Every year, approximately 21 million blood products are ordered and transfused, and one in every 10 hospitalized patients will receive a transfusion1. Blood transfusions are one of the most frequently performed procedures in U.S. hospitals. While blood transfusions can save lives and improve outcomes in certain patients, the use of blood products has never been under as much scrutiny as it is today.
The safety and efficacy of blood transfusion is being reevaluated as growing evidence associates transfusion with numerous adverse events and negative consequences2. Several studies demonstrate an association between transfusion and renal injury, cardiopulmonary complications, infections, cancer recurrence and even mortality3,4,5. While we continue to understand more about the true risks of transfusion, the use of blood products in the 21st century is beginning to reflect a common theme in healthcare: less is more.
Restrictive Strategy Has Benefits
Randomized controlled trials in multiple patient populations show that a restrictive transfusion strategy (using hemoglobin thresholds of 7 or 8 g/dl) is safe and may be associated with less morbidity and mortality compared to a liberal transfusion strategy (usually hemoglobin thresholds of 9 or 10 g/dl)6,7,. Transfusions are considered a "high risk" procedure, with morbidity and mortality increasing in a dose-dependent manner. The costs associated with transfusion are also substantial, with cost estimates of $522-$1,183 per RBC unit, translating into a conservative estimate of at least $7 billion annually for red cells alone8.
More concerning, recent studies report that 40-60% of red cell transfusions may be inappropriate and there continues to be wide variation in transfusion practice unexplained by patient characteristics9. Given the financial and human costs, the status quo of overuse and practice variation is no longer acceptable. Although there are stewardship and cost benefits associated with optimal blood use, this effort is a quality of care and patient safety initiative first and foremost. Many national and international organizations have identified evidence based use of blood products as a top priority, including The American Hospital Association10, The Joint Commission11, American Society of Hematology12, and American Association of Critical Care Nurses13 to name a few.
Nurses Promote Safety
How does this relate to nursing? Nursing is the nation's largest health care profession, with more than 3.1 million registered nurses nationwide14. As such, nurses are a major driving force behind many patient safety initiatives on a local, regional and national level. The majority of these are aimed at improving the safety, efficiency and cost-effectiveness of patient care. Acknowledged as the patient's advocate, nurses also play a critical role in promoting evidence based practice and protecting patients from unsafe practices. All of these elements carefully align with the philosophy of Patient Blood Management (PBM).
SEE ALSO: Earn CE: Organ and Tissue Donation
PBM is an evidence-based, multidisciplinary process designed to promote the following three clinical concepts: 1) improve blood product utilization and transfusion safety, 2) optimize recognition, diagnosis and management of anemia, and 3) minimize bleeding and blood loss in high risk patients15. These clinical concepts have historically been considered by most health care professionals to be a physician responsibility. However, let's evaluate the clinical concepts above and discuss the role that nursing can play in comprehensive PBM.
1. Improve blood product utilization and transfusion safety
a. Evidence based transfusion practice
i. Encourage a restrictive hemoglobin threshold (less than 7-8 g/dl) in stable patients
ii. In the absence of active hemorrhage, encourage physicians to order RBC units as single units, followed by a reassessment
iii. Review hospital transfusion guidelines for platelets, plasma and cryoprecipitate and support the medical staff in making evidence based decisions
b. Safe blood product administration - two leading causes of transfusion related mortality are preventable (hemolytic reactions and transfusion associated circulatory overload)
i. Ensure right patient/right product and administer blood over a safe time period (especially infants, elderly and patients with cardiac and renal disease)
c. Early recognition and management of transfusion related adverse events
2. Optimize recognition, diagnosis and management of anemia
a. Review hospital guidelines or order sets for anemia management and assist physicians with the recognition and management of anemia in patients at high risk for transfusion
b.Early recognition of anemia in patients undergoing major blood loss surgery and encouraging the patient and physician to pursue strategies to optimize RBC mass (e.g., IV iron, erythropoietic agents)
c. Encourage anemic patients to follow up with their physician and undergo a full diagnosis of the underlying reasons for the anemia, as well as ensure corrective steps are taken
3. Minimize bleeding and blood loss in high risk patients
a. Understand lab tests available to guide coagulation management in patients actively bleeding or at high risk for bleeding (e.g., platelet function, thromboelastography)
b. Support efforts to reduce phlebotomy induced anemia in high acuity patients by minimizing lab draws and utilizing in-line reinfusion devices
c. Support evidence based pharmacologic strategies to enhance coagulation and minimize bleeding (e.g., antifibrinolytics, prothrombin complex concentrates)
d. Promote perioperative techniques to minimize bleeding or recycle lost blood (autotransfusion)
PBM aspires to improve patient outcomes by ensuring that every blood product is given to the right patient, at the right time, in the right dose, for the right reason. PBM also promotes proactive, evidence-based strategies designed to reduce or eliminate the need for transfusion in high risk patients. Hospitals and health care professionals alike are strongly encouraged to learn more about PBM strategies and embrace PBM in their organizations. As the patient's advocate, nurses can be at the heart of PBM, helping to avoid unnecessary transfusions and ensuring that when given, transfusions are appropriate. We owe this much to our communities, our hospitals, and most importantly our patients.
Key Transfusion Bullet Points
- Transfusion is a Transplant - While blood transfusions can save lives in certain circumstances, they are a liquid "transplant" that can have a significant impact on short- and long-term patient outcomes. Unnecessary and avoidable transfusion causes patient harm.period.
- LESS is MORE - The best available evidence for transfusion therapy indicates that a more restrictive approach to blood transfusions (Hb trigger <7 g/dl and transfusing single units of RBCs followed by reassessment) not only saves blood but also saves lives.
- Just give two, is no longer true - For decades the standard transfusion order has been two units. Studies show that this results in unnecessary patient exposure and harm. In the absence of acute hemorrhage, RBC transfusions should be ordered as single units followed by a clinical reassessment prior to any additional transfusions.
1. American Red Cross. Blood Facts and Statistics. http://www.redcrossblood.org/learn-about-blood/blood-facts-and-statistics.
2. Thomas JJ. Transfusion Safety in the 21st Century. Transfusion Medicine's Emerging Leaders: Transfusion Safety Officers and Patient Blood Management Coordinators. Bethesda, MD: AABB Press, 2013.
3. Salpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: A meta-analysis and systematic review. The American Journal of Medicine. 2014; 127(2), 124-131.
4. Rohde JM, Dimcheff DE, Blumberg N, et al. HealthCare-Associated Infection After Red Blood Cell Transfusion. A Systematic Review and Meta-analysisJ. AMA. 2014;311(13):1317-1326.
5. Ferraris VA, Davenport DL, Saha SP, et al. Surgical outcomes and transfusion of minimal amounts of blood in the operating room. Archives of Surgery. 2012; 147(1), 49-55.
6. Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, et al. Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB. Ann Intern Med. 2012 Jul 3;157(1):49-58.
7. Villanueva C, Colomo A, Bosch A, et al. Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. N Engl J Med 2013; 368:11-21.
8. Shander A, Hoffman A, Ozawa S, et al. Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion. 2010 Apr;50(4):753-65.
9. Shander A, Fink A, Jividroozi M, et al. Appropriateness of Allogeneic Red Blood Cell Transfusion: The International Consensus Conference on Transfusion Outcomes. Transfus Med Rev. 2011 Jul;25(3):232-246.e53.
10. American Hospital Association. Appropriate Use of Medical Resources: Patient Blood Management. Quality Advisory. 2014 (April 17).
11.Joint Commission. Patient Blood Management Performance Measures Project - 2011. https://www.jointcommission.org/patient_blood_management
_performance_measures_project/ January 27, 2016.
12.Hicks LK, Bering H, Carson KR, et al. The ASH Choosing Wisely® campaign: five hematologic tests and treatments to question. Blood 2013. 122: 3879-3883.
13. Critical Care Societies Collaborative. Choosing Wisely: Five Things Physicians and Patients Should Question. 2014. http://www.choosingwisely.org/societies
14. AACN. Nursing Fact Sheet. http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-fact-sheet April 12, 2011.
15. Society for the Advancement of Blood Management, Inc. SABM Administrative and Clinical Standards for Patient Blood Management Programs. 3rd Edition. 2014.
Disclaimer: Accumen has no authority, responsibility or liability with respect to any clinical decisions made by - or in connection with - a provider's laboratory, patient blood management, or other operations. Nothing herein and no aspect of any services provided by Accumen is intended - or shall be deemed - to subordinate, usurp or otherwise diminish any providers' sole authority and discretion with respect to all clinical decision-making for its patients.
Joseph Thomas is Director, Patient Blood Management at Accumen.