Restricted transfusion practices are critical to improved blood utilization

SAN DIEGO – Introducing limited transfusion practices can play an essential role in blood utilization and reduction of inappropriate transfusions, according to a presentation given at the 38th Annual Cardiothoracic Surgery Symposium.

Lawrence Tim Goodnough, MD, professor of pathology and medicine (Hematology) in the departments of pathology and medicine at Stanford University, discussed the current state of blood utilization, cited practice principles for blood transfusion, and described his own hospital’s experience with restricted transfusion.

“Everybody agrees that blood transfusions are overused and transfused inappropriately, and it’s on everybody’s top five list of appropriate-use interventions,” Goodnough said. “The American Medical Association, on behalf of the medical societies, and the Joint Commission, on behalf of the regulatory agencies, have put this on the list as the definition of ‘overused.’”

Goodnough cited a shift in mindset at his institution regarding transfusion, which has historically been viewed as an effective therapeutic option.

“We decided to get away from the traditional concept of a blood transfusion as an effective intervention and move toward a new paradigm: that it’s an undesirable outcome,” he said. “Seemingly, that’s a radical thing to say, but I’ve never yet a patient who’s been enthusiastic about a blood transfusion.”

Goodnough outlined general therapeutic principles for improving blood utilization, including:

Avoid an empiric, automatic threshold for transfusion (such as hemoglobin <100 g/L [10 g/dL]);
View elective transfusion with homologous blood as an undesirable outcome;
When acute blood loss can be predicted, plan for the availability of autologous blood;
Administer transfusion unit-by-unit based on symptoms. One unit of blood may be sufficient.

“If your goal is to minimize allogenic blood, then why transfuse in aliquots of two, four and six?” he said. “Why not transfuse one at a time, and reevaluate your patient by whatever criteria you use before you decide to transfuse again?”

In 2010, Goodnough and his team at Stanford developed an approach to reduce the number of blood transfusions at the hospital.

“We came up with a best practices alert. This was a smart alert where, when the clinician orders a red cell transfusion, the computer knows what the last recorded hemoglobin was, and if it was more than 7 g/dL, or more than 8 g/dL for patients in acute coronary units, there would be an alert pop up,” he said. “This is not a recommended guide for transfusion; this is simply an opportunity for concurrent utilization review.”

Goodnough reported that after the implementation of the best practices alert, there has been a 42% decrease in RBC utilization through 2015, and a reduction in the percentage of patients transfused, from 22% to 17%, between 2009 and 2013 (P<.01).

Goodnough and colleagues assessed hospital-wide clinical outcomes since implementation of the best practices alert, and found a statistically significant reduction in mortality between 2009 and 2015.

“From a hospital point of view, it’s reassuring that we’re using much less blood in the setting of overall hospital mortality or death,” he said. “I can’t prove a cause-and-effect relationship – that mortality is going down because we’re transfusing less – and it’s also difficult to prove the negative.”

Days at risk increased after implementation of the best practices alert, as did case mix index, Goodnough said.

“Case index mix is a quality marker for complexity and serious illness of the patients, and that went up over time,” he said. “So we were taking care of more patients, more seriously ill patients, and mortality was going down.”

Goodnough and colleagues also evaluated the patients who did get transfusions, before and after the best practices alert. They found that the case mix index went up, and the average number of red cells transfused went down. The hospital length of stay was significantly lower after introduction of the best practices alert vs. before. Decreases were also seen in the 30-day readmission rate.

“These clinical markers of patient outcomes in the most vulnerable patients getting transfusions showed a reassuring improvement,” he said. “Things are moving in the right direction with improved red cell utilization.” - by Jennifer Byrne

Reference:
Goodnough LT. Patient blood management. Presented at: The Annual Cardiothoracic Surgery Symposium; Sept. 6-9, 2018; San Diego.

Disclosure: Goodnough reports no relevant disclosures.