Friday, March 15, 2013

Let’s do something about the overuse of blood transfusions

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.

Disclosure: I attended the Patient Safety Science and Technology Summit thanks to a grant from Masimo who had no input into what is written here.


Anonymous said...

Not just surgeons need to do something. If the pathologists set stringent transfusion guidelines for their hospitals and Enforce them, half of the battle is won right there.

Skeptical Scalpel said...

True, but are pathologists willing to serve as gatekeepers? My experience is that they aren't. Also, they are not clinicians and would be reluctant to arbitrate disputes about transfusion needs at 2 a.m.

Sabha Ganai, MD, PhD, MPH, FACS said...

People forget that blood was the first immunosuppressant used in organ transplantation... Not good for cancer patients! And half the time clinicians transfuse for a number and not a clinical need.

artiger said...

Scalpel, you probably see this too, but when did the magic number of 8 (for hemoglobin) become the trigger for transfusion? I see colleagues doing this knee jerk, no matter what the patient looks like, and it drives me nuts. Do you have any idea where when this would-be dogma originated?

Anonymous said...

In vet med they drill into our heads "treat the patient, not the paper/number" with regards to blood and plasma transfusions and I better be prepared to defend any recommendation for blood products with legit clinical evidence. Great post and really enjoy your blog!

Skeptical Scalpel said...

The magic number used to be 10. It changed to 8 many years ago when studies showed that most people, even those in ICUs, could tolerate a hemoglobin of 8. Like most guidelines, it wasn't meant to be an absolute, but it was taken that way by many.

Anon, I agree with you about the immunosuppression. Treat the patient. And thanks for the kind comments.

RuggerMD said...

In trauma it has been 7, but some data now suggesting even 6.

Unless your patient is having an MI, has brain injury and swelling, or is bleeding to death or might bleed to death, in shock, or some other life threatening issue why do you need to transfuse anyways?

Skeptical Scalpel said...

Agree. It's not even clear that you need to transfuse a patient who has had an MI.

Anonymous said...

Hi,as a med student (entering 3rd year) is it appropriate for me to make suggestions to attendings about topics I read like this? If yes, what's the best way for doing so?

Skeptical Scalpel said...

It's very appropriate but you must be careful. Some attendings don't like to be challenged or questioned. The residents can probably fill you in on who is receptive to that sort of thing and who is not.

You need to word things well too. I doubt that citing my blog as a reference would be good.

For example, let's say you have a patient who is borderline for needing a transfusion. You might say, "I have have read that transfusions may be overused." If you are engaged by the attending, cite something like the paper I linked to in the blog above.

I hope you have attendings who are open-minded and willing to discuss things.

Anonymous said...

Here is how it is in my hospital:
Nurse: His Hb is only 8.3, are you going to give him some blood?
Surgeon (me): No, he is stable and his UOP is fine. He clinically looks pretty good.

Next day:
Surgeon, looking at IV pole with empty transfusion bags: Why did you give him blood?
Nurse: They called Dr.X (covering for hospitalist) and he said to give him some blood.

Skeptical Scalpel said...

Great comment. I've had the same experience. You have described the essence of the problem.

Anonymous said...

Fast forward to 2017. The usual cutoff for transfusion is now a hemoglobin of 7 in a stable patient, 8 in a symptomatic patient, or 10 for a hem/onc patient with physician approval. There are still problems--doctors and nurses both tend to want to transfuse any patient who has a hemoglobin under 7, and they want to do it STAT. Cue eyerolling, you know where. If the patient is stable and not actively bleeding/hemodynamically unstable, then the patient can wait until the testing is complete. Of course that means that the correct specimens need to be collected and sent to the correct section of the lab. It means they need to be of sufficient quantity to complete ALL needed testing, not just a couple drops in the bottom of the tube. It means (per regulatory standard) those samples need to be correctly labeled with all required information.

And then, yeah, the new resident or the hospitalist will order blood STAT anyways, but refuse to accept uncrossmatched blood because that requires a signature.

Skeptical Scalpel said...

I agree that a stable patient does not need a stat blood transfusion.

Post a Comment