When Steve Frank, MD, director for the Center for Bloodless Medicine, Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medical Institutions, started a blood management program back in 2012, he hoped it would make a significant difference in the organization’s blood spend.
Fast-forward six years, and the result is millions of dollars in savings. In 2017, Johns Hopkins Institutions saved $1.1 million out of their $28 million budget. Projections for this year estimate a $2.8 million cost savings.
Moreover, Frank was thrilled to see the positive impact on patient care and progress toward achieving a true safety culture. He notes that, system-wide, median length of stay dropped from three days to two, 30-day readmissions decreased from 9 percent to 5.8 percent, and morbidity decreased from 1.3 percent to 0.54 percent.
In addition, Johns Hopkins has become an industry leader in establishing a safety culture for blood management. The program was among the first to be certified by The Joint Commission in patient blood management.
Changing the Transfusion Paradigm
The guidelines for transfusion developed by AABB (formerly the American Association of Blood Banks) have changed drastically in the last decade. Many of the older physicians at Johns Hopkins were practicing under the old standard, Frank says, collecting up to 50 percent more blood during transfusion than was necessary.
“Studies about the ‘less is more’ theory in transfusion have come out in the past five years,” Frank says. He notes that 10 studies published in The New England Journal of Medicine have supported restrictive transfusion strategies. “Rarely are there 10 randomized trials to support anything we do in medicine, but all 10 showed patients do better when we give less blood,” Frank says.
Blood transfusion is recognized as one of the five most overused procedures in modern medicine. Approximately 85 million red blood cell (RBC) units are transfused annually worldwide, including 12 million units in the United States, where between the cost of blood itself (approximately $2.5 billion) and the associated overhead costs of transfusion, the annual financial burden is approximately $10 billion. These figures do not include costs associated with managing transfusion-associated infectious and noninfectious adverse reactions.
Establishing Hospital Guidelines
Per Frank, it’s essential to agree upon transfusion guidelines and write them into official hospital policy. A template for blood management guidelines usually includes laboratory-based thresholds for:
A great deal of complication can be avoided by outlining in advance the reasons for ordering transfusions that exceed guidelines. These can later be used as evidence for bypassing best-practice advisory alerts that may be built into the electronic health record.
Getting Everyone on Board
As Johns Hopkins ramped up patient blood management efforts and eventually became involved in the certification process, nurse practitioners and physician assistants followed the best-practice updates and wanted to be involved in the changes. Their participation made sense because NPs and PAs order 33 percent of transfusions at Johns Hopkins, so a lecture series was developed.
While it was encouraging to have so much enthusiasm, hospital leaders quickly realized that the educational component wasn’t adequate. Creating an electronic educational module that was mandatory for new staff was a big undertaking but proved worthwhile.
The catchy phrase “Why Give Two When One Will Do?” oriented the entire staff to the concept of choosing blood units thoughtfully. Posting a graphic image on every screen saver in the hospital was a quick way to orient the entire organization to the initiative.
To reach doctors, Johns Hopkins enabled its Epic software to alert physicians with a best-practice advisory linked to one of the NEJM articles.
Most physicians offered positive feedback about being alerted to new guidelines, but some remarked that it was distracting during a massive transfusion. “If you’re in the middle of a transfusion with an active hemorrhage, a pop-up alert will slow you down,” Frank says. “In those cases, we had them turned off.”
Johns Hopkins physicians were also mindful about under-transfusion. “When you start giving less blood, you run the risk of giving too little blood,” Frank says. “We want to find that middle ground. If patients are actively bleeding, we always want physicians to remember that blood saves lives.”
The organization’s IT department also used Epic data to create a provider-specific compliance report that was shared monthly. Harnessing physicians’ competitive nature, this simple color-coded chart allowed physicians to compare themselves with their peers in the adoption of best practices for blood transfusions. “When they know we’re watching their practice, it tends to improve,” Frank says.