Despite the fact that many papers have identified the
problem, inappropriate blood transfusions continue in hospitals across the
nation.
This topic was featured at the recent Patient Safety Science
and Technology Summit that was held in Orange County, California last month.
Transfusion of packed red blood cells is very common. Over 2
million patients or 5.8% to 10% of inpatients are transfused every year with
some 15 million units of blood.
There is much variability and inappropriateness in the use
of blood transfusions.
A paper
in the February 2013 issue of Annals of Surgery reviewed the University Health
System Consortium database and the American Hospital Association Annual Survey
File for the years 2006-2010. The authors reviewed 54,405 total hip
replacements, 21,334 colectomies and 7929 pancreaticoduodenectomies.
Even when
adjusted for patient risk factors, hospital-specific transfusion rates ranged
from 1.5% to 77.8% for total hip replacement, 1.7% to 49.9% for colectomy and
0% to 90.9% for pancreaticoduodenectomy. Bear in mind that this study involved
university hospitals.
A recent survey showed that while medical schools devote an
hour or two to lectures about blood, they center on blood typing and
compatibility but not on indications. A speaker at the summit pointed out that
it is time to start focusing on the safety of patients rather than the safety
of blood.
One study showed that only 12% of blood transfusions were
appropriate, 59% were inappropriate and opinions were divided about the
appropriateness of the remaining 29%.
Here are some important points:
- Blood transfusion is rarely based on sound evidence because except in trauma patients, there is not much evidence in the literature.
- Few articles support the premise that transfusion improves outcomes.
- Blood transfusion has a poor risk-benefit ratio. There are many adverse outcomes such as infection, immunosuppression, transfusion-related acute lung injury, allergic reactions, errors in administration and even death, to name a few.
- The true cost of a unit of blood is estimated at $500 to $1200, which means that at 15 million units per year, overall costs could be as high as $15 billion. And that is just the cost of the blood itself. It doesn’t include costs of associated complications.
- Overuse leads to shortages causing patients who might really benefit from a transfusion to not receive it in a timely way.
- Informed consent discussions rarely mention the risks of transfusion.
- Many doctors and administrators are not aware of the problem of transfusion overuse.
With a concerted effort, the Cleveland Clinic has decreased
the use of transfusions by 30% in the last four years.
The panel discussion at the safety summit concluded the
following:
Anemia in patients scheduled for elective surgery should be
identified and corrected without transfusion if possible.
In the OR, the decision to transfuse should not be based on
a number. To avoid confusion, the trigger to transfuse should be discussed
during the pre-operative time-out.
Transfusion should become a quality indicator with physician
champions, education of medical staffs, justification of every unit transfused
and scorecards for those prescribing blood.
As surgeons, we should be leading the effort to rectify this
continuing problem.
A video of the presentation and panel discussion on the
overuse of red blood cell transfusions is here.
