Best Practices: How to stop wasting so much blood

In retrospect, the problem—and a feasible solution to it—seemed obvious. If blood was brought to the operating room and then stored unused at the wrong temperature, it would have to be thrown out.

“It happened pretty often,” recalled Barbara Martin, a registered nurse at Vanderbilt University Medical Center in Nashville who led a recent study on blood utilization and wastage that found systemic changes could successfully curb both.

The study, which began in 2012, examined the effect of implementing evidence-based guidelines for blood transfusion. Those changes cut blood utilization by more than 30%, researchers found, dropping it from 675 units per 1,000 discharges in 2011 to 432 units per 1,000 discharges last year. They also found the changes yielded $2 million in savings over three years.

The study also looked to stem blood wastage, putting in place a series of measures that ultimately helped bring waste down from 300 units in 2011 to fewer than 80 in 2015.

At the heart of the three-year study was a willingness to challenge protocols in place simply because that's the way things had always been done. But such processes are slowly evolving, driven in part by studies like Vanderbilt's that demonstrate the benefits of new, evidence-based practices.

When Dr. Louis Katz, who was not involved in the Vanderbilt study, trained as a doctor decades ago, he was taught unquestioned standards about blood transfusion. The appropriate threshold for hemoglobin was around 10 grams per deciliter, he learned, and doctors should always give two units of blood, never one.

“That's what I was taught. It wasn't based on evidence. It was based on, 'Here's how we do things,' ” said Katz, chief medical officer of the national blood bank network America's Blood Centers. “So we did what we were told by the people who taught us.”

As part of the study at Vanderbilt, Martin and her colleagues changed the default settings in the computerized provider order entry system. When doctors ordered blood for anemic patients, the order would be for a single unit of blood rather than requiring the doctor to specify the number of units needed.

The literature suggests one unit is the right amount, Martin said, but the revision “really was a practice change.”

The researchers built the order entry with anemic patients in mind, not surgical ones, but found a “sharp decline” in blood utilization even in the surgical population. Changing anemia ordering ultimately changed the management of surgical patients, too, Martin said.

When they turned their attention to blood wastage, Martin and her colleagues developed guidelines for handling blood, such as sending it in a cooler instead of a pneumatic tube, and tasking one staff member with “ownership” of the blood product to ensure someone had responsibility for storing it appropriately. (Red blood cells need to be kept refrigerated, while platelets are stored at room temperature.)

“It wasn't anything technical or magical or hard. It just took the ingenuity of a bunch of people to figure out the best way to do it,” Martin said.

Although such guidelines could certainly be implemented in other institutions, Martin noted that hospitals should consider whether expected savings would outweigh the resources required to invest in making these changes.

Clinicians must also keep in mind that some waste is inevitable, said Mary Kay Wisniewski, coordinator of the patient blood management program at the Pittsburgh-based UPMC health system. “It would be unrealistic to think that you can eliminate all blood waste in healthcare, because many times, heroic efforts to save lives use a lot of blood, and their efforts fail,” said Wisniewski, who was not involved in Vanderbilt's study. “It's very important that we talk about it in terms of unavoidable and avoidable waste.”

Wisniewski and her fellow researchers at UPMC have also found that revising the way doctors ordered blood through the computerized provider order entry system, by allowing them to reserve units of red blood cells for later use, helped reduce waste and save $123,300 a year. They, too, found that taking simple steps to change blood storage practices would cut down on waste.

Katz, of America's Blood Centers, said Vanderbilt's findings are not surprising in light of what many other institutions have discovered in recent years (UPMC's study is a case in point). “When patient blood management programs are instituted, you use a lot less blood,” he said. “We've learned that we can be much more conservative.”