UAB Synopsis, Vol. 27, No. 13, April 7, 2008

UAB Hospital’s alliance with the American Red Cross to serve as its primary provider of blood products prompted not only new impetus to increase blood donations, but also renewed interest in analyzing blood consumption practices.

“Because UAB is striving to build a self-sufficient blood supply, we recently opened a new blood-donation room and introduced a donor-recognition program with awards for regular participation.

As part of our contract with the Red Cross, we initiated a blood usage audit conducted by specialists in optimal blood utilization. They examined the hospital’s blood usage practices and offered recommendations for improvement,” says Marisa B. Marques, MD, UAB Hospital Transfusion Service medical director and cochair of the reorganized Blood Utilization/Management Committee. Dr. Marques represents Laboratory Medicine’s interests in the Blood Management Program.

Donna E. Salzman, MD, committee cochair, is charged with implementing the clinical arm of the program at UAB Hospital.

Two-unit Custom

“The current practice of transfusing two units of packed cells often is not necessary and exposes the patient to additional transfusion-related risks. I will be working with the physicians and clinical staff to provide education about and oversee implementation of the newer, safer transfusion guidelines,” Dr. Salzman says.

Although the survey group had difficulty finding hospitals comparable to UAB in size, type and number of surgical operations, and Level I trauma center designation, the survey results revealed liberal blood usage practices. To better compare UAB Hospital’s blood usage to other hospitals, the group analyzed blood usage patterns for specific diagnoses to define areas for improvement.

“Finding ways to decrease blood usage conserves a precious resource and controls costs. Furthermore, evidence confirms patients with selected diagnoses, such as chronic anemia and those in intensive care units, generally do well when they receive less blood,” Dr. Marques says. “It is not necessary to achieve a normal hematocrit. In fact, studies confirm that using fewer transfusions reduces mortality, infection rates, risk of transfusion reactions, heart attacks, and heart failure.”

Blood Management

“We are developing strategies to improve blood utilization by reviewing evidence-based criteria for use of allogeneic blood products and by recommending techniques, drugs, or medical devices that reduce the need for these products. The result will be better clinical outcomes, improved safety for our patients, and lower costs,” she says.

A recently published primer for clinicians on blood management emphasizes that hospitals need to develop evidence-based transfusion guidelines to reduce variability in transfusion practice with the deployment of multispecialty teams to monitor blood management strategies (Pharmacotherapy. 2007;27[10]:1394-1411). The article indicates the traditional practice of transfusing once hemoglobin falls below 10 g/dL or hematocrit drops below 30% is not consistent with current scientific knowledge. Using a hemoglobin of 7 g/dL as a transfusion trigger is equivalent to the more liberal usage of blood.

The Blood Utilization/Management Committee is charged with disseminating new evidence-based transfusion guidelines and methods to reduce blood usage at UAB Hospital. The committee also is revising blood product reports to facilitate continuing analysis of usage patterns.

Reducing Transfusion Needs

Other possibilities to reduce the need for transfusion include using smaller volume tubes for diagnostic phlebotomy, particularly in anemic and ICU patients; eliminating subsequent diagnostic phlebotomies when possible; performing bedside analytic processes that require smaller amounts of blood; and administering pharmacological agents such as those that stimulate erythropoiesis.

Also under study is use of a closed system blood sampling mechanism that does not require phlebotomy and an intraoperative blood recovery process for reinfusion of shed blood.

Bloodless Medicine

In addition, the committee is addressing bloodless medicine guidelines for patients whose specific blood type is unavailable and for those who refuse transfusion. Changes include providing access to a Jehovah Witness liaison — a physician who practices the faith — whom other physicians can call to discuss options and a Jehovah Witness minister who can be available through pastoral care services.

“This large project requires coordination of all members of the health care team to monitor and minimize blood usage,” Dr. Marques says. “We must do everything that we can to conserve blood because of its associated risks, decreasing availability, and mounting costs.”