Over the past century, we have seen several advances in blood management, including the adoption of blood storage and banking (1910s), and the discovery of blood-component separation (late 1930s). These discoveries underpin our modern-day blood supply. We have not, however, fully implemented methods of improving actual blood administration — to the detriment of patients and providers alike. All too often, modern blood-administration practices remain rooted in the myths and misconceptions of yesteryear, as revealed in the following 10 facts about blood transfusions.
1. Transfusions are inherently hazardous. While today's blood products are the safest in history, transfusions are not risk free and can cause a degree of harm in every patient, due to the physical properties of stored blood and their effect on immune-system function. The leading causes of transfusion-related morbidity and mortality are unrelated to viral transmission and include bacterial contamination of platelets, patient misidentification, transfusion-related acute lung injury or TRALI, and transfusion-associated circulatory overload. 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.
2. Blood is a liquid transplant. Blood transfusions are essentially organ transplants, so they logically cause changes in the immune system 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 post-operative infection rates, ventilator-acquired pneumonia, central-line sepsis, ICU and hospital length of stay, as well as short-term and long-term mortality rates.
3. Transfusions are double-trouble for hospital-acquired infections. 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. The common practice of automatically ordering two units of red blood cells makes no sense from a resource-consumption or patient-safety standpoint.
4. Less is more for transfusions. Based on 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 also improves patient outcomes and saves lives (less is more).
5. Transfusion education is a bloody mess. Most physicians who order blood products lack formal training in transfusion therapy and are unaware of current transfusion guidelines. Similarly, most nursing schools inadequately train students in transfusion-safety and blood-administration competency. Because of this, ordering and administering blood products is often shrouded by emotions, misconceptions, myths, and habits. Compounding these issues is the fact that effective blood-utilization oversight does not occur at most hospitals.
6. America is a blood-thirsty nation. Blood use in the United States is significantly higher than in most Western countries and the gap is increasing. While blood use in the U.S. increased by 16% from 1999 through 2004, it decreased by 8% in the United Kingdom. In the U.S., blood use is currently 15% higher per capita than in Europe and 44% higher than in Canada.
7. Blood shortages and blood costs have hospitals seeing red. Blood use in the U.S. has risen steadily at a rate of 2% to 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. As a result, blood prices have doubled in the past decade, and prices are expected to increase by 6% to 10% per year going forward.
8. Blood costs are the “tip of the iceberg” for the total cost of transfusions. 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 costs.
9. Transfusions are risky business. Several emerging areas of risk exposure and potential medical-legal liability relate to compliance with state, federal the Centers for Medicare and Medicaid Services, The Joint Commission, AABB, and the College of American Pathologists' regulations for blood-component therapy. From a compliance and medical/legal standpoint, the liability of inappropriate transfusions and transfusion errors can be substantial. Because of this, The Joint Commission is in the final stages of approval for Blood Management Performance measures as an element of hospital accreditation.
10. Transfusion complications: You break it, you pay for it. Financial penalties for adverse clinical outcomes related to inappropriate transfusion practices are increasing. 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 twofold to fivefold by blood transfusions.
Timothy Hannon, MD, MBA, is founder/CEO of Strategic Healthcare Group, an Indianapolis-based provider of blood-management consulting, and education and informatics services,
which partners with the U.S. blood-collection industry and more than 60 U.S. hospitals to promote patient safety and improve the stewardship of the blood supply.