Op-Ed: Unnecessary Transfusions in Hospitals May Be Fueling the Blood Shortage

With the combined impact of the COVID-19 pandemic on the health care workforce, consolidation of blood collection centers, and a shrinking donor pool, the nation’s blood supply its at its lowest level in more than a decade.1 And with costs for blood and blood products continuing to rise, appropriate blood use by hospitals is more important than ever.

In a recent study from Columbia Healthcare Analytics and Vizient of roughly 8,900 transfused patients across 15 hospitals in the western United States, researchers found that 44% of patients could have been managed without a transfusion (whether red blood cells (RBC), plasma, cryoprecipitate, or platelets), and 92% received at least 1 transfusion that was unnecessary.

The study found that nearly all unnecessary transfusions stemmed from common misinterpretation of Association for the Advancement of Blood and Biotherapies guidelines. Many clinicians inaccurately believed that transfusion is prescribed for a hemoglobin value less than 7 gm/dL. A closer reading of the guideline finds that a hemoglobin less than 7 is not an indicator for good blood management. Rather, it’s a permissible level below which transfusion may be appropriate but not necessarily warranted.

Because hospitals commonly use hemoglobin values to gauge transfusion appropriateness in combination with the guideline, this pattern likely occurs daily in hospitals across the country. This costs the health care industry millions of dollars annually and wastes this precious and increasingly scarce resource.

A first step to improving blood management starts with an evaluation of pre-transfusion and discharge hemoglobin values of RBC-transfused patients, followed by an estimation of the potential discharge hemoglobin if transfusion has not occurred. Assessing the data will reveal 3 key metrics about clinical practice: patients pre-maturely transfused, over-transfused, and those who could have been managed without transfusion.

An important way that physicians and pharmacists can collaborate when the patient’s Hgb value becomes a concern is through the use of erythropoietin-stimulating agents (ESAs), which work by stimulating the production of more red blood cells, in combination with intravenous (IV) iron.

Methods to adequately manage surgical patients who are not hemorrhaging with hemoglobin laboratory values below 7 gm/dL include:

• Diagnosing anemia prior to surgery and administering iron via an IV as appropriate
• Normovolemic hemodilution, in which the patient’s heart is maintained during surgery using their own blood, drawn before surgery
• Intra-operative cell salvage, in which a device is used to capture blood during surgery, process it, and return it to the patient via an IV

Lastly, clinicians can implement aggressive hemostatic techniques such as reducing sample sizes and frequency of sample draws and using shorter tubing.

How to Break a Pattern of Over-Transfusion With Physicians

In addition to COVID-19-induced market challenges to acquiring blood donations, the cost of blood products has dramatically increased due to FDA testing requirements that went into effect October 1, 2021. If hospitals can begin to implement better blood management and utilization practices, the reduction in unnecessary transfusions could lower costs and address much of the blood shortage the industry is currently experiencing.

Breaking a pattern of over-transfusing starts with 2 simple steps—measuring all blood use and engaging physicians.

First, hospitals should begin measuring all transfusion activity and providing that data to physicians monthly. To gain engagement, the data should show individual physician activity benchmarked against their peers’ activity. Providing benchmarking data can open the door for physicians to seek out additional decision-making skills related to transfusions that are less reliant on lab values.

The hospital’s transfusion committee should also follow up with clinicians to understand whether specific cases could have been managed without RBC transfusion. To improve physician engagement, consider offering continuing medical education (CME) credit and ongoing professional practices evaluation documentation required for certification maintenance.

An additional step to keep clinicians engaged is gamification. Monitor blood use from transfusion to credentialing. Award points for skill assessment, no committee referral, good patient management, and timely physician response. Then, reward clinicians with CME credits, certification, credentialing, or other incentives.

Engaging and rewarding clinicians through these types of activities will help effect change, and with the current shortage, the sooner the better. The real reward comes when the hospital laboratory is fully stocked with blood inventory.

About the Author

Akiva Faerber is senior principal of laboratory and blood consulting at Vizient.

Reference

Red Cross Declares First-ever Blood Crisis Amid Omicron Surge. News release. American Red Cross. January 11, 2022. Accessed August 15, 2022. https://www.redcross.org/about-us/news-and-events/press-release/2022/blood-donors-needed-now-as-omicron-intensifies.html