Referred TestsFive Steps to Improve Transfusion Medicine
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Blood transfusion is the most common procedure performed in hospitals in the United States.* Yet published evidence shows significant gaps in clinicians' knowledge of this critical aspect of patient care, including possible adverse reactions that can occur after blood transfusion.
In a "call to arms" published in an editorial in Transfusion, James Stubbs, M.D., Chair of the Division of Transfusion Medicine at Mayo Clinic in Rochester, Minnesota, urges that "this important gap in our clinical competency" be closed. "For the sake of our patients,” he writes, “the time to correct it is now."
Dr. Stubbs cites the results of a validated examination of transfusion-medicine knowledge taken by 149 hematology trainees from 17 international sites. The overall mean score was 61.6%—indicating an intermediate knowledge level. Students in the U.S. had a significantly lower mean score (56.2%) than students at non-U.S. sites (67.4%).
"From a patient-centric perspective, it is reasonable to expect, maybe demand, that hematologists have expert-level knowledge in transfusion medicine," said Dr. Stubbs.
In a subsequent discussion, Dr. Stubbs suggests the underlying problem is the routine nature of blood transfusion. "Transfusions are sometimes viewed as a relatively benign procedure. The reality is that transfusion is anything but a benign intervention," he says. "It's a transplant procedure—temporary, because most transfused blood cells go away after awhile. But you're taking tissue from one human and putting it into another. That's serious, and it needs to be taken into consideration when we transfuse blood products."
"There's an impression that all patients benefit from blood component therapies," adds Daryl Kor, M.D., an anesthesiologist and critical-care specialist at Mayo Clinic's campus in Minnesota. "In fact, for many patients, you're not saving a life by giving that blood component, but you’re increasing the risk of an adverse event."
Mayo Clinic has been an innovator in blood transfusion for more than a century. In 1914, Bernard Francis McGrath, M.D., a Mayo Clinic pathologist, helped modify the original, crude aspiration-injection apparatus for performing arm-to-arm blood transfusions. And in 1935, John Silas Lundy, M.D.—recruited to Rochester by Dr. William J. Mayo—developed the first blood bank in the United States.
More recently, Mayo Clinic has made strong progress in standardizing its transfusion-medicine procedures through educating physicians and developing algorithms to guide treatment decisions.
"Education is fundamental because although the blood product itself can be very simple, the patient being transfused can be in a whole field of gray," says Justin Kreuter, M.D., Medical Director of the Mayo Clinic Blood Donor Program in Rochester. "We have seen improvements in aspects of transfusion care primarily because we are teaching people to think about the patient and not the transfusion."
Together, Drs. Stubbs, Kor, and Kreuter have a quarter century of experience in transfusion medicine at Mayo Clinic. They offer this advice for improving the safety and efficacy of the transfusion-medicine practice:
#1: Develop standard protocols . . .
Mayo Clinic has a subcommittee that creates uniform, enterprise-wide guidelines for blood transfusion. The process is data-driven. "Data are beyond critical," Dr. Kreuter says, "because perception is one thing, and reality is another."
The transfusion guidelines go beyond general parameters to focus on the unique needs of various subpopulations of patients. "For example, hematologists and oncologists need to transfuse a lot of patients who have chronic low blood counts," Dr. Stubbs says. "In the surgical arenas, transfusions are generally ordered for acute blood loss and require a different set of knowledge to be effective. Our approach is to systematically develop discipline-specific transfusion guidelines for unique patient populations."
This effort began about 15 years ago with the creation of a simple coagulation-based algorithm to guide decisions about transfusions during cardiac-bypass surgery. Use of the algorithm resulted in a significant reduction in intraoperative platelet and fresh frozen blood transfusions. Subsequent work focused on transfusions for patients in the intensive care unit (ICU) following cardiac surgery.
"There are different thresholds for transfusion in the ICU due to the physiology of patients changing post-surgery. They're warming up outside the operating room environment, and many times, they're no longer on as many medications and support as they were during the procedure," says Andrew Higgins, R.N., Patient Blood Management Coordinator at Mayo Clinic's campus in Minnesota. "The idea was to achieve consensus for this patient population; to assist the surgeons, fellows, residents, and mid-level providers who are covering the ICU; and to help the nurses there to understand the when, what, and why of transfusion for the majority of their patients."
More than 3,500 patient records were examined, and more than 30 stakeholders convened, to develop an algorithm. In a three-month trial of the algorithm, transfusions of red blood cells declined by about 47%, fresh frozen plasma and platelets by 40% to 45%, and cryoprecipitate by about 20%. "In addition, patient outcomes didn't appear to worsen," Higgins says. Subsequent assessments of the algorithm showed a reduction in acute kidney and lung injuries and a decreased length of stay in the ICU.
Since then, engagement and approaches have been developed for other patient subpopulations in an effort to standardize practice.
"There are many different subpopulations of patients that might react to transfusion in different ways," Dr. Kor says. "We are methodically filling the gaps in our knowledge to enhance our understanding of best practices."
#2: . . . But stay flexible and patient-centric
Mayo Clinic clinicians aren't expected to follow transfusion guidelines robotically. "Best-practice guidelines are exactly that—guidelines," Dr. Stubbs says. "Like anything else in medicine, you have to take into account the unique situation of a patient and individualize the decision, with the guidelines as a frame of reference."
He cites a hypothetical example of a 22-year-old world-class marathon runner who has suffered acute blood loss but whose bleeding has stopped. "The guidelines say you can transfuse if his hemoglobin is less than 7," Dr. Stubbs says. "Say his hemoglobin is 6, but he's not showing any signs or symptoms of distress—no breathing difficulties or dizziness—and his bone marrow is normal. In this case, I wouldn't transfuse red blood cells because he's going to recover on his own. There's more risk than benefit."
#3: Involve all stakeholders
Like the cardiac surgery transfusion algorithm, all of Mayo Clinic's transfusion guidelines are developed through close collaboration across disciplines and campuses. That input paves the way for smooth implantation of change.
"You need the healthy perspective that everyone can bring something to the table," Dr. Kreuter says.
"Mayo Clinic is successful because we are collaborative—not only between specialties but also between professions. As physicians, we work very closely with our nursing and laboratory science staffs to make the best decisions.
"It's important to think about the ‘long game’ in your institution," he adds. "Focus on building relationships among stakeholders."
#4: Use data wisely
Mayo Clinic specialists use a unified health data platform to refine transfusion practices. These efforts include identifying patients at high risk of transfusion complications such as transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI)—the most common causes of transfusion-related death.**
Comprehensive data can also help assess and improve transfusion practices across a center's departments and specialties. "Some parts of your practice might perform well, others sub-optimally. Data are the only way you can really understand that," Dr. Kor says.
This monitoring might provide opportunities to educate clinicians. "For example, there was an impression on our service lines that patients with atrial fibrillation should be transfused to a higher hemoglobin level, to help prevent recurrence of that arrhythmia," Dr. Kor says. "It turns out, there's no indication in the literature or in our data that we should be doing that, and we were able to modify that practice."
Enhanced data entry can also help to further refine clinical practice. At Mayo Clinic, clinicians ordering a blood product must indicate an evidence-based, approved application for that particular component. Clinicians always have the opportunity to select "other indication," if desired.
"Historically, we have had a poor understanding of what providers really meant when selecting 'other indication' as the reason for administering a blood transfusion," Dr. Kor says. "As our monitoring processes and technologies have matured, we can now better identify these 'other indications' and follow up with the ordering providers when they do not seem consistent with best transfusion practices.
"It's also important for us to understand if that indication is something that should be built into an updated algorithm or that might provide an opportunity for us to teach best practices," he adds. "Our future blood transfusion practice is going to be based on data that allow us to drill down to individual providers and give feedback to them relative to their peers."
#5: Commit to an ongoing process
Because blood transfusions are so common, they might be considered a minor issue in the spectrum of patient care. "Clinicians' thinking about transfusions can be relatively simplistic: 'Red blood cells are low; give red blood cells.' What’s the big mystique?" Dr. Kreuter says.
Similarly, it might be tempting to adopt transfusion guidelines that never change.
"But at Mayo Clinic, we've learned that improving transfusion practices is an incremental process, not a destination," Dr. Kreuter says. "A lot of our solutions have been implemented not as the perfect fix but as a first step that will lead us to the next step in a process of improvement."
At Mayo, providers and trainees receive additional education on blood transfusion. Dr. Stubbs would like medical school curricula at other institutions to include robust blood transfusion education at some point in the first two years and to reinforce that information formally during clinical rotations.
"Most of what medical students know about blood transfusion is learned late in their training from mentors at patients' bedsides," Dr. Stubbs says. "The knowledge base those students receive needs to be equalized and normalized in the clinical training years and then in residency as well. There is some general information—about what blood products can reasonably be expected to provide for patients, the indications for transfusing various blood products, and the adverse reactions or unplanned consequences of transfusions—that everybody should know if they're going to be given the privilege of ordering blood products for patients."
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Sources
*Pfuntner A, et al. Most frequent procedures performed in US hospitals, 2010: Statistical Brief #149. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Health Care Policy and Research (US); 2006–2013.
**Clifford L, et al. Characterizing the epidemiology of perioperative transfusion-associated circulatory overload. Anesthesiology. 2015;122:21.
**Clifford L, et al. Characterizing the epidemiology of perioperative transfusion-related acute lung injury. Anesthesiology. 2015;122:12.
