CEO SUMMARY: New attention on both the risks associated with blood transfusions and the cost of blood products is triggering action by the nation’s hospitals. At the 719-bed Rhode Island Hospital, the laboratory is on the front line of the hospital’s blood management initiative. One change in long-standing practices is to encourage phlebotomists to draw only the minimum amount of blood required for lab testing. However, smaller specimens require changes to lab operations.
DRAWING BLOOD FROM PATIENTS FOR LAB TESTING has long been a routine task in every hospital nationwide. Everyday in every healthcare facility, phlebotomists working for laboratory departments fan out to take samples from patients.
But this routine phlebotomy task is about to undergo a major change as more hospitals recognize that what’s best for their laboratory is not necessarily what’s best for patients. “In fact, it may be best to conserve the amount of blood taken from each patient for each procedure,” said Kevin T. Wright, Program Manager for Transfusion-Free Medicine & Surgery at the 719-bed Rhode Island Hospital (RIH) in Providence. “Some patients may prefer to conserve their blood, while for others this is a necessity due to anemia.”
This trend is linked to the dramatic increases in the cost of blood products. In response, hospitals such as RIH launched programs to educate all clinical staff about the value of blood conservation. For three years, Wright has devoted full-time effort at RIH to working on these issues with the clinical staff. He finds the laboratory is the ideal department to spearhead the hospital’s blood conservation efforts.
“Hospitals are adopting blood conservation protocols, in part because of the high costs of purchasing blood and blood products,” noted Wright. “There are also patient safety issues associated with transfusing blood—a process that is not with- out risk and can introduce infectious agents to patients. As well, some patients simply prefer not to receive blood from someone else while other patients cannot afford to lose much blood during procedures because they may already be compromised by pre-existing conditions.”
One Goal: Draw Less Blood
One primary goal of the blood conservation program is to draw as little blood from patients as possible. This objective recognizes two realities. One, some patients can become anemic, in part because of blood drawn for laboratory tests. Two, this program accommodates the growing number of patients who prefer to conserve their blood.
“We must be mindful of the need to prevent a patient from becoming anemic,” stated Marilyn McAllister, Director of Pathology Administration at RIH, who works closely with Wright. She is the lab’s point person in the effort to change the hospital staff ’s awareness of the need for blood conservation. “We also need to recognize that some patients now want to conserve their blood. They question every request to draw specimens.
Clash With Today’s Reality
“That concept clashes with the reality of long-established phlebotomy practices,” continued McAllister. “For example, often the lab staff will ask, ‘What’s the big deal if we draw three tubes versus four tubes?’ In our hospital’s blood conservation program, the answer to that question is, ‘if we can meet the need for a set of lab test orders with one tube, that’s what we should do.’
“It is common practice for phlebotomists to draw ample quantities of blood because it makes the lab’s job easier,” observed McAllister. “Instead of taking one tube from a patient, a phlebotomist will draw four tubes simply so the lab will not need to aliquot.
“Drawing so much blood is convenient for a lab because chemistry gets its own tube, clinical gets its own tube, and toxicology gets its own tube,” she said. “This common practice is changing here at Rhode Island Hospital. Now we stress the importance of minimizing the quantity of blood we draw from each patient.
Drawing Less Blood
“Drawing less blood means more handling of tubes in the lab and perhaps using smaller tubes,” she explained. “Our lab and our phlebotomy staff must adjust to these new concepts in order to accommodate this new focus on blood conservation.”
The laboratory at RIH, which performs six million tests per year, recently converted to a new laboratory information system (LIS). “As we built the database in this new LIS, we had the opportunity to discuss how many tubes we should draw from each patient. Are we going to draw all the tubes we normally draw because it’s convenient for us? Or will we draw just the number that’s best for the patient? We are designing our new database to help lab staff and phlebotomists make the best decision about how to reduce the quantity of blood required from a patient.”
As a pioneer in the concept of implementing blood protocols, the RIH lab encounters some interesting obstacles. “Probably the single biggest problem we face in our goal of reducing the amount of blood we draw is the limitations imposed on us by vendors,” declared McAllister. “All the vendors make instruments, robotic lines, and automated systems that work only with tubes of a certain size.
“As a consequence, our lab doesn’t have the flexibility it needs to accommo- date different—and often smaller—tube sizes,” she noted. “For example, in circumstances where we could use pediatric tubes, the demands of the automated line and the analyzers force us to continue using larger tubes. We face the trade-off of losing the efficiency from automation were we to use the pediatric tubes.
“It’s not a surprise, then, that our interest in supporting blood conservation now shapes our equipment purchases,” she continued. “Coagulation is next in our instrumentation upgrade program.
“We want to connect this new coag system to an automated line and that raises a number of questions. What tubes can we use in this new system?” asked McAllister. “Are we limited to a certain tube size? Can we find an instrument platform that allows us to use multiple-size tubes—thus allowing us to draw pediatric tubes whenever that lesser quantity meets our needs?
“These are valid questions, but we recognize that vendors are probably not ready to support us in our blood conservation efforts,” she explained. “It means we will be educating our vendors about the need to accommodate blood conservation. This is one way in which our hospital’s blood management program has created new questions and new requirements to which vendors will need to respond.
An Eye Opener
“This effort has been an eye-opener for all of us, especially given that the concept of blood conservation is not new,” she said. “Most labs are accredited by the College of American Pathologists, which has a general question on its accreditation checklist that asks if the laboratory has taken steps to minimize the amount of blood drawing. Of course, every lab manager checks it off as ‘yes.’ However, I don’t think many lab professionals take these efforts seriously. And few labs ever get blood conservation as a deficiency. That is changing at our institution, as lab staff and lab administration actively work on this issue.”
Wright agreed, saying that New England lags behind some other areas of the country in adopting these programs. “Before I came to Rhode Island, I worked with hospitals in California and Illinois which had already implemented successful blood conservation programs,” he stated. “I also consulted with hospital that were developing their own programs. By contrast, hospitals in the upper parts of the Northeast have been slow to adopt blood management and blood conservation measures. That is one reason our hospital is considered to have the premier blood-management program in New England.”
THE DARK REPORT observes that blood conservation represents a fundamental mindset change in how a lab interacts with its patients. It puts the laboratory on the path to patient-centric services.
Blood Draw Practices Are Changing in Hospitals
IN AN EFFORT to limit the number of patients who get transfusions, hospitals are developing initiatives to recycle blood and prevent anemia. These efforts also help hospitals to cut the cost of purchasing blood and blood products while also improving patient care by helping to eliminate risks.
Traditionally, physicians believed blood was safe, and so saw no reason to withhold it from patients. “But the modern view is that, when we give blood unnecessarily, we cause measurable harm to patients,” said Timothy Hannon, Medical Director of the Blood- Management Program at St. Vincent Indianapolis Hospital, which is part of Ascension Health. “We must be sure we give the right dose of blood to the right patient at the right time, and make much smarter use of blood products.” Hannon was quoted in an article in The Wall Street Journal, “Hospitals Seek to Limit Use of Transfusions.”
Hospitals are developing guidelines for when transfusions are necessary, and checking patients for anemia before surgery.
The cost of a unit of blood has more than doubled over the past decade, and hospitals spend an estimated $25 billion to buy, to process, and to transfuse about 30 million units a year, according to the WSJ. Also, research shows that donated blood can cause infections, complications, and death. A recent study showed that blood stored for 29 days or more is associated with a higher rate of infections among patients getting transfusions.
At the same time, a technical advisory panel for the Joint Commission has developed 19 blood management performance measures for hospitals and will be making recommendations on the issue. The Joint Commission has decided that the panel should address blood conservation, appropriate transfusion, and a patient-centered focus regarding blood use in U.S. hospitals. The panel’s recommendations are expected soon.