Blood use in hospitals is a high-volume, high-risk, high-cost process that is often not appropriately utilized, says IHI faculty member Timothy Hannon, MD, MBA. In this interview with IHI Communications Specialist Jo Ann Endo, he explains why The Joint Commission, the AMA, the AHA, the Choosing Wisely Campaign, and others have targeted the overuse of blood products as a major issue. Dr. Hannon is Chief Medical Officer of Strategic Healthcare Group and faculty for the IHI Expedition on the Appropriate Use of Blood Products.
Q: Why is it so important to improve the management of blood products?
There are four main points:
- Risk: The most important point to me as a clinician is that blood products usage is very high risk. Although it is a very common procedure, scientific evidence over the last 15 years or so has consistently shown that blood transfusions are less effective and substantially more harmful than previously assumed. We are also increasingly aware of and concerned about what are called non-infectious risks associated with transfusions, including lung injury, immune suppression, renal injury, and volume overload.
- Volume: Blood transfusions are the single highest volume procedure in US health care. According to an AHRQ survey that has been done for the past several years, blood transfusions are the most common procedures performed during hospitalizations. Somewhere between 10 to 20 percent of patients admitted to the hospital will get blood transfusions.
- Cost: Transfusions are very expensive. Transfusions are only about one to two percent of a hospital’s budget, but that only reflects the cost to buy blood from a blood center or the Red Cross. If you include nursing time, laboratory time, supplies, and other factors involved with every transfusion, the costs rise to anywhere between three to five times the cost of buying blood to administer it. Transfusions can also lead to adverse events, including hospital-acquired infections, longer length of stay, etc. and those can substantially add to the costs, making it closer to eight times the cost to buy blood. But the fact that blood is expensive is not by itself a problem; the problem is giving blood that is unnecessary because that means wasting resources.
- Appropriate Use: Blood products are often poorly utilized. A variety of published studies show that easily 30 to 60 percent of transfusions given in the United States are not indicated, not warranted, and not appropriate according to evidence-based transfusion guidance and best practice.
So, if you consider that blood use is high volume, high risk, high cost, and is also poorly utilized, you then see the case for change.
Q: What are some of the benefits of improving blood management?
The most important benefit is that better blood management improves patient safety because when we give blood to patients unnecessarily, we cause avoidable harm. According to published studies, each unit of blood increases wound complications by four percent, increases hospital length of stay by a day and a half, and increases the mortality rate by about 0.9 percent.
For the hospital, another benefit of better blood management is spending less for a number of expensive resources. There is the blood itself, of course. Using only what’s needed translates to substantial costs savings for blood procurement. There is also the cost of nursing time. We free up almost two to two and a half hours of nursing time per transfusion when we stop unnecessary transfusions.
To be clear, we are not talking about rationing blood. This is simply “right patient, right product, right dose, right time.” We can view this like IHI’s 5 Million Lives Campaign. For every 1,000 units of blood that are not used because of safer, more evidence-based practices, we can avoid 40 wound complications, save 1,500 patient days, and save nine lives.
Q: Considering IHI first started working with you on this a few years ago, why do you think there is more interest in this topic now?
In 2013, the Joint Commission and the AMA released specific recommendations for appropriate blood management. Their top five list on overuse included blood. The American Hospital Association’s Appropriate Use of Medical Resources top five list also included blood. A number of medical societies, as part of the American Board of Internal Medicine’s Choosing Wisely Campaign, have included blood in their top five unnecessary procedures, including the Society of Hospital Medicine, the Critical Care Societies Collaborative, the American Society of Anesthesiologists, the American Society of Hematology, and the American Association of Blood Banks. All of these organizations are making this issue more “top of mind” than it was a few years ago.
Also, the number of articles published in a variety of specialty journals that focus on better blood use is increasing. The buzz, so to speak, is definitely greater today than it was three years ago. But more talk is not the goal. The goal is to sustainably change practice to make patient care safer as soon as we possibly can. Increased awareness certainly helps if it means more hospital administrators make this a priority.
Q: Why are these organizations and societies putting the overuse of blood products in their top five lists?
I think they recognize that blood product use is high volume, high risk, high cost, and poorly utilized. If it was just high volume or just high risk, it might not be on so many top five lists. It’s the combination of factors that makes it so important. The other reason is because current blood use practices can and should be modified. My experience over the past 20 years is that practices can be rapidly and sustainably modified to benefit the patient, the hospital, and the community. It’s a win, win, win.
Q: By using blood products appropriately, you decrease the possibility of harm to patients and save money. Would you say more about this convergence of improving care and reducing costs?
I am a physician with an MBA, so I try to understand both sides of the equation. But I really think that cost and quality in the health care space are exactly the same thing. When you do it right the first time, use the best available evidence, work together as a team, and work to eliminate avoidable errors and avoidable harm, you not only improve patient care, but you also lower your costs. Having worked in both the military and a large Catholic hospital, I understand “no margin, no mission.”
Q: I’ve heard you say, “Blood transfusions are essentially organ transplants.” Would you explain what you mean by that?
It’s an attention getter because it certainly sounds odd, but it actually makes perfect sense. Blood is a liquid transplant since we are taking large amounts of foreign cells and foreign proteins and delivering them to a patient, 300 milliliters at a time, directly into their vascular system. More than that, we often give patients multiple transplants during their hospitalization. Whereas patients typically don’t come to the hospital to get multiple organ transplants, we routinely give two, three, or four units of blood which is really two, three, or four donor exposures.
Another consideration for blood transfusions is the mechanism for immune system problems. As we give foreign tissues to a patient – and although blood is cross-matched, typically – it doesn’t really match the hundreds or thousands of foreign antigens and foreign proteins contained in that transfusion. The patient’s immune system recognizes these antigens as foreign and responds to the threat. The more blood a patient gets, the more work the immune system has to do to respond to the increasing immunologic challenge. At some point the immune system simply gets saturated and is unable to deal with further threats, and things like bacteria, viruses, and tumor cells slip through.
Q: What are the main factors that lead to the poor management of blood products?
There is no implication that anyone is willfully or wantonly mismanaging blood products. Poor management of blood products starts with a very basic fact that doctors and nurses aren’t trained in school on how to order or administer blood products. Blood product use is one of the things that slips through the cracks because there is no formal requirement for standardization of the curriculum for blood ordering for physicians or transfusion administration.
Let’s go back to the fact that blood is the single highest volume procedure in US health care. It’s extraordinarily high risk on a good day and very expensive, and it’s a precious resource that is poorly utilized. And the fact remains that doctors and nurses don’t get trained in medical school residency or nursing school to order blood or administer blood. That is certainly problem number one.
Problem number two is that physicians and nurses don’t know what they don’t know. There is the lack of awareness on the part of frontline clinicians. They are ordering and administering blood, but they don’t really know how to do it appropriately. We can say this is ultimately the responsibility of the CEO, the CMO, or the CNO, but these leaders also may not be aware of the gaps in practices. It’s a lack of education, and a lack of awareness.
Q: You're a strong proponent of a multidisciplinary approach to blood management. Would you describe the advantages of this approach?
A multidisciplinary approach is what’s required to improve patient safety and it’s what works. If you look at the safety chain from the blood bank all the way to the patient, there are a variety of disciplines involved. Before a patient is transfused, a specimen has to be drawn and sent to the laboratory to make sure we have the right specimen from the right patient, and we have the right unit of blood. That specimen could be drawn by nursing, by laboratory, or by other lab assistants.
The ordering process is the next step in the chain and physicians, and mid-level providers like physician’s assistants and nurse practitioners, may all write orders. When blood is transported from the blood bank to the bedside, we can have transporters, nurses, and clerks taking part in that process. At the bedside, nurses or nursing assistants address dual identification. Administering and monitoring blood involves nursing, feedback to physicians, and feedback to the laboratory as well. In addition, an organization’s quality infrastructure provides blood management oversight and resources. Pharmacy also has a role because there are drugs that can either cause or prevent bleeding. Finally, the patient, of course, needs to be involved.
The safety chain for blood has all of these different actors, and all of them have to play their role in a high-reliability organization to do it right, every single time, without error. If you don’t use a multidisciplinary approach, you are going to miss some links in the safety chain.
Q: What are the biggest challenges teams face when trying to improve blood management practices?
It starts with, “I don’t know, and I don’t care.” Hospitals may be unaware or defensive regarding current practice gaps. It’s also a challenge if teams identify gaps in practice, but they aren’t aware that these gaps create safety issues. That’s why you need to do a baseline assessment to identify the gaps and provide education about their patient safety implications.
Another challenge is that even motivated and aware clinicians can become intimidated by the scope of the project to improve blood management practices, thinking it will be impossible to get everyone moving in the same direction and to manage all the moving parts. Yes, it is intimidating to think about getting doctors and nurses, mid-level providers, laboratory people, pharmacy people, and administrators all on the same sheet of music. But, from a patient safety standpoint, it can and should be done.
It is hard work, but bringing together these different groups to focus on blood products can have additional, far-reaching benefits. I have seen it time and time again because those same teams also need to talk about a variety of other issues like antibiotic stewardship, falls, and readmissions, for example. Bringing together all of these groups to focus on blood, you can get the additional benefit of having a multidisciplinary team that’s geared up to address other safety projects.
Q: What can patients do to advocate for appropriate blood utilization?
Patients can do a lot. I trained in medical school during the emergence of HIV. In those days, the general populous was acutely aware of risks of blood and tended to ask their doctors pressing questions. That doesn’t happen anymore. I believe there are five questions patients should ask their doctor about blood use:
- Am I at risk for getting a blood transfusion? The answer may seem apparent because you are going in for heart surgery or major joint surgery, but there may be other less obvious high-risk procedures, so it’s worth asking.
- What are the risks of getting a blood transfusion? Physicians need to explain to their patients the risks of transfusions. Of course, the implication is that physicians have to first educate themselves about the risks of blood before they can explain those risks to others. Many patients still think the biggest risks are HIV and hepatitis. Those are still risks, but they are very low. The current danger is from the non-infectious risks I referenced earlier.
- What are my options? I may need a transfusion, and I understand that there are risks, but do I have options? It is important to offer the alternatives to transfusion because some of those options are not available on the day of surgery. For example, if I am having my knee replaced and I am at risk for receiving blood, if I arrive on the day of surgery and my blood count is low, I don’t have any options to immediately address that. If, however, I ask about my options or I’m told about them 30 days prior to surgery, then the doctor can treat my anemia and bring my blood count up so I am ready for surgery. New Jersey and California have specific laws around the need to provide options as well as time for options as part of their informed consent for blood products.
- How will you arrive at the decision that I need a transfusion during my hospital stay? This question is asked to learn how your doctor is doing due diligence and weighing the risks and benefits of a blood transfusion. You want to know that they aren’t going to automatically order a transfusion, and that they are going to balance the risks for and against, depending on your clinical situation.
- Will I be involved in the decision to transfuse during my hospital stay? Most patients are transfused when they are wide awake in an ICU or on a ward. What happens in practice is there is an informed consent signed at or before admission and there is almost never another conversation with the patient or the family prior to the actual blood transfusions. To me, the right thing to do – and I have done this personally – is go to the bedside and talk with the patient and their family and discuss the clinical situation that may warrant a blood transfusion. Unless it’s an emergency, there are plenty of opportunities to talk to the patient as you consider the transfusion decision – on daily rounds, for example.
Q: What keeps you so passionate about this issue?
I’m an anesthesiologist and we are the only specialists who actually put our hands on blood and administer it. I also had a mentor who got me interested in better blood management at a very early point in my career more than 20 years ago. What keeps me interested is that there is always room for improvement, and it is never boring because there is always new information that needs to be assimilated. I also really enjoy seeing people at the starting point of improving their blood product management program, going through the process of discovery and the change process, embracing the challenges, improving their practices, and eventually making the changes stick. Being able to play a part in a change process that leads to safer patient care is what gets me out of bed in the morning and gets me on airplanes headed across the country.