Reducing transfusions reduces patient risk at Maine hospital

In late 2006, Dr. Irwin Gross approached administrators at Eastern Maine Medical Center with an idea to curb inappropriate blood transfusions, improve patient outcomes and save money.

Like many hospitals, the 357-bed facility in Bangor transfused too much blood and did it too often, said Gross, who then practiced in an independent pathology group and served as medical director of the hospital's blood bank. Transfusion thresholds varied widely and more education was needed to inform physicians about evidence-based practices and the risks tied to transfusing blood.

“This was a rare opportunity to achieve better care and reduce costs at the same time,” Gross said.

Hospitals have taken a closer look at their blood management protocols over the past decade as research indicates transfusions in many cases do more harm than good. Patients face serious risks, including transfusion-related acute lung injury, respiratory distress following transfusion and suppressed immunity, said Dr. Jeffrey Rohde, an assistant professor of internal medicine at the University of Michigan, Ann Arbor.

Rohde was the lead author of a JAMA article published in April that found patients who received more red blood cell transfusions were more likely to develop healthcare-associated infections than patients who received fewer transfusions.

Professional organizations have set suggested guidelines for hemoglobin levels, the main metric used to determine when transfusion is appropriate. But hospitals' and physicians' acceptance of those thresholds is often inconsistent, Rohde said.

Transfusions also have been targeted by the Choosing Wisely campaign, an effort spearheaded by the ABIM Foundation to prevent unnecessary tests and procedures. A number of participating professional societies, including the American Association of Blood Banks and the Society of Hospital Medicine, have recommended “adhering to a restrictive transfusion strategy.”

The most effective way to reduce transfusions is through a patient blood management program, said Dr. Sally Campbell-Lee, medical director of transfusion medicine at the University of Illinois Hospital in Chicago and a member of HHS' Advisory Committee on Blood and Tissue Safety and Availability.

That's the approach Gross outlined for Eastern Maine administrators in 2006: The hospital would launch a robust blood management program and he would take the job as head of the program. The hospital's leaders gave the nod and the program started in 2007.

Eastern Maine's program uses multiple levers to encourage appropriate use of transfusion, including ongoing physician education and alerts embedded in the computerized physician-order entry system. For instance, if a physician orders a unit of blood for a patient whose hemoglobin levels are outside the hospital's usual thresholds, an alert is triggered. The CPOE system also made it more difficult for physicians to order more than one unit of blood at a time, a common practice that Gross says contributes greatly to overuse.

“CPOE alone won't change practice, but it's a tool that can reinforce and hardwire the principles of blood management,” he said.

Gross and his team also created a transfusion report card so physicians can see how they compared to their colleagues, a step that helped drive down unneeded clinical variation.

In the years since the program began, the number of red blood cell transfusions at Eastern Maine plummeted nearly 60%. Use of platelets and plasma fell 50% and 75%, respectively. And those reductions came with no significant change in clinical services, Gross said.

The percentage of preferred single-unit orders grew from 55% to almost 90%, and the hospital's target hemoglobin level for transfusion fell from 8.5 to 7.8. The hospital also has seen improvements in lengths of stay that Gross says are attributable to the program.

On the financial side, blood acquisition costs have fallen by $1.6 million annually. For cardiac surgery alone, costs per case have dropped 10%.

Dr. Mark Brown, chief of pediatrics and head of newborn medicine at Eastern Maine, said the blood management program has had a transformative effect on blood usage and patient outcomes. He is working with Gross to develop a version for the neonatal intensive-care unit. “I'm constantly surprised that more hospitals aren't doing this,” Gross said. “It fulfills all three corners of the Triple Aim triangle.”

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