CEO SUMMARY: Use of an innovative two-pronged approach helped University of Alabama at Birmingham Hospital rein in runaway cost increases in blood products. Not only did it achieve annual savings of $3.5 million in three years—a 29% reduction—but it increased blood donations from 200 units per year to more than 6,000 units per year. Education and physician engagement were two cornerstones of this hospital-wide effort to improve utilization of blood products in ways that improved patient safety and outcomes.
IN THE WORLD OF TRANSFUSION SERVICES and blood banking, the dramatic rise in the price of blood products over the past decade has become the number one budget-buster for most hospital laboratories.
However, there is often an equally-serious problem that gets less attention. It is the gap between blood use and blood collections in a community or region. Any hospital or health system laboratory attempting to bring the surging cost of blood products under control needs to address both of these issues.
That’s what makes the outcomes at University of Alabama at Birmingham Hospital (UAB) notable for pathologists and laboratory administrators looking for solutions to control the sky-rocketing costs of blood products costs in their own institution. Since 2006, UAB’s focused effort on better blood products utilization has produced annual savings of $3.5 million. That’s a 29% reduction in spending in three to four years.
On the supply side, during the 2007-2008 period, UAB increased its blood collections from less than 200 units per year to more than 6,000 units per year. Collectively, these twin initiatives provide a useful road map for other hospital laboratories that would like to break their upward spending curve for transfusion services and blood products.
Pathologist Marisa B. Marques, M.D., who is Medical Director, Transfusion Service, at the University of Alabama at Birmingham Hospital (UAB), said that, in recent years, hospital laboratories in Alabama found themselves at a special disadvantage in purchasing blood products. In 2006, there was a 35,000-unit gap between blood use and blood collections in the state.
Gap In Supply And Demand
Moreover, 908-bed UAB, the flagship hospital of the University’s health system, was a significant contributor to this gap. The hospital used 37,000 blood units more than it collected! That gap meant rising costs, as well as justified concerns about shortages in essential blood products.
“From 1997 to 2006, blood use at UAB increased 60%,” commented Marques. “That rate of increase was clearly not sustainable, particularly given the critical shortage of blood. It motivated us to take decisive action.”
In 2006, UAB hospital administration teamed with laboratory management to address this situation. An organization- wide, intensive campaign was initiated to achieve two goals. One goal was to improve how physicians utilized blood products. The second goal was to increase donations, thus adding to the supply of available blood.
“Our first step was to get recognition of the need for change from UAB physicians, along with their buy-in,” noted Marques. “We didn’t want to start until we had everyone on board. We also recognized the importance of having the physician champions at UAB involved in the process. Physicians want to hear from their peers—from those whom they respect.”
Improving Blood Usage
Because most physicians at UAB were willing to acknowledge shortages in the supply of blood, that made it easier for Marques and the change team to gain their agreement to explore and support strategies that would lead to reduced use of blood products.
Marquez’ group also studied how other hospitals had succeeded in improving blood utilization and controlling the cost of transfusion services. Impressed with the outcomes at 747-bed St. Vincent Indianapolis Hospital in Indianapolis, Indiana, the team sought advice from anesthesiologist Timothy Hannon, M.D., MBA, Medical Director of the Blood Management Program at St. Vincent. He is also President and CEO of Strategic Healthcare Group LLC, a blood-management consulting firm.
Hannon recommended a strategy of physician education and feedback, anchored in data. To gather that data, UAB had Hannon’s firm survey blood use by UAB physicians. Each physician received an individual report of their performance, benchmarked against high performers in their specialties.
“Pathologists and laboratory scientists know the power of good data,” stated Marques. “Providing credible data to the individual physicians was the right first step. We all know that physicians are competitive people. They want to be the best and provide the best care for their patients.
“Some of our surgeons had never compared their blood utilization with blood utilization rates at other hospitals,” she continued, “and when they saw their data, they were ready to make changes to improve their performance.”
The next step in the UAB lab’s program to improve blood utilization was physician education. Hannon’s firm organized a series of CME (continuing medical education) lectures on blood management. These lectures were organized around the landmark study published in 1999, “Transfusion Requirements in Critical Care.”
“It’s incredible that ‘Transfusion Requirements in Critical Care’ was published more than 10 years ago, but many physicians still don’t know about it,” observed Marques. “It’s powerful information and we made that study an essential part of our blood management program.” This study was published in the medical journal Transfusion in 1999. The study’s researchers determined that critically ill patients did better when treated with a restrictive transfusion approach.
Unaware Of Risks
“Physicians at UAB were unaware of these risks associated with utilization of blood products,” noted Marques. “The CME lectures we instituted also included information on the wide variations in blood use among physicians in the same specialty, as well as variation among hospitals and across national boundaries.
“We involved enough physicians in the CME to be sure that all the UAB physicians felt they were hearing from someone in their field whom they respected,” added Marques.
“Another element to the change compaign was the employment of a nurse to be a transfusion safety officer,” she noted. “This individual works with nursing and laboratory staff on blood management, and also educates them on blood administration, patient monitoring, as well as transfusion reactions and other issues.
“One element of this was to have her work with staff to help minimize anemia, including reducing the amount of blood collected for laboratory testing,” continued Marquez. “We succeeded in cutting blood loss from about 70 MLs per day per ICU patient to about 39 MLs per day. This reduces iatrogenic anemia and eventually the need for transfusion.”
UAB’s Blood Utilization Committee was renamed the Blood Utilization and Management Committee. It was empowered to work with physicians on reduction strategies. Marques, who had been the committee’s sole chair, recruited a co- chair, Donna E. Salzman, M.D., who is a bone marrow transplant specialist. “This physician could stand up and say ‘My patients, who don’t have a functioning bone marrow, don’t need as much blood as we’ve been using.’ In turn, this made an impact on other physicians.”
Clinical Practice Change
Many UAB physicians had been trained to order two units of packed red blood cells at a time, explained Marques. They were encouraged to change that practice and order only one unit—unless the physician was certain that more would be needed. This is now standard practice with most UAB physicians.
The cardiovascular OR team instituted blood-saving protocols to reduce blood loss and to capture and reuse the patients’ blood during surgery. “These new proto- cols have produced good results,” noted Marques. “In the two years since the initiative began, blood use in patients undergoing cardiac valve procedures dropped from an average of 9.5 units per patient to less than three units per patient.”
The team also created a laminated Transfusion Guidelines pocket card and distributed these cards widely throughout the medical and nursing staff. Even the hospitals’ electronic medical record (EMR) system plays a role in managing the utilization of blood products. Marques and Salzman use the EMR to review patient records for transfusion justification.
“If the patient record does not show evidence that justifies the transfusion, the physician is sent an email message asking for an explanation about why the transfusion was ordered,” stated Marques. “It’s critical to have a non-punitive review process and create a way for physicians to feel comfortable discussing blood use.”
Positive feedback is regularly offered to physicians and has contributed to sustaining the progress made in improved utilization of blood products at UAB. “Everyone wants to be thanked for their work; to hear someone say, ‘Your blood use is improving. Thank you for your efforts’,” said Marques.
This ongoing campaign has produced impressive accomplishments. “In the decade prior to the program’s launch in 2007, our hospital had doubled its use of red blood cells,” declared Marques. “From 2007 to 2009, these efforts succeeded in reducing use of packed red blood cell units by 29%, from .925 units per discharge to .65 units per discharge.”
These achievements were anchored in two fundamental practice changes at UAB. Not only were fewer patients being transfused, but the amount of blood per patient was greatly reduced. Notably, utilization of blood products at UAB had declined so much that it was below the national aver- ages for every patient type that was studied.
“Financial results have also been positive,” explained Marques. “The annual cost of blood product acquisition has declined by $3.5 million, which is a 29% decline compared with 2006, the last year before implementation of the blood management program. There were also significant savings produced by improved administration and the reduction in risk of complications.
Supply Of Blood Products
“Of course, improving utilization of blood products was only one side of our two-pronged strategy,” she added. “Even as these steps were underway, we worked with the local American Red Cross, one of our main suppliers, on the supply side of the blood products equation.
“UAB administrators negotiated a contract with the American Red Cross which reduced the price UAB paid for blood if it met collection targets,” continued Marques. “From the beginning of 2007 to the end of 2008, the hospital increased collections from less than 200 units per year to more than 6,000 units per year. This went a long way in helping close the gap between resources used and resources gathered.
“To jump start this collection program, we developed a reward-points strategy,” she stated. “This rewarded our employees for giving blood. It also encouraged those in the community to donate blood. Another source of donors was the University of Alabama student body, which prior to their efforts had not participated fully in blood collection drives.
Blood Drive Champion
“Within the hospital, we recruited blood drive champions for each department. The departments engaged in friendly competition for quarterly celebrations in honor of the highest scoring team,” recalled Marques. “Another helpful secret is to convince managers to agree to let their workers give blood during their shifts, rather than using personal time. For the future, we plan to arrange a light lunch for donors who come during their noon breaks.”
The UAB team now ties these blood drives into local events, such as the local Susan G. Komen Race for the Cure. They also created holiday-themed blood drives, such as an appeal to staff patriotism on July 4th, to keep staff enthusiasm high.
UAB’s contract with the American Red Cross called for lowering the price of each unit of packed red blood cells supplied if the hospital met annual collection goals. So far, the hospital has met and exceeded their goals, further reducing their costs.
“This process of reducing blood use and increasing collections required the efforts of all hospital staff,” stated Marques. “There was a critical need for success and that translated into wide-spread support. Hospital management was a driving force for change throughout the process.
Education Was Key
“If I had to sum up our success in one word which had the biggest impact, I’d say it was education,” concluded Marques. “Education, when combined with good data, allowed all staff involved in blood transfusions to understand how patient safety and improved patient outcomes were associated with better utilization of blood products.”
As the UAB experience shows, pathologists and lab managers do not have to accept the spiraling cost of blood products and transfusion administration. A concerted reduction campaign anchored in evidence-based practice, combined with effective blood donation marketing, can save money, relieve blood shortages and improve patient safety.