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Patient Safety Tip of the Week
January 9, 2024
Hopkins Blood
Management Program 10 Years Later
Ten years ago we highlighted a blood management program at
Johns Hopkins Hospital (see our June
2013 What's New in the Patient Safety World column “Hopkins Blood Ordering Initiative”). A recent study presented at the 2023
annual meeting of the American Society of Anesthesiologists (ASA 2023, Vlessides 2023) reported
on the financial savings that program produced, and they are phenomenal, all
without harming patient outcomes!
They actually have 2 programs at
Hopkins:
·
a blood management program that seeks to reduce
unnecessary transfusions
·
a bloodless program designed to avoid
transfusions for patients who decline them, primarily Jehovah’s Witness patients
Together, these programs
had a greater than sevenfold
return on investment (ROI).
Steven M. Frank, MD,
Professor of Anesthesiology and Critical Care Medicine at Johns Hopkins
Medicine was lead author of the study. He noted 22 things they do to avoid
unnecessary transfusions, including things like treating preoperative anemia
before elective surgery, using evidence-based transfusion triggers, a “Why Give
2 When 1 Will Do?” single unit of blood transfusion campaign, and other
anesthesiology-led before, during or after surgery measures of “keeping blood
in the patient” such as using tranexamic acid during surgery or intentionally
lowering blood pressure to reduce bleeding, and even using smaller tubes to
collect blood for lab tests. Over a 10-year period, the annual blood
acquisition cost reduction was $2.9 million, a 10.9% decrease and a 9.6-fold
return on investment.
Frank said “We like
to say that blood saves lives when you need it, but only increases risks and
costs when you don’t. Our results showed that a comprehensive blood management
program can substantially help the bottom line — for every dollar spent, we
received $7.50 in return.” Clinical outcomes such as infection, blood clots,
kidney injury, heart attack or stroke were the same before and after the
Patient Blood Management Clinical Community program was instituted.
The bloodless
surgery program brings in revenue by attracting patients who are often turned
down by other hospitals. Over 10 years, that program brought in approximately
$5 million a year (after subtracting the direct cost of care), representing a
6.6-fold return on investment.
Clinical outcomes
such as infection, blood clots, kidney injury, heart attack or stroke were the
same before and after the Patient Blood Management Clinical Community program
was instituted. Clinical outcomes were the same or better for the Center for Bloodless
Medicine and Surgery program, as the incidence of hospital-acquired infection
was significantly lower when transfusions were avoided.
Frank notes that “we
are actually doing more with less
and providing higher value care”. Most
of our prior columns have pointed out some of the downsides of transfusions
from a patient safety standpoint. But a few did discuss potential cost savings
as well. The Hopkins experience clearly demonstrates that evidence-based blood
management programs make sense from both a patient safety standpoint and an
economic standpoint.
The Hopkins
experience appears to have focused especially on transfusion strategies in
surgery. But most of our prior columns regarding transfusion strategies, listed
below, have pointed out the benefits of more restrictive transfusion strategies
in multiple clinical situations. Results of the MINT (Myocardial
Ischemia and Transfusion) trial were also just recently reported (Carson 2023).
That study found that, in patients with acute myocardial infarction and anemia,
a liberal transfusion strategy did not significantly reduce the risk of
recurrent myocardial infarction or death at 30 days. However, trial end points
did suggest some potential benefit of a liberal strategy over a restrictive
strategy, but additional studies would be needed to confirm that conclusion.
Given the
substantial financial benefit demonstrated by the Hopkins group, it is
imperative that all organizations implement evidence-based blood management
programs.
Prior columns on
potential detrimental effects related to red blood cell transfusions:
·
March 2011 “Downside
of Transfusions in Surgery”
·
August
2011 “CPOE Alerts Reduce Blood Transfusions in
Children”
·
January
2012 “Need for New Transfusion Criteria?”
·
April
2012 “New Transfusion Guidelines from the AABB”
·
February
2013 “More Evidence Favoring Restriction of
Transfusions”
·
June
2013 “Hopkins Blood Ordering Initiative”
·
May 2014
“Blood Transfusion and Infection Risk”
·
June
2015 “Economics and Blood Transfusion”
·
November
2016 “AABB
Updates Transfusion Guidelines Again”
·
December
2017 “Study
Confirms Safety of Restrictive Transfusion Policy”
·
January
2018 “Transfusion
in Cardiac Revision Surgery”
·
August
2018 “Thromboembolism:
Another Downside of Transfusions”
·
August
2021 “New
Blood Management Guidelines for Cardiac Surgery”
References:
ASA (American
Society of Anesthesiologists). Anesthesiologist-led blood management programs
save hospitals significant amounts of blood and reduce costs with same or
better patient outcomes. ASA Press Release October 13, 2023
Vlessides M. Blood Management
Program Yields Significant Cost Savings, Comparable Patient Outcomes.
Anesthesiology News 2023; December 5, 2023
Carson JL, Brooks MM, Hébert PC, et al. Restrictive or
Liberal Transfusion Strategy in Myocardial Infarction and Anemia. N Engl J Med
2023; 389: 2446-2456
https://www.nejm.org/doi/full/10.1056/NEJMoa2307983
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