Omaha-area hospitals saved more than $1 million in 2012 and expect to save hundreds of thousands more this year by conserving blood.
Physicians in Omaha and across the country, as a result of years of study, revised guidelines and hospital education programs, increasingly are choosing not to order blood for patients who previously would have routinely gotten a couple of units of red blood cells.
That shift, medical experts say, improves patient safety and reduces costs.
“The really good news for health systems and for patients is that they receive blood only when they need it,” said Dr. Gene Herbek, medical director of the blood conservation program at Methodist Hospital. “It's an education process for physicians.”
Methodist Health System officials estimate that its blood conservation efforts will save almost $250,000 this year on red blood cells, platelets and other blood products at Methodist Hospital and Methodist Women's Hospital. They saved $61,600 on just red blood cells in 2012.
In 2012, six metro-Omaha hospitals in the Alegent Creighton Health system spent $702,000 less on red blood cells than they did in 2010. That's arrived at by using the national average of $225.42 per unit of red blood cells as a constant over those three years.
Also using that method, the Nebraska Medical Center estimates that it saved $417,000 in blood costs last year.
Dr. Scott Koepsell, associate director of transfusion and tissue services at the Nebraska Medical Center, said the savings would be much greater if the total included the cost not only of the red blood cells but also related costs: compatibility testing, the nursing time to transfuse the unit, plastic tubing sets and filters and the refrigerators used to store the blood.
Both the Nebraska Medical Center and the Bellevue Medical Center monitor physicians' adherence to the guidelines and provide education sessions for the minority of physician groups that aren't compliant, Koepsell said. Before the hospitals implemented the policy in 2012, more than 30 percent of transfusions didn't meet guidelines. Now, he said, only 5 percent to 8 percent of transfusions fall outside the guidelines, “and those usually are just barely out.”
The attitude toward blood management has changed dramatically over the past two to three years, said Dr. Jonathan Waters, a spokesman for the AABB, formerly the American Association of Blood Banks. “Where 17 years ago I was getting thrown out of people's offices,” he said, “now people want me to come and consult for them.”
Waters, a professor in the anesthesiology department at the University of Pittsburgh School of Medicine, is a founding member and former president of the Society for the Advancement of Blood Management.
The recent increase in awareness, Waters said, is driven in part by the actions of officials from the Joint Commission, which accredits health care organizations in the U.S., and the American Medical Association. At a symposium last year, the groups included blood transfusions among their list of the five most overused medical therapies.
Early last year, the AABB recommended that doctors take a more conservative approach to red blood cell transfusions in most hospitalized patients.
The nation's blood supply, Waters and others said, is as safe as it ever has been, and the risk of contracting an infectious disease from blood products is very low because of the testing that's done.
But “there's a whole slew of things that can occur when you get transfused beyond infectious complications,” Waters said. “Patient length of stay, patients' in-hospital infection rates, allergic reactions, all these things have been raised to a significant level in people's minds.”
People who are given blood can develop an elevated temperature because proteins in the blood react with the patient's white cells, Herbek said.
“There are also some patients who have heart problems,” he said, “and any kind of volume increase, a unit or two of blood, may complicate or worsen their congestive heart failure.”
It's also a remote possibility, Herbek said, that a patient could be given the wrong blood type because of a clerical error.
Physicians long have known that people could donate a unit of blood without any problems, Koepsell said. “So they figured that if somebody looked a little sluggish or their blood level was a little low, you should get two units of blood.”
The “a little low” level generally was hemoglobin that had dropped below 10 grams per deciliter. Hemoglobin, which makes red blood cells red, delivers oxygen from the lungs to the body's tissues and moves carbon dioxide back to the lungs. (A normal hemoglobin range for a woman is 12 to 15; it's about 14 to 17 for a man.)
“So for years and years and years,” Koepsell said, “physicians gave two units of blood anytime the blood level got pretty low in patients. It's kind of a historic thing. It was passed forward in medical teaching.”
About 20 years ago, Koepsell said, Canadian researchers wondered, “ 'What if we don't transfuse you until your blood level gets even lower? What happens then?' They found that patients don't do any worse if you conservatively transfuse them. In fact, they tend to do better by withholding transfusions.”
A large study reported on in 1999 in the New England Journal of Medicine compared transfusions given when hemoglobin levels fell below 10 grams per deciliter to transfusions that didn't occur until the patients' hemoglobin dropped below 7 grams per deciliter.
Researchers found that critically ill patients in the 7 grams group had fewer heart attacks and less pulmonary edema.
That study and others “created an uproar,” said Dr. Michael Petzar, transfusion service director at Creighton University Medical Center. “It just didn't seem right to a lot of physicians. More oxygen capacity wasn't better?”
Petzar noted that physicians at Creighton have been performing transfusion-free surgery since the mid-1990s. The effort began as an attempt to accommodate groups such as the Jehovah's Witnesses who have religious proscriptions against receiving blood. Such techniques also have been applied to other patients to reduce the need for blood transfusions, he said.
Generally, though, it took several years and more clinical trials to convince many physicians that they didn't need to transfuse so early and often.
Medical teams from Children's Hospital & Medical Center discovered the problems transfused blood could cause while on mission trips to Central America in the mid-2000s, said Joe Deptula, the hospital's chief perfusionist.
“Blood is poisonous outside of the U.S. We had some bad outcomes just because we gave blood and for no other reason ... (Now) we do a lot of things to minimize the amount of blood exposure we have to give our kids.”
The doctors started looking at taking the practice back to Omaha, Deptula said. “If it's safer to not give blood products,” he said, “it's safer not to give blood products in the U.S., as well.”
Blood obviously still is needed in many cases, blood conservation backers note. But the conservation practices have helped reduce the amount of donated blood distributed in the area by the American Red Cross, which collects and distributes about 40 percent of the nation's donated blood.
In fiscal 2013, the Midwest Blood Services Region, which includes Nebraska and western Iowa, distributed about 4.7 percent fewer pints of blood, on average, to hospitals than it had during the past four years, said April Oppliger, a Red Cross spokeswoman. During that same time, about 2 percent more pints of blood were collected in the area, she said, allowing the Midwest Region to supply blood to hospitals across the country.
|Units of red blood cells transfused by area hospitals|
|Alegent Creighton hospitals in the Omaha metro area (Bergan Mercy, Creighton, Immanuel, Lakeside, Mercy, Midlands):|
|2010: 19,008 units|
|2011: 16,575 units|
|2012: 15,893 units|
|2013 (forecast): 14,500 units|
|2010: 5,881 units|
|2011: 5,988 units|
|2012: 5,649 units|
|2013 (forecast): 5,004 units|
|Nebraska Medical Center:|
|2010: 18,251 units|
|2011: 18,102 units|
|2012: 16,401 units|
|2013: 13,228 units|
|(through October; on pace for 15,873)|
|Bellevue Medical Center:|
|2010: 429 units (hospital opened May 17)|
|2011: 830 units|
|2012: 889 units|
|(through November; on pace for about 590)|
|Methodist Women's Hospital:|
|2010: 100 units (hospital opened June 21)|
|2011: 127 units|
|2012: 216 units|
|2013 (forecast): 191 units|
|Source: the hospitals|