Despite the fact that many papers have identified the problem, inappropriate blood transfusions continue in hospitals across the nation.
This topic was featured at the recent Patient Safety Science and Technology Summit that was held in Orange County, California last month.Transfusion of packed red blood cells is very common. Over 2 million patients or 5.8% to 10% of inpatients are transfused every year with some 15 million units of blood
There is much variability and inappropriateness in the use of blood transfusions.
A paper in the February 2013 issue of Annals of Surgery reviewed the University Health System Consortium database and the American Hospital Association Annual Survey File for the years 2006-2010. The authors reviewed 54,405 total hip replacements, 21,334 colectomies and 7929 pancreaticoduodenectomies.
Even when adjusted for patient risk factors, hospital-specific transfusion rates ranged from 1.5% to 77.8% for total hip replacement, 1.7% to 49.9% for colectomy and 0% to 90.9% for pancreaticoduodenectomy. Bear in mind that this study involved university hospitals.
A recent survey showed that while medical schools devote an hour or two to lectures about blood, they center on blood typing and compatibility but not on indications. A speaker at the summit pointed out that it is time to start focusing on the safety of patients rather than the safety of blood.
One study showed that only 12% of blood transfusions were appropriate, 59% were inappropriate and opinions were divided about the appropriateness of the remaining 29%.
Here are some important points:
- Blood transfusion is rarely based on sound evidence because except in trauma patients, there is not much evidence in the literature.
- Few articles support the premise that transfusion improves outcomes.
- Blood transfusion has a poor risk-benefit ratio. There are many adverse outcomes such as infection, immunosuppression, transfusion-related acute lung injury, allergic reactions, errors in administration and even death, to name a few.
- The true cost of a unit of blood is estimated at $500 to $1200, which means that at 15 million units per year, overall costs could be as high as $15 billion. And that is just the cost of the blood itself. It doesn’t include costs of associated complications.
- Overuse leads to shortages causing patients who might really benefit from a transfusion to not receive it in a timely way.
- Informed consent discussions rarely mention the risks of transfusion.
- Many doctors and administrators are not aware of the problem of transfusion overuse.
With a concerted effort, the Cleveland Clinic has decreased the use of transfusions by 30% in the last four years.
The panel discussion at the safety summit concluded the following:
Anemia in patients scheduled for elective surgery should be identified and corrected without transfusion if possible.
In the OR, the decision to transfuse should not be based on a number. To avoid confusion, the trigger to transfuse should be discussed during the pre-operative time-out.
Transfusion should become a quality indicator with physician champions, education of medical staffs, justification of every unit transfused and scorecards for those prescribing blood.
As surgeons, we should be leading the effort to rectify this continuing problem.
A link to the video of the Patient Safety Summit presentation and panel discussion on the overuse of red blood cell transfusions is here.
Disclosure: I attended the Patient Safety Science and Technology Summit thanks to a grant from Masimo who had no input into what is written here.
Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages 800 page views per day, and he has over 4700 followers on Twitter