When Dr. Abe DeAnda trained in cardiac surgery years ago, he was given some dangerous advice.
“There were a lot of old rules of thumb such as, ‘If you need to give one (unit of blood), give two,’” recalled DeAnda, who is now professor and chief of cardiovascular and thoracic surgery at UTMB. “Every resident memorized that about blood transfusions. It was probably the most dangerous rule you could learn in medicine.”
While DeAnda is quick to point out that blood transfusions can be life-saving when necessary, he often sees scenarios where the risks outweigh the benefits. Blood transfusion has been named one of the top five overused procedures in U.S. hospitals—and studies over the past two decades have found that liberal transfusion practices make patients more susceptible to infections and increase the risk of poor outcomes such as longer hospital stays and even death.
“It’s a patient safety issue,” he said. “While blood is generally very safe, there are always risks for the receiving patient, such as cardiac overload, lung injury and infections—and the risks are higher if you get more blood. Again, if you need a transfusion, you should get a transfusion. The caveat to that is if you don’t need a transfusion, the blood can hurt you.”
DeAnda started using less blood—even performing bloodless heart surgeries— nearly two decades ago, when he started a heart program at another institution to treat Jehovah’s Witnesses who refused donated blood on religious grounds. He found that the cardiac patients got out of the ICU and hospital faster with significantly better outcomes, so he began fine-tuning ways to apply these techniques to provide care to the broader population. As an added benefit, the techniques helped conserve blood—a precious resource—and reduced hospital and patient care costs.
“I don’t think most people realize how much blood products cost,” he said. “A unit of blood can be upwards of $1,500 when you take into account processing, lab and delivery costs—it all adds up. So, for big programs that use a lot of blood, that’s a significant amount of money going out the door—and it’s not always to the benefit of the patient.”
Blood management was recently introduced by Health System leadership as one of five focus areas that builds upon the Best Care initiative to help UTMB become a high-value practicing organization. DeAnda was appointed to lead a multidisciplinary group tasked with adding “teeth” to UTMB’s Patient Blood Management Program (PBM)—which uses evidence-based guidelines to promote the appropriate use and management of blood—and reducing unnecessary blood transfusions.
“Right now, we are analyzing data to see which services use the most blood and if there are certain groups where one physician uses no extra blood and another one uses a lot of blood—why is that?” he said. “One of the first steps is to figure out the practices that people are using. Once we do that, we’ll know where changes are needed to ensure the best outcome for our patients, based on the most current evidence.
“Physician education is going to be No. 1. We are going to have to meet with a lot of people, give grand rounds, give lectures, explain why this is important, and show them the literature—there’s thousands of papers written on this subject, yet, we still need to shift our mindset. It’s going to take some time.”
Part of the physician education will emphasize how to proactively plan to avoid the need for transfusion in the first place. For example, if a patient has preoperative anemia, instead of relying on transfusion as a quick fix, a more sensible approach may involve postponing an elective procedure and giving the patient iron, or screening at-risk individuals weeks in advance to make sure anemia is managed appropriately.
“There are certain things we can do on all fronts to decrease the need for transfusion and improve patient outcomes,” said DeAnda. “We have a target of where we would like to see transfusions based on national guidelines. Right now, we are well above that target. So, we have work to do, but I know we can do it.”
Ultimately, DeAnda would like to see UTMB attain Patient Blood Management Certification from the American Association of Blood Banks and The Joint Commission— a distinction that may take several years to attain, but is the right thing to do for patients.
“It’s all about providing the best care possible for patients,” said DeAnda. “What we do know is that when we do fewer transfusions, lengths of stay go down, hospital-acquired infection rates go down and patients do better—that’s what it’s all about."
UTMB recently received the first-quarter performance report for the 2018 Quality and Accountability Study. To check our progress and read more about UTMB’s efforts to become a high-value practicing organization, visit intranet.utmb.edu/best-care.