Inappropriate blood transfusions: Surgeons should lead the way

Inappropriate blood transfusions: Surgeons should lead the way

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.

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 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.

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • Ian

    “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.”

    This is a good article, however some clarification is in order. I would not anticipate the indications for blood transfusions to have much coverage time in the didactic portion of medical school at all. This aspect of patient management is likely to be taught during the clinical years in the non-didactic training of medical students and/or during the post graduate residency years. The standards and indications for transfusions for say a Hematologist is likely to be very different than say a Cardiothoracic or Transplant surgeon. In the didactic portion of medical school students learn the basic science of blood transfusions and the difference between a type and cross and a type and screen. This doesn’t take more than a couple of hours. While a case can be made that more standardization and/or a decrease in the rates of blood transfusions is warranted (and your suggestions for the most part are good ones (I will leave the scorecard idea to any surgeons out there)), suggesting the didactic portions of medical school as lacking is not accurate.

    • http://twitter.com/Skepticscalpel Skeptical Scalpel

      Ian, thanks for the comments. I acknowledge your point about the specificity of teaching indications for transfusion to students in the first two years of med school. But they need to learn about this somewhere and they obviously are not learning it during residency. You still see doctors transfusion patients because their hematocrits are 29.9%.

      Maybe they should learn more about when to transfuse and not so much about the basic science in med school.

      If they aren’t getting it in school or residency, then where should they get it?

      • Ian

        They should get it in residency and most of your recommendations seemed to imply as such. I was more pointing out to the non-medically trained that most medical students aren’t ready for that level of clinical training when they are still doing classroom work. A minor point to make in regards to an otherwise excellent article. My apologies if you took it as a criticism to the overall point you were trying to make. I tried to be very specific in regards to the quote I used implying it only accounted for the lecture portion of medical school. This was not meant to take way from your overall point that it is not being taught sufficiently at any time. Your observation applies to my medicine colleagues as well given different clinical circumstances.

        • http://twitter.com/Skepticscalpel Skeptical Scalpel

          I appreciate your explanation. No offense taken. Like I said, let’s teach it somewhere.

          • Shalena Garza

            As a pathology resident we have been assigned the task of sifting through so called “flagged” cases in which there was not an obvious reason for transfusion. Our job is to search through the chart and try to find a reason to let it “pass”. The guidelines regarding this have been vague and there is a lot of room for allowing a “pass”. If it doesn’t pass the first time then the director reviews it and if it doesn’t pass by the director of the blood banks eyes then it will go to a committee for review. I am interested to know, what people would think about the pathologist or blood bank director giving lectures to clinicians about blood transfusion indications or how we are suppose to review these cases? Would this be accepted or met with resistance?

      • Andrew Levin

        In my 3rd year clerkships I had several physicians–and a few upper-level residents–pimp me on indications for blood transfusions. They often did this in ways that stimulated critical thinking (“Why are we not transfusing patient X even though his hemoglobin is 8?”), and I appreciated it because this level of clinical management was not taught during the first two years.

        • http://twitter.com/Skepticscalpel Skeptical Scalpel

          Thanks for commenting. It sounds like your school is on the right track regarding this topic.

  • http://twitter.com/TimHannonMD Tim Hannon, MD

    Nice summary of the issues regarding blood use. Blood transfusion is a high volume, high risk, high cost therapy that is poorly utilized. As you pointed out, the root cause is a lack of standardized training in blood component therapy in medical school and residency, so physicians essentially get on the job training that is institution specific. I am an anesthesiologist, so for years I tried to figure out why different surgeons approached transfusion practice in similar patients quite differently. The answer is that transfusion practice is largely inherited, so it depends on where you trained and when you trained. Beyond this initial lack of basic training, transfusion guidance has become substantially more conservative over the past decade, and there is often a significant lag in published information becoming common clinical practice. The situation is made worse by the fact that most hospitals are unaware of these knowledge gaps, so they don’t provide adequate oversight and education for appropriate blood use (e.g, effective transfusion committees). I firmly believe that doctors and hospitals want to do the right thing regarding blood use- they just don’t know what they don’t know. I have found the driving factor for changing transfusion practice must be patient safety: inappropriate transfusions cause avoidable harm, so the decision to transfusion is a critical component of transfusion safety.

    • http://twitter.com/Skepticscalpel Skeptical Scalpel

      Tim, I agree that a lot of things we do depends on how we were trained. We need to move away from that.

  • http://twitter.com/KarenSibertMD Karen Sibert MD

    Certainly it’s a good thing that we’ve moved away from the knee-jerk response to transfuse as soon as the Hct drops to 30. Unfortunately, what I see as an anesthesiologist in a tertiary care center is that often things have gone too far the other way. Sick inpatients will be scheduled for surgery with Hct in the low 20s, and then need more blood acutely in an unstable situation. If transfusion is to be used as a quality indicator, then failure to transfuse in a timely manner should be considered as well.

    Like so many things, it’s difficult to set a universal “evidence-based protocol” for perioperative transfusion. The risk of causing immunosuppression in cancer patients may be a predominant consideration at times. For other patients, the need to preserve cerebral and coronary perfusion may indicate transfusion earlier. It’s always best when the surgeon and the anesthesiologist are on the same page in determining when transfusion is appropriate, both for the current condition of the patient and taking into account the likelihood of further surgical blood loss.

    • http://twitter.com/Skepticscalpel Skeptical Scalpel

      Karen, I agree with you. As I said, the decision to transfuse in the OR should be based on a discussion between anesthesiologist and surgeon, preferably before the case even starts.

  • Cheriece

    Is it recommended to give a blood transfusion at a blood level 5.8?