Blood products represent a critical function for hospital laboratories. Poorly managed, they place hospital services in jeopardy and may impact the accreditation status not just of the laboratory, but the entire hospital. Even properly managed, routine use of blood products still poses a danger to patients through issues such as adverse transfusion reactions, which can compromise patient care and present a financial burden to the facility. Therefore, best practices in blood product processing, storage, distribution, and management require the involvement of numerous members of an organization, and herein those most critical to the laboratory will be discussed.
To Transfuse or Not Transfuse
Annually, the United States transfuses 21 million units of packed red blood cells (PRBCs) at a cost to the hospital of $210 per unit.1 This means that hospitals can spend $4.4 billion a year to transfuse red blood cells alone. The cost passed on to the patient is measured in the thousands of dollars per unit, but this does not factor in the true cost. A serious adverse transfusion reaction is reported in 1.1% of all transfusions with transfusion-associated circulatory overload representing the bulk of those reactions (1%).2 Furthermore, transfusion-related acute lung injury (TRALI) is documented in 0.08% (1 in 1250) of transfusions.2 Transfusions are linked to additional lengths of stay no matter the original admitting diagnosis, and this in turn increases the likelihood of contracting nosocomial infections, leading to further complications and comorbities.3-6
As blood product transfusions are expensive and are associated with complications, they should not be endeavored with any attitude other than do no harm. Due consideration and deliberation must be used when ordering and administering what are essentially liquid transplants. Blood usage is on the decline in the US and has been for the last decade; from 2013 to 2015, blood usage in the US declined by 13.9%; a trend that is continuing.7,8 Thus, consider employing some laboratory-based, administrative-decision tools associated with transfusion initiations and the evaluation of their utility. While blood management can be extrapolated beyond PRBCs to fresh frozen plasma (FFP) and apheresis platelets (APPLT), the methodology is consistent.
Establish Blood Management and Review
The establishment of a blood management program is a highly effective method for reducing unnecessary transfusions, and this requires an understanding of current and ideal utilization. In performing a comprehensive review of blood usage in a given facility, a desirable blood-usage level should be determined based on the patient population served.
As physicians (providers) write transfusion orders, the process for changing transfusion rates must involve these providers in all phases. During preplanning and throughout program implementation, input from providers will help reduce issues downstream. For the laboratory, this means pathologist involvement, but the lab must provide the pathologist with relevant data to analyze and share with the providers. The same data should be shared with the nursing staff who directly care for the patients and influence provider ordering. To enable these actions, the goal of the first foray into a blood management program should be the establishment of a blood utilization and review committee (BRC) consisting of self-identified champions from amongst all clinical stakeholders.9
A Solid Review Committee Structure
There are multiple ways to structure a BRC depending on the facility and patient population profile. Thus, each laboratory can use the following as a template and make adjustments as needed. The BRC should be chaired by a pathologist or the chief medical officer (CMO). The blood bank manager/supervisor/lead should serve as the primary data collector and keeper. The invited committee membership should comprise a provider from each of the major transfusing departments, as well as departments where transfusion is rare but often emergent.
Typical departments include (but are not limited to) the emergency department (ED), intensive care unit (ICU), operating room (OR), hematology-oncology (HEMOC), and obstetrics (OB). A senior nurse from each of these departments should be invited as well. Nursing managers can often serve in the role of champions and are welcome additions to the committee. Regarding C-suite involvement, if the facility does not have a CMO, the chief nursing officer (CNO) is a viable option. As always, this committee should be formed in accordance with hospital committee policy and be approved by the hospital to have maximum efficacy.
Primary Data Points
The staff member(s) responsible for data collection (ideally, the blood bank manager) should be highly instrumental in driving positive change. Typical data points that would most benefit the committee incorporate the number of transfusions per provider, facility/department average hemoglobin (HGB) trigger point, crossmatch to transfusion ratio, and the number of transfusions occurring in each of the following categories: <7 g/dL, 7-8 g/dL, 8-10 g/dL, and >10 g/dL.
Number of Transfusions
Notably, variations between providers and departments, and temporal variations within the same individual or department should be reviewed and analyzed. Within a department, direct and accurate comparisons can be made; if one ICU provider transfuses an average of 25 units per month, but another ICU provider transfuses 60 units per month with similar or worse outcomes, opportunities for practice improvement may be self-evident. These data can be presented (deidentified) at pathology review meetings, offering opportunities for peer-to-peer education among providers.
Average Trigger Point
Given that the average HGB trigger point (ie, average hemoglobin at which a transfusion order is given) is a key metric to the blood management program, this hemoglobin should be obtained within 4 hours of the transfusion event and after each transfusion under routine circumstances (eg, before initiating additional transfusion events). While many blood bank and transfusion services practitioners have encountered or even espoused the historic attitude of “it can’t hurt and it might help” regarding transfusion, more recent studies have indicated that transfusion below 7.0 g/dL, compared to more liberal transfusion, results in better 30-day post outcomes.10,11 This statistic and the associated median and mean data point for the institution should be presented at every BRC and education meeting. Furthermore, if these data can be distilled down to individual departments, then targeted improvement becomes more likely.
The crossmatch-to-transfusion ratio is another way to look for improvement opportunities. When a provider or department orders crossmatches that are ultimately not used, it represents an opportunity to share transfusion medicine updates with that provider. For years, blood banks have engaged in ordering crossmatches on patients who have antibodies or may have delayed transfusion for any reason. On all other patients who have a valid type and screen, blood banks can have blood products ready for issue within five minutes of notification.
Transfusions per Category
Using the opportunity to identify an ordering pattern by a specific provider and integrating that information with the laboratory and blood bank information systems will benefit all stakeholders. Best practice recommends the following hemoglobin ranges with the corresponding actions: Transfusions below 7.0 g/dL are in full agreement with modern best practice and require no investigation. Transfusions from 7-8 g/dL will likely be in line with best practice, or ambiguous enough that many providers in similar circumstances would have concurred with the order to transfuse. Orders from 8-10 g/dL may be necessary, but generally these transfusions do not hold up well under investigation and provide best practice improvement opportunities. Orders above 10 g/dL should be investigated thoroughly every time, preferably in real time.
How to Make Improvements
While substantial time can be spent identifying opportunities, incorporating certain tools so the BRC and the laboratory can facilitate improvement as they engage with providers is likewise essential. The laboratory information system (LIS) can be key to data collection as mentioned, but it can also assist in real-time through the utilization of a transfusion review/utilization (TRU) test. Laboratory leadership can set the LIS to default all crossmatch orders to single unit; historically this default was for two units.
The critical value and delta (rapid change in) values also can be revised in such a way as to drive improvement while keeping patient safety at the forefront. Finally, safety valves can be put in place to assure providers that, in emergent situations, these programs will not prevent them from providing needed care. The BRC can provide education both in the form of peer mentorship and grand rounds.
The TRU Test
The development of a TRU test can be incorporated into the initial crossmatch order. At the time of crossmatch, require entry (or pull) of the last date, time, and value of the most recent hemoglobin. Have the values coded such that <7.0 g/dL triggers no review, values >10.0 g/dL require real-time pathologist notification, values 8-10 g/dL go for retrospective review, and values 7-8 g/dL have an X% random review (% determined by the BRC). A similar approach can be taken with FFP and APPLT using INR and PLT count respectively.
Practical examples of the above would be where a technologist receives a crossmatch order, pulls the most recent hemoglobin as 8.2 g/dL three hours prior and, upon entering the data, the system automatically orders a pathologist review. In another example, an 11 g/dL hemoglobin is noted triggering a hard stop requiring a real-time pathologist review.
Single Unit Transfusions
The LIS can be programed to default the order from the traditional method of transfusing two units to the more modern approach of single unit transfusion.12 This does not restrict the provider from ordering additional units; it simply establishes single unit transfusion as the default setting. By way of example, a monthly 10% review of hemoglobin between 7-8 g/dL finds a transfusion initiated at 7.6 g/dL. This case is then presented at the next BRC meeting and discussed as a group so that all may benefit from possible lessons learned. If the transfusion is unjustified, a peer-to-peer discussion or letter from the board takes place to provide educational benefit to the ordering provider.
Critical Value and Delta Values
The purpose of critical values is to prompt immediate life-saving action on the part of the provider. By leaving the critical hemoglobin value at older values >7.0 g/dL, a facility may initiate unneeded action.13 Some facilities have adopted hemoglobin critical values as low as 6.0 g/dL (eg, Mayo Clinic, University of Louisville Health Network). However, what may be of greater importance is the delta setting. Rapid blood loss leads to death, and a strong delta program, once correctly explained, should provide comfort to providers when introducing such a radical idea as a 6.0 g/dL critical low value.14 Delta policies are lab managed processes to prompt action if rapid changes in laboratory values are detected. A good delta for hemoglobin is 2 g/dL between readings.
As previously discussed, the real key in adjusting provider behavior is positive peer-to-peer discussion. While education from the BRC can be meaningful, engagement in CEU backed grand rounds remains a simple and tested method leading to lasting change.15 To be clear, hospitals and laboratories should have a method to bypass the above procedures and save them for retroactive review. Emergency transfusion protocols should end discussions and result in immediate life-saving transfusions. This policy should be well distributed and clear. If not used regularly, drills can prevent mishaps during a real emergency.
Transfusion medicine expert Dr. Robert Beal famously said, “Blood transfusion is like marriage: It should not be entered upon lightly, unadvisedly or wantonly or more often than is absolutely necessary.” This tongue-in-cheek phrase remains valid today; transfusions can introduce the opposite of their intended effect and represent a considerable expense to the organization when improperly or wantonly administered. Establishing a blood management program featuring a utilization and review committee, revising protocols, and engaging in provider education is the responsible, necessary course of action for all laboratory, blood bank, and transfusion services professionals.
Michael Veri, MLS(ASCP), MS, is currently serving the United States Military overseas as the laboratory advisor to more than 40 labs in over 20 countries. Michael and Christoff Coetzee are the principal authors of “Lab Management 101,” a free weekly webinar to educate current and future lab leaders. He collaborates with LTS Health to provide this service to the benefit of the laboratory community.
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