For safety and savings, lab takes on transfusions

“Looking at our existing data, we clearly had a great deal of improvement that could be made simply by following the evidence-based guidelines. Of course, we fully understood what this meant—changing some very ingrained physician practices and all the communication that that would take.”

That might be an understatement, Beasley jokes. “Trying to get it through four groups took an act of God,” she recalls. “The challenge wasn’t the administration—they were already on board. The hard part was trying to get past the medical staff’s mindset. But the way I look at it is that I’m a blood banker—this is what I do; this is what I’m good at. If you ask me about the latest surgery techniques, I can’t keep up with that. So I can’t imagine being a surgeon or physician, trying to keep up with the latest guidelines on medication, procedures, and everything else. We tried to approach it that way.”

Just when it seemed as if the approval process might never end, all four hospitals signed on. By April, the new guidelines took effect.

“Within the first month, give or take, we really didn’t see a big improvement because we had the new criteria, but we had nothing to stop or alert the physicians and nurses who were ordering transfusions outside of criteria,” Nascimento recalls.

That’s where the story gets interesting, he says. In April, the blood bank took the reins and started accessing patient medical records to confirm every transfusion met the new criteria. “Clearly, we needed somebody in the blood bank who owned this topic and was profoundly interested in it,” Dr. Gurri says. “The techs gave up their lab shyness to pick up the phone and tell people that they’re transfusing out of parameter. Taking the lab techs out of the lab and into the mainstream, that was important.”

Once the phone calls started, the savings began to roll in. “I think that’s what changed the culture. That’s when we really started to see the decline in blood utilization,” says Nascimento.

By all accounts, the blood bank staff took the initiative and ran with it. “They wanted to be educated on this; they wanted to know to look for hypoxemia and that kind of thing,” Beasley says. “And they drew the line themselves: When you have an emergency and you have to hand out many units of blood, you don’t bother them. But when somebody’s asking for one or two units and the patient is going to be discharged, we start questioning, and a lot of times physicians will change their minds on that.”

Physicians always have the option of overriding the criteria and, in the beginning, a fair number did. Whenever the technologists encountered resistance—the lab’s phone lines were recorded to discourage “nastiness,” Beasley says—a follow-up call from Dr. Gurri would usually cool tempers and bring reason to light.
“We never stopped anyone at the door and said absolutely not,” Beasley recalls. “We tried to reason with them. Our famous line was, ‘You know, this isn’t in the criteria anymore and we’re considering this a transplant, and we don’t want you to get in trouble with any committees.’”

To track adherence to the guidelines, the laboratory staff generates a daily report using information from the order-entry system. The report lists all transfusion orders from the day before, along with the criteria for the transfusions, the physician, and pre-lab values such as platelet counts or hemoglobin levels.
“My technologists go down the list and remove people who had 6 g hemoglobin or a trauma patient who got 20 units; we’re not going to argue over that,” Beasley says. “Then our techs go into our clinical system and read doctors’ notes for each patient left on the list to see if there’s an obvious explanation for the transfusion. We look to see if they had palpitations, low blood pressure, that kind of thing. Then I glance through and see if I can remove anyone else.”

None of the technologists complained about the extra work. “At first it was very difficult to handle the extra workload with limited staff, but my staff is driven,” Beasley says. “They did this in their spare time, they integrated it into their workflow—that’s how it evolved. Now that our transfusions have dropped so drastically, we have more time to work on these sorts of things. We’re spending less time doing patient work and transfusion review, so it evened out in the end.”

At month’s end, the daily reports are compiled and sent to Dr. Gettings, who reviews the list and enters “letter” or “OK” next to each patient’s name. The physician of each patient with a letter notation receives a note, signed by the laboratory medical director and transfusion committee chair, Carl Smedberg, MD, explaining that he or she appears to have transfused out of guidelines.

“We have two letters,” Beasley explains. “One says, ‘You gave two units, do you think you could have given one?’ And another one says, ‘We don’t see a good reason for the transfusion, so please consider the guidelines the next time because it’s akin to liquid transplant.’”

Nowadays, the outliers are few and far between. But that wasn’t always the case.

“At first, we had a lot of letters, I mean a few dozen every month were going out,” Dr. Gettings says.

But within about six months, he says, that number dropped off dramatically. Now the group just sends a handful of letters, and most of those are not significant. Perhaps the hemoglobin is just a bit high, perhaps the physician gave two units where he or she might have given one.

“The letter isn’t saying, ‘You’re doing this wrong,’” Dr. Gurri is quick to note. “The letter is saying, ‘In this case, you transfused to exception of the recommended parameters. That might be OK if you have a reason, but you didn’t document that reason, and perhaps you need to document it.’”

At first, some physicians weren’t pleased. Nascimento recalls, “I remember going to a meeting and someone said, ‘You’re going to tell us when we can and can’t transfuse blood?’ And we said, ‘Absolutely not. It’s just a tool to aid the physician in deciding if this transfusion is the best approach for this patient.’ Some of them would answer with letters back because they were so upset. They’d say, ‘I can’t believe you are sending me this letter!’ They didn’t understand at first that this is ultimately good for the patients and we are doing this for the greater good. That was a challenge in the beginning.”

Beasley remembers one surgeon in particular whose patients invariably received two units of blood on the second day after surgery—always for the same reason. “Tired and weak, that was the only criterion we could find. For every single surgery. This probably comes from years of doing things the same way; it’s probably how he first learned it in medical school,” Beasley says.

But then something changed. Physicians started to pride themselves on reducing unnecessary blood use. “It seemed like we were hitting a brick wall for a while, but slowly and surely, as word got out there, things began to come together,” Beasley says. Reducing unnecessary transfusions became a goal. A victory. A status symbol, even.

Says Nascimento: “I remember one of the physicians passed me in the hallway and said, ‘Hey, I transfused one patient with a 7.1 hemoglobin but it’s only because he was bleeding quite a bit.’ And I said, ‘OK! It’s OK. You don’t have to explain that.’ It was interesting to see that they are really aware. Now, when we go to a quarterly transfusion committee meeting, the acceptance and the pride of the physicians really makes it a success.”

The group still struggles when patients from skilled nursing facilities—where the hemoglobin parameters are not always consistent with national guidelines, and lab tests are done off site—are sent back to Health First for transfusions. The transfusion committee continues to work on educating this group about evidence-based practices.

“Overall, this initiative was a lot easier than others we’ve had,” says Dr. Gettings. “If you ask physicians to change a practice dramatically—if you say, ‘We want you to do more work, change your process, and save the hospital some money’—that’s not nearly as good an argument as saying, ‘We’re giving too much blood and that’s dangerous to our patients; by giving less, we could save money.’ That’s a lot easier to sell.”

Moreover, the measures of success are more clear-cut than those of other hospital initiatives. “If you give a unit of blood, you can track it, you know what it costs, you know the numbers around that. When you transfuse a unit of red cells, you have a starting measure of hemoglobin, an ending measure, you’ve got clinical proof. But if somebody stays a bit longer in the hospital, you have to figure out why,” Dr. Gettings explains. “So I would rate it as one of our easier change initiatives.”

“We just celebrated one year now, in April,” says Nascimento. “Physicians now are very appreciative. We hear no noise. There are no complaints. It’s almost like it’s their project as well. At the transfusion committee meetings, they’re extremely excited because they know that blood transfusion is not in the best interest of the patient if there’s not an actual need.”

Importantly, the initiative demonstrates that money can be saved in a way that improves care. “Projects that benefit the patient are available, are identifiable, and are readily doable if we all set our minds to do it,” Dr. Gurri says. “It’s important as a cost saver, it’s important as a clinical improvement, and it’s important as a safety issue. But I think its greatest importance is as a model.”

Spurred on by the success of the transfusion project, the administration at Health First is exploring whether the same strategy might help save money in other departments. So far, new evidence-based guidelines are being considered in the imaging workup of patients with stroke and transient ischemic attack, patient flow through operating rooms, and the intubation workflow, just to name a few.

In the end, it’s thanks to the laboratory for having stepped up.

“It’s all about the lab. The beauty of this is that the lab came up with this and all the rest of us listened to them,” Dr. Gurri says. “This is a blood bank/lab leadership project. They were stellar.”

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Ann Griswold is a writer in San Francisco.