Abstract
Background:
Red cell transfusion is the only available therapy for patients with life threatening anemia or hemorrhage. However, it is not risk-free. Complications are both common and potentially severe including infection, volume overload, renal and lung injury, multisystem organ failure, and immunomodulation. Some studies suggest that up to 60% of blood transfusions provide little to no benefit and potential for harm. Each unit is associated with increases in wound complications by 4%, length of stay (LOS) by 1.5 days, and mortality by 0.9% in hospital wide populations, and randomized trials support these estimates. Restrictive red cell transfusion has become vital to minimize patient risks, provide only what the patient needs, and ensures safer transfusion. Medical centers nationwide have begun to adopt restrictive, evidence based guidelines and initiating Patient blood Management (PBM) programs. Our PBM program began in July of 2014 with the primary goal of promoting the optimal use of blood components throughout the medical center.
Methods:
After formalizing our plan and enlisting support from hospital leadership, our medical center contracted with a major consulting and analytics firm specializing in blood management to provide support in establishing a PBM program. Following review and updating our general transfusion guidelines (Table 1) via consultation with specialty practitioners, we began to evaluate all daily transfusion requests for appropriateness utilizing laboratory and clinical data, in concert with educational presentations to our highest use departments. Multimodal education via lectures, transfusion guideline reference cards, newsletters, and just in time instruction and consultation were used to capture different practitioner types and to create a cohesive message. A multidisciplinary Transfusion Safety committee was established to share goals, information and to encourage collaboration.
Following utilization review and benchmarking of our highest use departments we collaboratively developed special transfusion guidelines for select patients. One such group, our outpatient Hematology/Oncology patients, was particularly challenging for guideline development. Their disease process limits treatment options, making transfusion essential for some. Outpatient treatment also poses challenges with monitoring and a variety of social and lifestyle issues, such as resources, travel time and quality of life. In the absence of randomized trial evidence, these issues necessitated a more liberal and broad transfusion guideline (Table 2) while still maintaining the objective of minimum dose for desired benefit. Improved communication and follow through with audits and attendance of Transfusion Medicine representatives at hematology service meetings, as well as extensive transfusion safety education with nursing has enhanced the impact of this initiative.
Results and Discussion:
Our latest data shows that since implementing our PBM program hospital wide blood component expenditures has decreased by 29% with outpatient cancer transfusion expenditures down 14%. Benchmarking data from October 2014-December 2016 improved our ranking from 5th to 50th percentile overall (100 percentile is lowest utilization) with oncology improving from 20th to 56th percentile amongst all hospitals surveyed. Based on National Surgical Quality Improvement Program data this reduction might be expected to mitigate 661 complications, 24,788 patient inpatient days, 149 deaths, and 36,356 nursing hours.
Conclusion:
Blood transfusion is increasingly recognized as carrying frequent and serious risks, and should be utilized as a lifesaving resort. Adherence to more parsimonious transfusion practice improves patient safety, minimizes risks, optimizes clinical outcomes, and reduces costs, although data on outpatients with hematologic diseases is low quality at present.
No relevant conflicts of interest to declare.
This feature is available to Subscribers Only
Sign In or Create an Account Close Modal