1. Tolich, Deborah J. MSN, RN
  2. Blackmur, Sheila MSN, RN
  3. Stahorsky, Ken MBA, RN
  4. Wabeke, Danita BA, RN

Article Content

Blood transfusions to treat anemia can have a significant impact on patient outcomes. Because transfusion practices vary among healthcare providers, many clinicians question the best practice for blood product use. Blood management is defined as a patient-centered standard of care in which strategies and techniques are used to reduce, eliminate, or optimize blood transfusions to improve patient outcomes.1 Blood management programs have addressed the variances in healthcare provider practice as they've reduced blood use and healthcare costs.

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This article reviews the evidence and experience gained from formal blood management programs. It identifies and discusses these three areas of blood management: methodology, implementation, and nurses' direct-care practice.


Putting evidence into practice

Anemia isn't a disease but a sign of an underlying illness or condition. Anemia falls into three major categories: nutritional deficiency, acute or chronic blood loss, and anemia of chronic disease. All three contribute to a limited number of red blood cells (RBCs) carrying oxygen to organs and tissues, resulting in signs and symptoms that may cause decreased physical performance.1 (For more information, see What's anemia?)


If evidence shows that reducing allogeneic (donor blood) transfusions improves patient outcomes while decreasing costs, how should nurses translate this evidence into their practice? Current research about advanced anemia management, cost accountability, and the negative consequences of allogeneic blood transfusions continue to influence nursing practice. With today's limited supply of blood products and increasing costs associated with transfusions, it's prudent for healthcare institutions to advance their standard of care by adopting blood management practices.


Many underestimate the true cost of blood. According to a recent analysis, the cost of a unit of RBCs is between $522 and $1,183.2 Nurses and healthcare providers have a responsibility to exercise good stewardship and take measures to reduce waste. Before blood is obtained from the blood bank, nurses must make sure they're following policies and procedures ensuring safety and proper administration of all blood products. (See Using best practices for blood transfusions and Practice guide for nurses.)


Why blood management?

Blood transfusion is the most commonly performed procedure in the United States.3 Labor intensive, it takes more than 75 minutes of nursing time from prescription through completion.4


Blood management, a best-practice methodology, evolved from bloodless medicine and surgery, which were developed to address the healthcare needs of those refusing blood products for religious or other reasons. This evolution has broadened the scope of clinical application and now includes the functions of blood utilization, practice variability, and optimal use of blood products.


Blood management consists of prevention, early identification, and treatment of anemia coupled with the best possible transfusion practices. A blood management program translates these standards into clinical practice.


A robust body of evidence supports the need for blood management programs. Paul Hebert and colleagues conducted a study introducing evidence that restrictive transfusion practices are as effective in terms of outcomes as liberal use.5 This landmark study demonstrated that patients could tolerate lower levels of hemoglobin.


The evidence is categorized into supply and demand of blood products, risks and safety of transfusion, and outcomes correlated to transfusion. The U.S. Department of Health and Human Services 2009 National Blood Collection and Utilization Survey (NBCUS) demonstrated that collections compared with transfused products produced a 12% surplus and that the overall number of transfused products remained statistically unchanged from 2008.6 Despite a reported surplus, periodic local shortages have led to some cancellations of elective surgery. Because the population is aging, demand is expected to increase and donations to decrease.7


The American Association of Blood Banks circular of 2009 provides best-practice guidelines for using blood products.8 For example, RBC transfusion is indicated only for symptomatic anemia or a critical oxygen-carrying deficit. Although the circular doesn't indicate a specific lab value for transfusion, it does state that RBC transfusion is contraindicated for volume expansion and anemia that can be treated using hematinics, agents that stimulate erythropoiesis and increase RBC production.


The efficacy of blood transfusion outside of traumatic blood loss has never been scientifically proven. Although the blood supply in the United States is relatively safe, the threat of new and emerging transfusion-transmitted infections continues.9 Advances in nucleic acid-based testing have improved the ability to effectively screen for HIV and hepatitis B and C viruses. But the FDA in a public forum demonstrated that the threat of arboviruses such as dengue and West Nile viruses have the potential to become widespread in areas of the United States. In the absence of the ability to eliminate causative agents, the safety of future blood supplies is reduced.10 If blood products had to submit to FDA scrutiny, they wouldn't gain approval because of safety concerns: The risks of using these products would greatly outweigh their efficacy.11


Much data correlate poor outcomes to blood transfusion.12-15 A dose-response relationship shows blood transfusions lead to increased postoperative infection, higher rates of multisystem organ failure, increased mortality, increased mechanical ventilator time, and increased length of stay.16 The combination of changes during storage and biochemical reactions leads to complications.


Decreased immune function in a recipient of a blood transfusion is called transfusion-related immunomodulation.15,17 The intensity of the immune response varies from person to person, but the effects related to the length of time the blood has been stored increase morbidity and mortality.11 Stored blood undergoes morphologic changes that make the cells more rigid and less pliable, so it's harder for them to flow through small capillaries. A 2006 study found that mortality increased significantly in patients undergoing open-heart surgery after just one unit of RBCs.19


In a landmark study, the Cochrane Collaboration group examined evidence of the effect of RBC transfusion triggers (recommended by the AABB as transfusing a patient with a hemoglobin level of 7 g/dL; or a hemoglobin level of 8 g/dL for a patient who's symptomatic or has a preexisting cardiovascular disease) on clinical outcomes.5,19 Called the Transfusion Requirements in Critical Care (TRICC) trial, it compared outcomes in 838 critically ill patients who were transfused using two different transfusion thresholds. A liberal transfusion strategy, in which transfusions were given when the patient's hemoglobin concentration fell below 10 g/dL and maintained hemoglobin concentrations at 10 to 12 g/dL, was compared with a restrictive transfusion strategy in which transfusions were given when the patient's hemoglobin concentration fell below 7 g/dL and maintained at 7 to 9 g/dL. The results showed that the restrictive strategy was "at least as effective as and possibly superior" to the liberal transfusion strategy in decreasing mortality in critically ill patients, with the exception of patients with acute myocardial infarction and unstable angina. In less acutely ill patients younger than 55, the restrictive strategy was superior to the liberal strategy because it was associated with a decrease in mortality.5 Maintaining hemoglobin concentrations between 7 and 9 g/dL resulted in a 54% decrease in RBC transfusions when compared with the liberal strategy group. Most research concurs with the findings in the TRICC trial; that is, in the absence of cardiac disease, best practice is to use a restrictive transfusion strategy.20


The evidence supports a comprehensive approach to blood management. In Ontario, Canada, blood management was incorporated into the care of patients having three procedures: knee arthroplasty, abdominal aortic aneurysm surgery, and coronary artery bypass graft surgery.21 Patient outcomes included a significant decrease in allogeneic blood transfusions, postoperative infection rates, and length of stay.


Three of the four authors of this article work for the Cleveland Clinic Health System, which comprises 10 community hospitals. When researchers compared blood use among these facilities, they found that hospitals with blood management programs had lower blood utilization, which signifies less healthcare provider variation in transfusion practice.


The Joint Commission (TJC) is now defining core measures that will help set the standard and guide transfusion practice.22 The Blood Management Performance Measures Project was implemented as a two-phase process from 2007 to 2010. During Phase I, a stakeholder meeting led to the development of a technical advisory panel. During Phase II, this panel identified priority areas and potential measures for blood management. These were posted for public comments in 2008, with final measure recommendations made by the panel in November 2010. These final patient blood management (PBM) measures are:


* PBM-01 Transfusion Consent


* PBM-02 RBC Transfusion Indication


* PBM-03 Plasma Transfusion Indication


* PBM-04 Platelet Transfusion Indication


* PBM-05 Blood Administration Documentation


* PBM-06 Preoperative Anemia Screening


* PBM-07 Preoperative Blood Type Testing and Antibody Screening.



Although these seven PBM core measures aren't yet endorsed for use at the national level, they're an ideal source to be considered when beginning the implementation of a blood management program.


Implementation tips

Blood management is best implemented by using existing processes and organizational structure.23 Formal programs incorporate an interdisciplinary patient-care approach, such as nutrition referrals for patients with anemia to receive dietary instruction and pharmacy-managed anemia clinics.24 Blood management initiatives assimilate standardized practice, eliminate outlier patterns such as automatic ordering of two units of RBCs rather than one, and enforce evidence-based practice.


Before proceeding with formal blood management initiatives, organizers need to gain support from administrative groups. Next, the organization should identify a core group of healthcare provider champions who'll drive blood management into practice among peers.25


Successful blood management programs have a dedicated leader, such as an RN, who assumes responsibility for developing and driving initiatives. Many current programs owe their existence to nurses who persevered to overcome barriers. If creating a new position isn't feasible for an organization, undertaking blood management initiatives is an alternative. Regardless of the execution model, high quality and outcome gains are associated with decreased length of stay, positive financial impact, and cost-effectiveness in transfusion avoidance.21


A three-phase implementation plan, including a focused planning phase, practice roll-out, and maintenance phase, has been used successfully at approximately 200 hospitals across the United States.26 Implementation begins with analyzing how to incorporate best practices into policies and protocols. A formal proposal or business plan provides a starting point and a roadmap for program development. Because barriers are likely to surface, it's important to identify potential roadblocks in the initial planning phase.


The circumstances surrounding transfusion utilization must be isolated by identifying clinical signs and symptoms, lab values, and presence of active bleeding. Strategies must be developed to identify and address opportunities for improvement. This may be done through healthcare provider-based report cards where transfusion practice and triggers are compared within medical specialties. The Cleveland Clinic has developed blood transfusion dashboards to make transfusion practices transparent, with focused plans targeting outlier practice. To reveal trending successes as well as challenges and opportunities, individual dashboards have been designed to capture specific benchmarks such as the following:


* service-line utilization


* a drill-down to healthcare provider use


* administration of blood products by hemoglobin category


* comparative usage by surgery type.



Intermittent peer reviews to evaluate compliance with established standards for blood product utilization provide the basis for behavioral interventions. Simple interventions such as education and healthcare provider feedback have been effective in changing transfusion practice, according to a review conducted by Tinmouth and colleagues.27 Small measures have a large impact on patient outcomes, and continuing education with healthcare providers and nurses is instrumental in maintaining positive outcomes and sustaining a culture shift by solidifying new practice habits.


Empowering stakeholders

A multidisciplinary committee can guide blood management initiatives. The committee should include representatives from medical leadership, anesthesia, surgery, pharmacy, blood banks, and nursing, among others. This group will establish quality indicators and monitor blood product administration, healthcare provider tracking, and service-line blood utilization. Extracted metrics are used for quality assurance, performance improvement, and measurements of program success.


First steps include establishing transfusion criteria for the clinical indications for each blood product that reflect current evidence and a general hospital policy for blood management. This dedicated team will implement, promote, and evaluate initiatives within the hospital.28,29


An effective approach in the clinical implementation of blood management is to identify areas of greatest impact that will provide measurable improvement in patient outcomes with realized cost savings. Consider high-volume blood utilization departments such as orthopedics, cardiac surgery, and medicine.21


Choosing a delivery model

Published literature provides evidence that protocols, pathways, and algorithms supporting blood management, although simple in design, provide significant impact.21 Tools to aid in the identification, evaluation, and treatment of presurgical and postsurgical anemia, as well as acute and chronic anemias, are essential. Examples include an anemia assessment guide, treatment process, preprinted prescription forms, and patient education materials. These tools provide the framework for transferring blood management methodology into clinical practice.


An outpatient anemia treatment center can be established by partnering with an existing cancer center, heart-failure clinic, or outpatient clinic. The outpatient treatment area can grow by expanding services to include treatment for patients with presurgical anemia, acute anemia, and chronic anemia.30 Outpatient volumes can be increased while new revenue streams are captured.30


Communication pathways

While preliminary measures are coming to fruition, prepare staff through education. Instructional plans designed for medical staff, nursing, and ancillary personnel can help prepare staff for clinical implementation. Product vendors are another source of educational support.


To make blood management recognizable in both the hospital setting and the public sector, it must be described in understandable terms, from its roots in religious conscientious objection through its evolution to practices. More than mere transfusion avoidance, blood management is a comprehensive strategy that conserves the patient's blood and contributes to better outcomes.


Website development can be a successful tool for internal and external marketing as well as business development. This medium can be instrumental in providing current and relevant clinical resource material for staff.31 Use electronic visual screens, posters, and charts depicting goals, objectives, and outcomes to heighten awareness.


Fostering relationships with primary care healthcare providers encourages involvement. An annual educational event endorsed by administrative leadership and healthcare provider champions keeps the program at the forefront.


Focus on program sustainability throughout the implementation phase. Maintain a vibrant and effective blood management program by continuing engaged committee membership, and by understanding and using evidence-based standards, procedures, and tools developed by the team. Monitoring outcomes using defined metrics keeps the program focused on goal attainment. Share quality metrics with hospital executives, service-line divisions, and hospital quality committees to drive initiatives for improvement. Medical and nursing leadership must be actively involved in endorsing and advancing a blood management program.


Execution of blood management will continue to evolve as new research is completed and delivery models are tailored to specific healthcare systems. A planned and methodical approach with clearly defined metrics will provide direction in program development and data analysis from which to gauge success. The challenge is in concept implementation, education, and sustainability. Because blood management is process and structure, the key to long-term success is setting up a self-sustaining infrastructure.


Nursing implications

Nurses can change practice to apply blood management principles at the bedside. Iatrogenic anemia resulting from lab testing is responsible for preventable transfusions.32 Techniques to reduce iatrogenic anemia include minimizing lab draws, using low-volume collection tubes, returning waste volume from arterial and central lines to the patient, and documenting lab blood volumes as output.29,33


Nurses must pay attention to patients' hemoglobin concentrations on admission. For example, if a patient is admitted with a hemoglobin concentration of 10 mg/dL or below, he or she is at risk for transfusion, warranting a more in-depth anemia assessment. This includes obtaining a history of factors contributing to anemia, as well as physical assessment findings.


A major contributor to anemia is iron deficiency, the most common nutritional disorder in the world.34 Iron studies, including serum iron, total iron-binding capacity, iron saturation, and ferritin levels, are helpful in evaluating iron stores.


Nurses play a crucial role in recognizing the signs and symptoms associated with decreased oxygen states due to low hemoglobin levels. Nurses are responsible for notifying the healthcare provider of a patient's hemoglobin and hematocrit, but they must report the whole patient picture and not just the lab values. For example, if the patient's hemoglobin is 7.2 g/dL and the hematocrit is 21.4%, the nurse must assess the patient's signs and symptoms and take into consideration the patient's medical history. This information will help the healthcare provider determine the appropriate course of treatment.


In the past, assessment of anemia has been based on hemoglobin and hematocrit with less emphasis on functional ability and quality of life.35 Thinking critically and accurately communicating quantitative lab values and symptoms of anemia are pivotal steps leading to appropriate treatment.


Changing habits, elevating standards

Improving patient safety and delivery of care should be top priorities. In striving to provide the very best care for every patient and do no harm, we must be open to changing the way we think about blood products in evaluating the risk versus benefits. By implementing the measures outlined in this article, nurses can advance the standard of care and be in compliance with best practices and the forthcoming TJC core measures. Individual nurses can implement blood management strategies into nursing practice, but changing habits to elevate the standard of care requires a multidisciplinary team approach. Use this article as the impetus for enacting practice change.


What's anemia?

Anemia, an abnormally low hemoglobin level and/or level of circulating RBCs, decreases the blood's oxygen-carrying capacity. Anemia can be classified according to its cause, which is most often excessive bleeding, hemolysis (destruction) of RBCs, or inadequate RBC production due to either a nutritional deficiency or a bone marrow problem.


The effects of anemia can be grouped into three categories: signs and symptoms of impaired oxygen transport and the compensatory mechanisms that result, reduced RBC indices and hemoglobin levels, and signs and symptoms of the pathology causing the anemia. A patient's signs and symptoms depend on the severity of the anemia, how rapidly it developed, the underlying pathology, and the patient's age and health status. When anemia develops slowly, the body compensates for the blood's decreased oxygen-carrying capacity with increases in plasma volume, cardiac output, and respiratory rate. These changes can largely compensate for the effects of mild-to-moderate anemia in otherwise healthy people but are less effective in those with respiratory or cardiac problems.


Anemia causes pallor of the skin, mucous membranes, conjunctivae, and nail beds because blood has been redistributed from cutaneous tissues or because of a deficiency of hemoglobin. Patients may experience tachycardia and palpitations as their bodies try to compensate by increasing cardiac output.


Anemias caused by premature destruction of RBCs (hemolytic anemias) are associated with hyperbilirubinemia, jaundice, and pigment gallstones. Patients with anemias that result from ineffective hematopoiesis (premature death of RBCs in the bone marrow) may have excessively high levels of iron absorption from the gut, which can lead to iron overload and damage endocrine organs and the heart.


Lab tests can help determine both the severity and the cause of the anemia. The RBC count and hemoglobin level provide information about the severity of the anemia. The size (normocytic, microcytic, macrocytic), color (normochromic, hypochromic), and shape of RBCs may provide information about the cause of anemia.


The figure shows (A) microcytic and hypochromic RBCs, which are characteristic of iron-deficiency anemia; (B) macrocytic and misshaped RBCs, which are characteristic of megaloblastic anemia; (C) abnormally shaped RBCs, which are seen in sickle cell disease; and (D) normocytic and normochromic RBCs as a comparison.


Using best practices for blood transfusions

The AABB provides the following guidelines:


* A restrictive transfusion practice in stable hospitalized patients is a hemoglobin level of 7 to 8 g/dL.


* A restrictive transfusion practice in patients with cardiovascular disease is to consider transfusion when the hemoglobin level is 8 g/dL or less with clinical symptoms.


* The transfusion decision should be based on clinical symptoms in conjunction with lab values.



Source: Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2012;157(1):49-58.


Practice guide for nurses

Keep these points in mind:


* A blood transfusion is a human tissue transplant.


* Anemia tolerance is based on the assessment of signs and symptoms.


* Provide clinical information related to anemia tolerance when reporting lab values.


* Verify blood products at the patient's bedside according to facility policy and procedure.


* Transfuse one unit of RBCs at a time, then reassess the patient.


* Limit phlebotomy and blood loss from lab testing.





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