Improving Blood Transfusion; Hemoglobin Level an Inadequate Metric
Posted Mar 20 2014 12:00am
This is a guest blog note by Dr. David Jadwin, a pathologist and founder of Columbia Analytics , a company that provides external medical chart reviews. He is particularly active in the assessment of hospital blood transfusion practices and an advocate of external chart review. --BAF
Although not required to have a specific transfusion committee, hospitals are required to review hospital blood use to ensure that transfusions meet appropriateness criteria established by the medical staff. When hospitals perform such blood use reviews, they are often cursory and frequently fail to recognize the 30 to 50 percent of non-beneficial transfusions that occur in nearly every hospital. There are many reasons that internal chart review is not effective. These include lack of subject matter expertise, uncompensated physician review time, inappropriate criteria, and reviewer bias that occurs when physicians review the work of physicians they know and with whom they may have economic, political, social, and referral relationships.
The fact that our country spends $800 billion dollars for unnecessary healthcare services and that medical error is perhaps the third leading cause of death in the US highlights the failure of internal review to ensure high quality patient care. While some hospitals have made modest gains in reducing blood use, few, if any, have reduced blood use by the percentage necessary to achieve "bloodless" healthcare. That's because they focus on the wrong metric, the percent reduction in blood use, rather than the percent of avoidable transfusions accompanied by more than 20 other metrics that measure the effectiveness of patient blood management. Unless a standardized, objective, comprehensive, and independent (external) review is performed, hospitals and physicians will probably not recognize the extent to which non-beneficial transfusions occur.
Hospitals persist in using single laboratory values as benchmarks for appropriate use of blood such as the hemoglobin level. This despite the fact that such decisions are too complex to be based on a single lab test (see: Red blood cell transfusion: a clinical practice guideline from the AABB ) We routinely find transfusion orders that meet the hospital-approved hemoglobin level of <8 gm/dL for packed red blood cells in a stable non-bleeding patient. Decisions to transfuse blood are not simple and it's not possible to create specific rules that every physician can employ.
Transfusion medicine requires physicians who have specific complex knowledge and decision-making skills and particularly those who feel comfortable not transfusing patients. It is perhaps for this reason that AABB has recently proposed standards to specifically credential physicians for transfusion medicine just as physicians currently are credentialed for conscious sedation privileges.
A hospital system-wide, state-wide or even national review process will be required to improve blood use across the country. An external review process can ensure that every chart, every physician, and every hospital is reviewed in a standard manner and create transparency about blood transfusion practices that currently doesn’t exist. Since blood represents one of the highest supply costs for hospitals and 30 percent or more (perhaps even 70 percent) of transfusions are non-beneficial, then 100 percent chart review capable of identifying all inappropriate events is necessary. Technology currently permits cost-effective review of all hospital blood transfusions and educational feedback to physicians to improve hospital blood use.