time blood is issued and implemented retrospective auditing of blood use. Blood cost and use management initiatives have resulted in a 20% decrease in total blood costs for the health system during the last 4 years.

Wm. Andrew Heaton, MD, senior director of transfusion medicine for North Shore-LIJ Health System, believes physicians need to discuss their plans for blood use with patients so they may partner in reducing blood use. "As a result the transfused product is better customized to patient need, better aligned to patient expectations and results in lower blood use per case treated," said Heaton.

Less blood use also reduces a facility's total laboratory cost. The blood cost per patient at the North Shore-LIJ Health System, for example, decreased by more than 10% during the last 3 years, with the rest of the savings coming from lower costs/unit.

Preventing Adverse Effects
Patients should only receive blood products when they need them, Hager told ADVANCE. Transfusion products, he explained, should be used judiciously because they introduce a variety of potential bacterial/viral diseases and affect homeostasis.

"Although both lifesaving in an emergency and supportive for types of treatment that were not previously possible, there is increasing evidence that transfusion predisposes patients to infections," said Heaton.

These infections may delay a patient's departure from the hospital after therapy. "Less transfusion does appear to translate to shorter hospital stays," he said. "IT and electronic patient charting can help clinicians make informed decisions by tracking a patient's history and symptoms."

Historically, a transfusion was ordered by a physician based on a value from the lab, with less focus on the status of the patient's overall health. The BMP, according to Hager, requires more thoughtful consideration of each individual patient rather than relying on a trigger.

DeChristopher cautions physicians to balance the likely benefits of transfusion with the possible risks. "Both sides of this clinical equation must be known, recognized and taught to all of our healthcare personnel," he said. "Because recipients of blood remain at risk for many adverse effects, blood transfusion should either be avoided, when possible, or minimized to just what is required for appropriate and indicated patient-centered support."

Education & Training
Setting up a blood management program requires significant investment in continuing education initiatives. Nationwide, there is little or no formal transfusion medicine education built into physician medical school curricula, physician training programs, nursing undergraduate or graduate programs and medical technology programs, DeChristopher told ADVANCE.

"Most know-how regarding transfusion including consent issues, indications, quality assurance, recognition and management of adverse effects of transfusion are learned on the job by healthcare personnel," he explained. "As a result, they are not learning enough or learning the wrong lessons, because there remain widespread myths and misunderstandings about blood and transfusion."

To ensure appropriate blood requests, training needs to begin with educating physicians on appropriate blood use by the blood bank experts in the field, Heaton explained. "Transfusion triggers need to be developed and taught to nurses and laboratory technicians so everyone is focused on appropriate requests," said Heaton.

With the advent of BMPs, blood banks have a more collaborative role in assisting physicians in making conscientious choices about blood care, according to Hager. "The blood bank is no longer just a supplier of blood products as it was in the past," he stated. "The blood bank can now be part of the healthcare team."

Rebecca Knutsen is on staff at ADVANCE. Contact: rknutsen@advanceweb.com

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