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Blood Management: "In 2008, everyone was talking about it. In 2009, everyone wants to do it."
In his presentation at Terumo's Optimizing Cardiac Surgery Symposium in Orlando on May 21, Timothy Hannon, MD, opens by posing the question, "Why the sudden interest in blood management?"
He answers the question in his presentation, Blood Management Primer, by providing a realistic definition of blood management, an overview of transfusion usage in the U.S., and a discussion of the key drivers of the blood management movement, including issues related to blood storage, patient safety, and cost.
He also suggests that "clinician education is the linchpin of any blood management program."
Dr. Hannon's own interest in blood management is far more long-lived. He has been practicing blood management for 16 years, beginning with his medical training in the U.S. Navy where conditions made it necessary to conserve blood. As an anesthesiologist and current Medical Director of the Blood Management Program at St. Vincent Hospital in Indianapolis, Dr. Hannon has participated in driving 30% reduction in blood transfusions at the 750-bed institution. And as the President of Strategic Healthcare Group, a blood management consulting company, Dr. Hannon has counseled many organizations on implementing best practice and has seen the interest in the subject extend to such non-clinical publications as the Wall Street Journal.
The right product in the right dose at the right time
When Dr. Hannon defines blood management — an evidence-based, multidisciplinary process designed to promote the optimal use of blood products throughout the hospital — he spends several minutes focusing on the words optimal use. He explains that it is not always practical or advisable for an institution to abandon transfusions. Instead he proposes that an institution aim to give "the right product in the right dose at the right time."
He adds that the goal of any blood management program is "to achieve the safe and efficient use of the many resources involved in the complex process of blood component therapy," an important goal when an institution considers that "each transfusion takes two hours and fifteen minutes of nursing time" alone.
Lack of standardized training
Dr. Hannon describes most U.S. physicians' transfusion practices as "habit-based" instead of "evidence-based."
As a result- or perhaps as a cause- there is tremendous variation in the percentage of patients that receive a transfusion. He cites a study of 24 US hospitals in which there was a four-fold difference in the percentage of patients transfused and another international study using similar patients that found a 12-fold difference.
Dr. Hannon contends that transfusion practices vary not only from institution to institution, but also from physician to physician within a single institution. This variation contributes significantly to the U.S.' 16% increase in transfusion rates from 1999- 2004, a time when they were decreasing in other countries. In fact, the U.S. uses 15% more red blood cells per capita than Europe and 44% more than Canada.
"Education about blood management is the linchpin for reducing transfusions," says Dr. Hannon. "It is more effective to minimize transfusion exposure in the first place than to use even the highest quality of banked blood."
Dr. Hannon then reviews the most significant issues that have been propelling the recent interest in blood management, focusing on blood storage, safety and cost.
He describes the changes in formed blood elements as they age in the blood bank, including the deformation of red blood cells and the build-up of inflammatory markers, cytokines and other debris. "We have overestimated the ability of banked blood to deliver oxygen," he begins.
He proceeds with an overview of the safety issues associated with transfusions, reminding the audience that transfusions are "allogenic transplants associated with infections, allergic reactions, and hemolytic errors."
He concludes with the inevitable discussion of the costs of transfusions, citing a study in which the costs of labor, adverse effects, and overhead raise the cost of a unit of blood from $200 to $1900.