Over the last decade there has been increasing evidence of the potential harms associated with blood transfusions. Transfusions have been associated with increased risk of infections, SIRS (systemic inflammatory response syndrome), and other complications. While clinical factors need to be considered in any decision about whether to transfuse, use of a hemoglobin (Hb) threshold or trigger is still commonly used. Studies have demonstrated that use of more restrictive Hb triggers (8 g/dL) do not adversely impact patient outcomes and this has been reflected in multiple new guidelines regarding transfusion (see our April 2012 What’s New in the Patient Safety World column “New Transfusion Guidelines from the AABB”).
Now a new study from Johns Hopkins (Ejaz 2015), which has been a leader in improving transfusion practices (see our June 2013 What’s New in the Patient Safety World column “Hopkins Blood Ordering Initiative”), shows that substantial variation in transfusion practices persists, with potentially inappropriate transfusion practices leading to considerable consumption of resources. Ejaz and colleagues looked at PRBC transfusions in patients undergoing major abdominal surgery at Johns Hopkins over almost a 4-year period. They defined “liberal” Hb trigger as transfusion of PRBCs for an intraoperative Hb level of 10 g/dL or greater or a postoperative Hb level of 8 g/dL or greater. Overall, they found that 11.4% of units were transfused using a liberal trigger. They then calculated the estimated costs of such “liberal” transfusions, using an acquisition cost of $220/unit and an activity-based cost of $760/unit (the latter representing the mean cost from another study that calculated the cumulative costs for each step involved in delivering 1 unit of PRBC’s from a donor to a recipient, including technical, administrative, and clinical costs). They estimated that the total overall PRBC transfusion costs may have been reduced by $27,360 to $94,516 per year by adhering to the more restrictive transfusion triggers.
Note that the current study only assessed the acquisition costs of the blood and the estimated costs involved in getting the blood to patients (technical, administrative, and clinical costs). It did not include any additional costs that might have resulted from complications of the transfusion (eg. surgical complications, infection, longer length of stay, etc.). Patients in their study who received transfusions had more perioperative complications and longer lengths of stay even after adjusting for multiple clinical variables. So, given what we know about the potential downsides of unnecessary transfusion, the costs in the current study may be an underestimate of the true total cost of unnecessary transfusion.
The Ejaz study also revealed that the use of “liberal” transfusion varied significantly by type of surgery and by individual surgeon. Significantly, of the 92 participating surgeons the 9 surgeons least compliant with their institutional guidelines accounted for 80% of the total overall estimated excess transfusion costs.
We’ll bet your organization has a similar opportunity to improve both patient outcomes and the financial bottom line by instituting the more restrictive transfusion guidelines and auditing adherence to them.
Prior columns on potential detrimental effects related to red blood cell transfusions:
Ejaz A, Frank SM, Spolverato G, et al. Potential Economic Impact of Using a Restrictive Transfusion Trigger Among Patients Undergoing Major Abdominal Surgery. JAMA Surg 2015; Published online May 06, 2015
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