Blood utilization in the United States is significantly higher than in most Western countries and the gap is increasing. While blood utilization in the U.S. increased by 16% from 1999- 2004, it decreased by 8% in the United Kingdom during the same period. Remarkably, blood utilization in the U.S. is currently 15% higher per capita than in Europe and 44% higher than in Canada. This difference is likely attributable to a combination of national transfusion education programs, hemovigilance programs which spotlight transfusion risks, and accountability for performance and compliance at the hospital level.
(1) Wallis JP, Wells AW, Chapman CE. Changing indications for red cell transfusion from 2000 to 2004 in the North of England. Transfus Med 2006;16:411-7. (2) Yazer M, Triulzi D. Messages from national blood data collection reports. Transfusion 2007;47:366-8. (3) MacPherson J, Mahoney CB, Katz L et al. Contribution of blood to hospital revenue in the United States. Transfusion 2007;47:114S-6S.
Most physicians who order blood products lack formal training in transfusion therapy, and many are unaware of current transfusion guidelines. Similarly, most nursing schools fall short in terms of training in transfusion safety and blood administration competency. Because of these gaps in knowledge, the ordering and administration of blood products is shrouded by emotions, misconceptions, myths, and prescribing by habit. Compounding these issues is the fact that blood utilization oversight is lacking at most hospitals as witnessed by studies that document wide variations in transfusion practice between institutions and among physicians at the same institution.
(1) Dzik WH. Emily Cooley Lecture 2002: transfusion safety in the hospital. Transfusion 2003;43:1190-9. (2) Stover EP, Siegel LC, Parks R et al. Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study. Institutions of the Multicenter Study of Perioperative Ischemia Research Group. Anesthesiology 1998;88:327-33. (3) Corwin HL, Gettinger A, Pearl RG et al. The CRIT Study: Anemia and blood transfusion in the critically ill--current clinical practice in the United States. Crit Care Med 2004;32:39-52.
Based upon the current risks of blood transfusions and controlled studies of transfusion efficacy (risk: benefit ratio), the best available evidence for transfusion therapy indicates that a more conservative approach to blood transfusions not only saves blood but improves patient outcomes and saves lives (less is more).
(1) Hebert PC, Wells G, Blajchman MA et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999;340:409-17. (2) Corwin HL. Anemia and red blood cell transfusion in the critically ill. Semin Dial 2006;19:513-6. (3) Napolitano LM, Kurek S, Luchette FA, et al. Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care. Crit Care Med 2009; 37:3124-57.
The blood collection industry has done a remarkable job of reducing the risk of viral transmission through donor screening and blood testing. While it is true that blood products are the safest in history, transfusions are not risk free and cause some degree of harm in every patient due to the physical properties of stored blood and because of impairments in immune system function. The leading causes of transfusion-related morbidity and mortality are unrelated to viral transmission and include bacterial contamination of platelets (1:2000- 3000 transfusions), transfusion errors from patient misidentification (1:16,000- 19,000), transfusion related acute lung injury (TRALI) (1:1000- 5000) and transfusion associated circulatory overload (TACO) (1:350). Analogous to chemotherapy, blood transfusions can improve outcomes but only when used in the right patient for the right indication and in the right dose.
(1) Boucher BA, Hannon TJ. Blood management: a primer for clinicians. Pharmacotherapy 2007;27:1394-411. (2) Goodnough LT. Risks of blood transfusion. [Review] [124 refs]. Critical Care Medicine 2003;31:S678-S686. (3) Toy P, Popovsky MA, Abraham E et al. Transfusion-related acute lung injury: definition and review. Crit Care Med 2005;33:721-6. (4) Dzik WH. Emily Cooley Lecture 2002: transfusion safety in the hospital. Transfusion 2003;43:1190-9.
Blood transfusions are essentially organ transplants so they logically cause changes in the immune system function of patients who receive them. Because each transfusion represents a new donor and a new set of immune challenges, each transfusion causes a stepwise increase in serious complications including postoperative infection rates, ventilator-acquired pneumonia, central line sepsis, ICU and hospital length of stay, as well as short term and long term mortality rates.
(1) Boucher BA, Hannon TJ. Blood management: a primer for clinicians. Pharmacotherapy 2007;27:1394-411. (2) Shorr AF, Duh MS, Kelly KM et al. Red blood cell transfusion and ventilator-associated pneumonia: A potential link? Crit Care Med 2004;32:666-74. (3) Taylor RW, Manganaro L, O’Brien J et al. Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient. Crit Care Med 2002;30:2249-54. (4) Shorr AF, Jackson WL. Transfusion practice and nosocomial infection: assessing the evidence. Curr Opin Crit Care 2005;11:468-72.
By some estimates each unit of allogeneic blood increases nosocomial infection rates by 50%, so transfusing a patient with two units of blood will double the rate of hospital acquired infections. Therefore the common practice to automatically order two units of red blood cells at a time makes no sense from a resource consumption or patient safety standpoint.
(1) Shorr AF, Duh MS, Kelly KM et al. Red blood cell transfusion and ventilatorassociated pneumonia: A potential link? Crit Care Med 2004;32:666-74. (2) Taylor RW, Manganaro L, O’Brien J et al. Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient. Crit Care Med 2002;30:2249-54. (3) Shorr AF, Jackson WL. Transfusion practice and nosocomial infection: assessing the evidence. Curr Opin Crit Care 2005;11:468-72.
There are a number of emerging areas of risk exposure and potential medical-legal liability that relate to compliance with state, federal (CMS), Joint Commission, AABB and CAP regulations for blood component therapy. These include patient safety issues (the Joint Commission National Patient Safety Goal #1 is to eliminate medication and transfusion errors), appropriateness and documentation of physician transfusion orders, nursing compliance and documentation, oversight systems and effectiveness of peer review, and informed consent for transfusion. From a compliance and medical-legal standpoint, the financial liability of inappropriate transfusions and transfusion errors can be substantial. Because of these many issues, the Joint Commission is currently testing Blood Management Performance measures as an element of hospital accreditation.
(1) Boucher BA, Hannon TJ. Blood management: a primer for clinicians. Pharmacotherapy 2007;27:1394-411. (2) http://www.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Blood+Management+-+Utilization.htm
Blood utilization in the U.S. has risen steadily at a rate of 2- 3% a year because of an aging population, increasingly complex surgeries and aggressive chemotherapy regimens. At the same time, the number of eligible donors has been declining because of a growing number of donor deferral criteria which are instituted to protect the blood supply. A recent study estimated that 66 million fewer people are eligible to donate blood than previously thought, leaving only about 37 percent of the U.S. population as potential donors. This supply and demand mismatch means that blood banks now have to work harder to recruit donors and blood shortages will become more frequent, leading to interruptions in hospital operations and cancellation of elective surgeries. The end result of donor recruitment challenges and the increasing costs of testing and processing blood has been a doubling of blood prices in the past few years, and prices are expected to increase by 6- 10% per year going forward.
(1) Riley W, Schwei M, McCullough J. The United States’ potential blood donor pool: estimating the prevalence of donor-exclusion factors on the pool of potential donors. Transfusion 2007;47(7):1180-88. (2) Hannon TJ, Paulson-Gjerde K. Contemporary economics of transfusions. In: Spiess BD, Spence RK, Shander A, eds. Perioperative Transfusion Medicine. Philadelphia: Lippincott Williams & Wilkins, 2005.
The total cost of transfusing patients exceeds blood acquisition costs by five times or greater when labor, supplies, blood administration and transfusion-related adverse events costs are considered. The cost to purchase blood products, while significant for many hospitals, is only the “tip of the iceberg” for total blood costs.
Hannon TJ, Paulson-Gjerde K. Contemporary economics of transfusions. In: Spiess BD, Spence RK, Shander A, eds. Perioperative Transfusion Medicine. Philadelphia: Lippincott Williams & Wilkins, 2005.
Topping it all off, financial penalties for adverse clinical outcomes related to inappropriate transfusion practices are increasing. Since October 2008, Medicare and most commercial health insurance carriers will no longer pay for transfusion errors, bleeding complications in cardiac surgery and a growing number of hospital acquired infections that are increased two to five-fold by blood transfusions.
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