Healthcare professionals tend, like everyone else, to make some choices based on habit or training. The web site Choosing Wisely encourages physicians and patients to question some of those routine choices.
Choosing Wisely® aims to promote conversations between physicians and patients by helping patients choose care that is:
- Supported by evidence
- Not duplicative of other tests or procedures already received
- Free from harm
- Truly necessary
One of the lists on the site is from the Critical Care Societies Collaborative; five things physicians and patients should question:
1. Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.
2. Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 g/dL.
3. Don’t use parenteral nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay.
4. Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.
5. Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.
Read the explanations for these five recommendations here:
There are numerous benefits to applying blood conservation principles in patient care, most often referred to as Patient Blood Management. For example:
Conventional wisdom may lead you to believe you’ll fare better (during surgery) if you get a transfusion, but that’s not always the case, said Colleen Koch, MD, vice chair for research and education in cardiothoracic anesthesiology at the Cleveland Clinic in Ohio. In fact, heart surgery patients who receive blood transfusions tend not to do as well as those who don’t receive them, Dr. Koch noted.
During a coronary artery bypass graft (CABG) surgery, for example, a patient at one hospital might be given two units of blood, while doctors at another center may decide not to give a similar patient a blood transfusion.
Before you head to the operating room, it’s smart to ask your medical team about the likelihood of needing a blood transfusion and whether it can be avoided.
Read the rest of Questions to Ask About Blood Transfusion and Heart Surgery to see questions to ask prior to surgery.
Bloodless medicine programs have been formed in hundreds of leading hospitals around the globe in the last 20 years. Initially established to meet the needs of patients who decline transfused blood for religious or personal reasons, as healthcare consumers become more educated a growing number of patients are now requesting care without the use of donated blood whenever possible.
What lessons in blood management have we learned during the past two decades?
Transfusion triggers have been lowered.
In 1998 the “10/30 rule” (i.e., RBC transfusion indicated below a hemoglobin concentration of 10 g/dL or a hematocrit of 30%) was standard in most hospitals. “There is now increasing evidence that RBC transfusions are associated with adverse outcomes and should be avoided whenever possible.” 1
Most hospitals now use a transfusion trigger of around 8 g/dL hemoglobin.
The value of treating pre-operative anemia is more recognized
Studies have indicated that nearly 50% of patients entering an OR may be anemic at the time of incision.
An article in The British Medical Journal stated “Previously undiagnosed anaemia is common in elective orthopaedic surgical patients and is associated with increased likelihood of blood transfusion and increased perioperative morbidity and mortality. Anaemia should be viewed as a serious and treatable medical condition, rather than simply an abnormal laboratory value.” 2
It is important to know your hemoglobin level, just like you know your cholesterol and blood pressure numbers.
Many hospitals are moving toward patient blood management
An advisory committee of the US Department of Health and Human Services issued a letter in 2011 that stated, in part, “Blood transfusion carries significant risk that may outweigh its benefits in some settings and add unnecessary costs. Improvements in rational use of blood have lagged behind improvements in the quality and safety of the products.” 3
Organization-wide patient blood management incorporates lessons learned in managing the care of bloodless medicine patients into improved care for all patients.
- Anemia and perioperative red blood cell transfusion: a matter of tolerance. Crit Care Med 2006 May;34 (5 Suppl):S102-8. PMID:16617252
- Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines Br. J. Anaesth. (2011) 106 (1): 13-22. doi: 10.1093/bja/aeq361
- US Department of Health and Human Services Advisory Committee on Blood Safety and Availability www.hhs.gov/ash/bloodsafety/advisorycommittee/recommendations/reommendations_201106.pdf
I just want to say thanks to Specialty Care, provider of clinical services and quality benchmarking, and one of the vendors that suported the recent SABM Conference.
I stopped by their booth at the conference and entered their drawing for a Google Nexus 7″ tablet – and won! Cool!
I’m enjoying the tablet, and want to thank Specialty Care for both the tablet and their support of SABM.
Variant Creutzfeldt-Jakob disease (vCJD) is a rare, but deadly infection that can be transmitted in transfused blood or blood products.
An article in the UK Telegraph Killed by a needless blood transfusion, notes that Deryck Kenny, who died in 2003, was the first recorded death from vCJD traceable to contaminated blood. His widow, a retired nurse, later reviewed his medical record and could find no documented reason for the three units of blood Deryck received during surgery for prostate cancer. She concluded that it was simply the surgeon’s routine to transfuse patients.
Routine is a more common reason for transfusion than most would think. As a result, hospitals around the globe are beginning to adopt patient blood management as a key safety concept. The roots of the program lie in alternative treatments developed for patients who decline all blood transfusions in their care, in the past primarily Jehovah’s Witnesses, but now a choice that is being made by an increasing number of others as well.
For those anticipating a planned surgery, consider asking your physician to do a routine blood count in advance, and if anemia (low hemoglobin / hematocrit) is noted, to take steps to correct that anemia prior to surgery. That simple step alone would eliminate the need for many transfuions during or after surgery. In cases of mild anemia iron supplements may help, or if the problem is more pronounced, IV iron or medication that stimulates a patient’s own bone marrow to produce red cells, may be needed.
It has been said that “the safest transfusion is the one not given.”
PBS explores communities, physicians, and hospitals that have improved the quality of healthcare while controling and in many cases even lowering costs: US Healthcare: The Good News
Findings of the U.S. Department of Health and Human Services Advisory Committee on Blood Safety and Availability, June 8, 2011:
- Blood transfusion carries significant risk that may outweigh its benefits in some settings and add unnecessary costs.
- Wide variability in use of transfusions indicates that there is both excessive and inappropriate use of blood transfusions in the U.S.
- Medical advances and aging of the population are expected to drive demands for transfusions that could exceed supplies in one to two decades.
- Improvements in rational use of blood have lagged behind improvements in the quality and safety of the products.
- Additional data on blood utilization and clinical outcomes are needed to identify gaps in knowledge.
- Programs at some hospitals have demonstrated significant reduction in blood use without increase in patient harm, based on expert decision-making
I recently returned from the annual meeting of the Society for the Advancement of Blood Management (SABM). The focus of the program was education and support for individuals involved in improving patient care and safety while curtailing healthcare costs through effective blood conservation and management.
We in Pittsburgh, PA were quite pleased to hear that next year’s SABM conference will be held in our city, September 20-22, 2012.
Over half of the attendees, and the majority of presenters at this year’s conference were physicians. The audience was international and multi-cultural; I personally met individuals from China, Malaysia and Switzerland.
We may think of blood transfusion as a long-held medical practice, but in reality its history is relatively recent. The first successful direct transfusion was performed between two brothers by Dr. George W. Crile (one of the founders of the Cleveland Clinic) in 1906 at St. Alexis Hospital in Cleveland. Transfusion didn’t become a commonly prescribed medical therapy until the Second World War. From the 1940′s until 1982 when researchers determined that the AIDS virus was being transmitted via transfused blood, it was a liberally prescribed treatment, and believed to be almost completely safe.
Transfusion is still a commonly prescribed therapy, and is now relatively safe from blood-borne diseases (such as HIV/AIDS) due to extensive testing. However, as the body of medical research continues to grow, the practice is being viewed with increasing concern for patient safety, both short and long term. In addition, in today’s resource-starved healthcare world, the cost vs. benefit of transfusion is under considerable scrutiny.
If this is an area of interest for you or your staff, and you’d like to visit the lovely city of Pittsburgh, consider saving these dates on your 2012 education calendar. Watch the SABM web site for more information.