Improving Blood Management

It’s a rather vicious cycle; no resource is in greater demand in the hospital environment than blood, yet only a fraction of institutions have a program dedicated to improving blood management. At the Cleveland Clinic, leaders addressed this quandary by leveraging technology—in the form of a blood bank data system and a business intelligence dashboard—to clean up the blood management process.

By Ajay Kumar, MD, MRCP, FACP

In the hospital setting, blood products are precious resources, and transfusions are common practice. Management of blood products is both complex and resource-intensive; however, many clinicians remain only vaguely familiar with the indications of transfusion, management of waste, and risks associated with transfusion.

Allogeneic blood transfusions are known to be associated with an increase in the rate of postoperative complications. Patients who receive blood transfusions have been reported to have higher rates of perioperative infection, longer hospital stays, and increased mortality.

Not surprisingly, the public has expressed concern for the safety of the blood supply, and particularly for the risk of HIV transmission through blood transfusion. Generally, the transmission of disease through blood transfusion is lower than it has ever been; in the US, the per-unit risk of transmission is estimated at one in 1.8 million for HIV and one in 1.6 million for hepatitis C (http://hcp.lv/bVMnek). However, in a national telephone survey of 1,204 respondents (conducted in the US in 1997-1998), a substantial portion of participants did not consider the national blood supply to be safe and would not accept banked blood if hospitalized (http://hcp.lv/c2Qibk).

Presently, the most serious known risks for allogeneic blood are ABO-incompatible blood transfusions caused by administrative error, and transfusion-related lung injuries. It is also known that exposure to leukocytes in allogeneic blood can cause immunosuppression (http://hcp.lv/90TZDL; http://hcp.lv/b1yBDF).

In 2006, the total number of units (both red blood cell non-RBC components) transfused in the US was roughly 30 million, marking an increase of about 1 million (3.5%). This accounted for over 82,000 products transfused each day. Almost 72,000 blood transfusion-related adverse reactions were noted in 2006 that resulted in therapeutic interventions (http://hcp.lv/b5CVBg)—and one may wonder about the underreporting due to the lack of a hemovigilance program. Regulatory and profession-al organizations, including the Joint Commission, the American Association of Blood Banks, and the College of American Pathologists, require ongoing monitoring of blood utilization within institutions. Despite the commitment to a number of resources necessary for the delivery of blood components, and the focus of the FDA and the Joint Commission on safety initiatives, many practitioners have only a vague understanding of the issues related to perioperative risk associated with blood transfusion therapy.

Blood management is a concept that is just beginning to evolve in the health care setting. It incorporates an evidence-based approach with respect to the use and management of blood components. The concept of blood management, however, differs from blood conservation. The latter applies largely to reducing blood use or the expression “bloodless,” which is generally targeted toward patients of certain religions or a sector of the populace who prefer to avoid blood transfusion. Blood management pro-grams in the hospital setting are ideally multidisciplinary programs that involve systematic efforts to provide oversight, education, benchmarking, and resources for practicing clinicians.

Cleveland Clinic's Mission

The Cleveland Clinic in Cleveland, OH, launched an all-encompassing blood management program in late 2007. The intent was to create a comprehensive, evidence-based, data-driven, patient-centric initiative. Through support from leadership, an initiative was established with the goal of improving quality and patient safety. It has further developed into a state-of-the-art program that incorporates data benchmarking, education, and a patient-focused peri-operative blood management program.

The program began with a critical analysis of the data and the creation of an indication-based process for ordering blood components. The process—which utilizes a computerized patient order entry (CPOE) system—requires users to answer a series of questions, including the authorizing staff physician’s name and the Cleveland Clinic’s blood component transfusion guidelines. Developed by a multidisciplinary group of clinicians, the guidelines serve as a standard for the indications with respect to each of the various blood components.

The data from the EHR, blood bank data system, and intraoperative data management system are collected and analyzed, and a business intelligence dashboard sorts through the data each month. The results are then displayed as the ordering practice for each physician on a transparent dashboard. This, in turn, is used as part of a quality-improvement process by each department and institute within the Cleveland Clinic. The transparent dashboard is a state-of-the-art system that provides views from the executive, institute, and physician-specific levels; at the physician-specific view, details are provided about the indications for which the blood component was ordered. The dashboard is still in development, and in the near future will comprise a comprehensive data set for all aspects of the blood components, including blood waste information.

Education is provided by several physician champions to incoming staff, as well as the residents of Cleveland Clinic, where a comprehensive intra-net site has been created to provide evidence-based information about the appropriate use of blood components, including handling and storage. It also provides links to various educational sites, as well as CME information.

At the Cleveland Clinic, our team has begun evaluating the effectiveness of intraoperative blood saving techniques, such as the Cell Saver autologous blood recovery system. The aim is to create a process to deliver services to the right patient while simultaneously improving the efficiency of the tech-nical and personal resources.

Our patient-centered care approach is designed to improve the overall experience for patients who are undergoing elective surgeries at the Cleveland Clinic. At our IMPACT Center (Internal Medicine Preoperative Assessment and Consultation Center), patients are evaluated for anemia, which is then corrected with the appropriate treatment tailored to the needs of that patient (iron repletion, vitamin supplementation, and ery-thropoietin-stimulating agents may be included as part of the regimen). This helps patients to correct their anemia prior to elective surgeries and avoid the risk of allogeneic blood transfusion.

Over the last two years, we have worked to establish a heightened awareness of the appropriate use of blood components through vehicles such as newsletters, grand rounds, the Intranet, e-mails, and resident education forums, as well as a national-level blood management summit. And in spite of the rise in volume and complexity of the patient population, Cleveland Clinic’s blood management program has been successful in bending the curve in blood component utilization.

Ajay Kumar MRCP, MD, is medical director of the Internal Medicine Preoperative Center and is medical director of blood management at the Department of Hospital Medicine at the Cleveland Clinic in Cleveland, OH.Dr. Kumar would like to acknowledge the following colleagues from the Cleveland Clinic: Priscilla Figueroa, MD; L. Kate Gowans, MD; Andrew Proctor; Mital Patel, MD; Moises Auron MD, FAAP, FACP; San Miguel “Mick” Benitez-Santana, BSN, RN; and Brian Parker, MD.