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."