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For safety and savings, lab takes on transfusions

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Ann Griswold, PhD

July 2014—Hospitals are under fire to cut costs, and more often than not that means layoffs, forgoing new equipment, and watching from the sidelines as the medical literature touts advances that could help patients now—if only institutions could afford to implement them.

Dr. Gettings

Dr. Gettings

“If institutions can’t reduce costs dramatically while improving quality, they just won’t survive. It’s pure and simple,” says Scott Gettings, MD, senior vice president and chief medical officer of Health First, a not-for-profit organization in Central Florida that encompasses four hospitals, a physicians group, a separate-entity laboratory, and a health insurance plan. “There’s a concept now called Medicare Breakeven, which means that if your institution can’t survive as if everybody were on Medicare, then you might not be in business in the future.”

The way forward—one part of it at least—is clear, Dr. Gettings says: practice evidence-based medicine. Nothing more, nothing less. “We believe it’s better to deliver more value and reduce unnecessary costs than to lay off people. And blood overutilization is one example of an unnecessary cost that does not add value. In fact, transfusions have significant risks.”

In April 2013, Health First began implementing a new blood use initiative, spearheaded by the laboratory blood bank, to educate physicians about the national blood transfusion guidelines and to change practice patterns. The team led efforts to devise new systemwide criteria, which included recommending transfusions in stable patients with hemoglobin levels less than 7 g/dL. The team also began to question every transfusion order that did not meet the new guidelines. Electronic orders for blood products were updated to require an acceptable indication.

“Compared with the same period a year before, there are almost 9,000 units of blood that we did not use because they were going to be unnecessary transfusions. We’re talking $150,000 of savings every month, give or take,” says Fernando Nascimento, MSLA, MT(ASCP), system director of laboratory services for Health First and director of respiratory, EEG, and PFT for Holmes Regional Medical Center in Melbourne, Fla.

If it sounds like a get-money-quick scheme, that’s because it is. Health First has saved $1.44 million over one year by changing transfusion practices to conform to national guidelines. The blood bank never denies a transfusion, even those that are out of sync with the guidelines. Medical staff are educated but never chastised. And data collected so far indicate that the initiative hasn’t delayed urgent transfusions. It merely establishes checks and balances to remind physicians the guidelines exist. A tears-free approach to cutting costs.

“The amount of cost with blood transfusion is unbelievable. It’s unnecessary—not just here, but across the country,” Nascimento says. “And this is just one department: the laboratory. Imagine if every department did their part in the hospital. In the nation. We could definitely achieve a major reduction in today’s health care costs.”

The initiative was brought to the administration’s attention in 2012, but for years before that it simmered in the mind of Darlene Beasley, BS, MT(ASCP), SBB, systemwide blood bank supervisor for Health First. Beasley had long lamented the lack of a mechanism to stop or question transfusions performed outside of the system’s approved criteria, which previously set the bar at Hb levels less than 8 g/dL. Despite those criteria, patients with Hb levels as high as 12 or 13 g/dL were sometimes transfused without question, and there wasn’t anything anyone could do about it.

“But, you know, until you get the buy-in from above, one person can’t pull it off,” Beasley says. “So I was fortunate that with our new administration in 2012, all of a sudden the moon and the stars lined up. That particular year, the system picked blood management as a systemwide goal, which helped bring these issues to the forefront.”

One member of the new administration, Nascimento, listened with interest as Beasley described her idea during a meeting in November 2012. “When I met with Darlene, it became clear we were popping blood like it’s aspirin,” he recalls. “Meanwhile, the new guidelines say transfusions should be restricted.”

The eventual impact of overuse can be detrimental. “When these patients come for a future transfusion, it becomes a lot more complicated if they’ve developed antibodies to a previous unit of blood,” Nascimento notes. “People were not as aware of the antibody problem 30 or 40 years ago as they are today. Back then there were no hard guidelines, and that’s one reason we have so many antibodies out there now.”

Nascimento

Nascimento

That initial meeting sparked the administration’s interest in pursuing Beasley’s idea. But it meant hard work—and a lot of it. “Not only did we need to come up with new blood-management parameters, but we realized we needed to do a larger-scale project to lower the hemoglobin to the national standards, and include some tools to identify physician outliers,” Nascimento says.

Over the next couple of months, Beasley crafted a new set of criteria based on the AABB evidence-based literature. She sought input from the AABB, the Health First administration, and Richard Gammon, MD, a medical director for One Blood, the system’s blood supplier. Finally, the team decided on 7 g/dL Hb as the new parameter for transfusion, with a few exceptions: Surgical patients would have a higher limit of 8 g/dL, cancer patients would likely have frequent exceptions to the guidelines, and trauma patients would be excluded.

“Aside from these exceptions, pretty much every other patient population here, every other unit at Health First, benefits from the transfusion initiative,” Nascimento says.

Then came the hard part: seeking approval from the chiefs of medical staff and the medical directors overseeing the system’s four hospitals. “That was the major slow-down for us,” Nascimento recalls. “But for hospitals that already have a systemwide medical board, or standalone hospitals, it would be much easier to put the new criteria together, to follow national guidelines, and to communicate that this can improve patient care and save money, so it’s a win-win.”

Beasley laughs, recalling how she and Nascimento attended a round of medical executive meetings at each hospital in January 2013, only to return the following month and repeat their appeal. The process seemed like an uphill battle at the time, but the pair had strong support: Dr. Gammon provided a steady stream of research showing the importance of restrictive transfusion practices, and presentations were given by one of the initiative’s biggest proponents, Joseph Gurri, MD, a longtime blood donor, surgeon, and vice president of medical affairs for Holmes Regional Medical Center, the largest Health First hospital.

“The project was extremely attractive to begin with because it’s a marvelous evidence-based project,” Dr. Gurri notes.

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