A January study of almost 1,000 patients with acute gastrointestinal bleeding has found that restrictive blood transfusion strategies produce better patient outcomes. The study, “Transfusion strategies for acute upper gastrointestinal bleeding,” discovered that patients with severe acute upper GI bleeding who received blood transfusions when their hemoglobin levels fell below 7 g/dL, rather than 9 g/dL, had higher probabilities of survival at six weeks, as well as reduced rates of further bleeding and fewer adverse events (Villanueva C, et al. N Engl J Med. 2013;368:11–21).
“Not cutting edge but new and important,” Lauren Anthony, MD, medical director of Allina Health Medical Laboratories, Minneapolis, says of the research. “They looked at patients who were actively GI bleeding, and that hasn’t been addressed in the literature before.” And it adds to the body of evidence that patients do just as well, if not better, under restrictive rather than liberal transfusion strategies.
Despite this having been known for years now, physicians have been strangely slow to embrace them. “People don’t really get educated about this, because it doesn’t really fall into any clinical disciplines,” Dr. Anthony says.
“It’s a counterintuitive physiologic principle to most of us,” says David Tierney, MD, a hospitalist and the assistant program director for the internal medicine residency program at Abbott Northwestern in Minneapolis, one of the Allina Health System’s 11 hospitals, which are located in Minnesota and Wisconsin. “We think of red blood cells as being good things only and carrying oxygen. And so the concept that adding more of them to someone who has a partially full ‘tank’ is deleterious—that innately doesn’t make sense to the physiology we’re taught as physicians.”
And then there’s the power of tradition. “For a long time, the existing dogma of transfusion was always giving at least two units, and transfusing at a hemoglobin threshold of 10 [g/dL],” says Josh Martini, MD, an anesthesiologist at Allina Health’s Mercy Hospital in Minneapolis and chair of the hospital’s transfusion committee. “I was taught that as a medical student back in 1996 on my first medicine rotation. It has nothing to do with any evidence or any scientific backing. I was a resident when the original TRICC [Transfusion Requirements in Critical Care] trial came out. I remember I was on the orthopedic surgery service, and I felt like I made headway if I could get the orthopedic surgeon I worked with to transfuse at 9.5 instead of 10. That was my big goal.”
Against the twin foes of intuition and tradition, how can laboratories go about getting physicians to embrace restrictive transfusion strategies? A few physicians become convinced on their own after undergoing personal experiences like that of Charles Terzian, MD, a hospitalist at Allina Health’s United Hospital in St. Paul, Minn. As a trauma patient at a (non-Allina) hospital, Dr. Terzian received a blood transfusion in 1995. Two years later, “I got letters saying, ‘We might have transfused you bad blood,’” he recalls. “Luckily, all my serological testing was negative. But just going through that experience was enough to reinforce my position that blood transfusions can save lives, granted, but they can also cause problems.”
|Jodi Hartwig (left) was a clinical nurse specialist in CVD surgery when she stepped forward to help Dr. Anthony (right) map the project and committee structure. Hartwig then became a full-time program manager for transfusion.
Others change from mere supporters of restrictive blood transfusion strategies to active proponents after seeing the dire effects an unnecessary transfusion can have on a patient. Dr. Martini recalls a patient in her 50s who came in with a GI bleed: “She wasn’t able to receive any blood products, because she had multiple antibodies and we couldn’t find blood for her. She ended up dying. When I looked through her records, it was evident that the only exposure she had to any blood products was a total knee arthroplasty a few years before. The most likely explanation for her development of antibodies was from this prior transfusion. When I looked at the records, the transfusion was inappropriate. I was limited in saving this woman because I couldn’t get appropriate blood products. You think: ‘One person’s decision to not follow the evidence contributed to this.’”
As powerful as experiences like these can be, it takes more than a few isolated proponents to affect how and under what conditions blood is transfused, especially in a system as large as Allina Health. In the last two years, Dr. Anthony has led a massive, systematic effort to get physicians in the 10 Allina Health hospitals where blood transfusions are performed to understand and embrace appropriately restrictive transfusion protocols. And it’s worked: Red blood cell use has dropped significantly. So significantly, in fact, Dr. Anthony calls Allina’s continuing efforts in this area “a game of inches.”
Before Allina Health began to consider systemwide transfusion education in 2010, “we certainly weren’t doing any worse [in this regard] than any major hospital system, but we had a large area for improvement,” Dr. Martini says. One of his colleagues, Dirck Rilla, CCP, remembers going into a meeting with surgeons a couple of years previously and attempting to give a process improvement talk that focused on blood conservation. “I was happily escorted out,” says Rilla, director of perfusion operations for the entire Allina Health System.
That all began to change when the system’s chief clinical officer, Penny Ann Wheeler, MD, decided to champion a transfusion education effort at Allina after hearing about the issue at an AHA meeting. And the then newly hired Dr. Anthony, who had recently left a hospital with a successful blood management program (Bronson Methodist, Kalamazoo, Mich.), was the right person to lead it. The first step: To get a clear picture of Allina hospitals’ blood use. It wasn’t pretty.
Utilization review by an external consultant through the Red Cross showed “we had overtransfusion of about 25 to 40 percent, depending on DRG code and patient mix,” Dr. Anthony says. And blood use varied dramatically by hospital. Rilla says, “In the cardiovascular arena, one hospital had an RBC transfusion rate of about 67 percent, and across town it was closer to just under 30.”
The second step: To assess physician readiness. “The lab can serve a leadership role, but it can’t implement it without physician champions who order blood,” Dr. Anthony says. “I mean, the lab just can’t do it, because the lab doesn’t order the blood. So I sent out to all the medical staff a physician readiness survey. It was basically: ‘Do you observe a lot of variation in transfusion practices when you’re on the floors? Do you think there’s a need for more transfusion education? What is the typical hemoglobin level you use to decide to give a transfusion?’ Questions like that. The responses showed us that most people definitely agreed that they were hearing about it in their professional societies and knew it was something there was an opportunity for.” The survey also asked whether respondents would be willing to become physician champions for restrictive transfusion strategies across Allina Health’s hospitals.
|At Mercy Hospital alone, says Dr Martini, here with ICU nurse Renee Zinken, red cell transfusion is down by 24 percent. Zinken says getting physicians to comply with the guidelines takes “a lot of repetitive, respectful discussion.”
Many said yes. Even better, among those who said yes were several physicians in high-blood-use specialties. Says Dr. Tierney: “It’s hard for me as an internist to convince a cardiovascular surgeon that he shouldn’t give a postoperative heart patient a unit of blood when his hemoglobin’s 7.5. But for a cardiovascular surgeon to convince his partner is a much more effective practice.”
Once the physician champions had been identified, they gave Dr. Anthony surprising feedback. In their view, the transfusion effort should be rolled out systemwide, rather than piloted at one hospital and introduced only gradually at the others. “Some of the high-level champions, like a cardiovascular surgeon and a liver surgeon, said, ‘This is only going to work if you do it at the system level, because we have an EMR,’” she says. “They said, ‘You can’t be making changes to order sets and transfusion guidelines if you don’t include all the hospitals as you move forward; it’s not going to work.’ And it’s because of them that this has worked.”
Subsequently, Dr. Anthony visited each hospital’s medical leadership committees to discuss what a blood management program would entail, why it should be done, and how it would get started—“just starting the discussion, getting people used to the idea,” she says. In a further effort to “get a lot of people engaged and enthusiastic,” she invited blood management pioneer Aryeh Shander, MD, chief of anesthesiology, critical care medicine, and hyperbaric medicine at Englewood Hospital and Medical Center, NJ, to deliver to Allina medical staff talks about plasma and red blood cell transfusions.
As a newcomer to Allina Health, Dr. Anthony had to learn her way around hospital performance improvement in a large integrated system. Her guide: clinical nurse specialist Jodi Hartwig, who showed her how to structure the project and plug it into Allina Health’s performance improvement model. “Jodi explained how initiatives are rolled out in the system and said I needed to configure blood management the same way.”
With the help of a consultant, Dr. Anthony and her colleagues identified five areas of focus: revision of transfusion guidelines and order entry; cardiovascular surgery blood conservation; minimization of iatrogenic blood loss; preoperative anemia management; and awareness/education. “At that point, we knew what we needed to do, and we formed a systemwide transfusion care council that has all 10 hospitals represented,” she says. “We made sure everyone had the opportunity to participate in work groups, and through the care council, we brought the work group decisions back to the main group, and they were communicated to all 10 hospitals.”
For instance, they moved the hemoglobin threshold in their guidelines from eight to seven for stable, hospitalized patients. “When we implemented it, everyone was fully aware and had signed off on it, so it ended up being very successful. We didn’t have these small hospitals saying, ‘You changed something on us, and we had no input.’”
It helped that many of the working groups had people from more than one hospital. “Because we’re such a large system, Allina has excellent audio- and videoconferencing systems,” Dr. Anthony says. “We’re always sharing over the Web in live meetings. It’s such a part of our culture.”
As for the smaller hospitals, “we had a couple that didn’t want to have any part of blood management at first,” she adds. “They didn’t have time, or they didn’t think it was a big deal. We brought this up to Dr. Wheeler and said, ‘Look, we must have physician champions at all the hospitals. We can’t have people opting out.’ So she made sure we had all 10 hospitals represented, whether they wanted to be there or not. Most did, but there were a couple latecomers.”
By July 2012, the care council had succeeded in revising and launching the transfusion electronic order set to make it more difficult for physicians to order two units of blood at a time, since “single-unit transfusions are best in non-bleeding patients,” Dr. Anthony says.
|The revised transfusion order set is “much more instructive to clinicians,” says Dr. Katz, above with Dr. Tierney, who expects the systemwide dashboard to be another powerful force.
That revised order set, says pathologist Brenda Katz, MD, medical director of Allina Health’s central laboratory, is “much more instructive to clinicians in terms of things like demanding a reason why they’re transfusing. And now one unit comes up automatically, instead of two. It used to be that they could choose whatever they wanted.” Hospitalist Dr. Tierney, who served as Abbott Northwestern’s physician lead for the order-set modifications, agrees that the order-set changes have been a powerful tool in altering physician behavior, in part because “we’ve tried to incorporate a lot of evidence into the ordering process,” he says. “That’s ultimately what helps physician practice change. Without the evidence, people just get pissed off because they get frustrated not being able to order something in the way they always have.”
At the same time, another working group focused on implementing some of the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines, which include recommendations such as washing and reinfusion of intraoperative blood, at the three Allina hospitals where open-heart surgeries are performed. “At this point, we have 18 of the 20 standards we chose implemented, and by April, all 20 of them will be implemented,” Dr. Anthony says. “We’ve already significantly decreased blood utilization in the cardiac surgery group without the patients becoming more anemic.”
Still another working group strategized ways to minimize iatrogenic blood loss from critical-care patients. Chief among those ways: switching to low-flow collection tubes and making sure that reinfusion devices are used on 100 percent of patients. An initiative to decrease the frequency of blood draws is still underway.
Working group member and Abbott Northwestern medical/surgical/neurological ICU nurse Renee Zinken, RN, BSN, took this opportunity to conduct an informal study of three ICUs. Her aim: “To figure out how much waste we are creating when we do blood draws,” she says. “It was eye-opening to see just how much waste there was, since when we have patients with arterial or central lines, we have to remove a certain amount of blood as waste product before we take the sample.” Her informal study found a collective waste of up to a couple pints of blood. “If you’re a patient in the hospital for an extended period of time, you’re losing quite a bit of blood just with lab draws.”
“Do you realize how much blood we’re throwing away?” Zinken asked the rest of the nursing staff. “Can we start grouping some labs together so we’re not doing them every two hours, but every four or six hours? Is it necessary that we do a draw at 11, or can we do it at 1 when the patient has this other stuff going on at the same time?” She also championed the switch to blood-conserving arterial line systems, which allow a patient’s blood to be retransfused rather than discarded. “Otherwise, you’re wasting up to 10 ccs of blood, and that adds up over time,” she points out. “Plus, now you’re not having to throw away that syringe.”
The larger effort undergirding all of these initiatives, awareness and education, proved to be the biggest, but most entertaining, task of all. It began with a logo, a simple drop of blood containing the word “think.” “It doesn’t say ‘Transfusions are bad.’ All it says is ‘Think,’” Dr. Anthony says. The logo appears on the care council’s agendas, visual presentations, and lapel pins. It also appears on the council’s poster campaign, which uses various transfusion-related slogans such as, “Why use two [units of blood] when one will do?” The logo varies slightly depending on what transfusion information is being emphasized. For example, “When we changed the transfusion threshold to seven grams of hemoglobin, we changed the drop to include the number seven,” she says. And on plasma-related materials, the blood drop includes the letter K, “because we’re trying to emphasize that vitamin K is the first-line agent for nonurgent reversal of warfarin.”
The entertaining part of the council’s educational efforts? That was the short film they created, “Blood Police.” The idea came about when the council realized there was no way to give educational talks at every hospital. “It’s too much,” Dr. Anthony says. “Getting someone out to 10 hospitals is not feasible. And we have 4,000 nurses. Even if you go out to all the hospitals, it’s not a sure thing that all the physicians and nurses can attend your presentation. That’s why someone said, ‘We need to have a video, and it shouldn’t be too long.’”
The film’s underlying concept—a member of the “blood police” reprimanding a physician and nurse for attempting an inappropriate transfusion—was sparked by Dr. Anthony’s realization that “people are always sarcastic when you start talking about blood management. They say, ‘Oh, no, now we’re going to have the blood police.’ I said, ‘Why don’t we take that and make it a funny thing?’” She wrote the script; Rilla, Dr. Martini, and nurse Zinken agreed to play the starring roles. Allina’s media services department produced it.
“I sort of had a vision of someone wandering around with a camcorder, so I was quite surprised when the director—I believe he has a degree in film from UCLA—showed up,” Dr. Martini laughs. “I was amazed by all the detail.”
“Blood Police” became an instant hit. Made part of the nurses’ mandatory online education, it was also posted on the health system’s intranet and shown at many physician meetings. “Normally, mandatory education can be quite boring,” Zinken says. “It’s a handout, it’s a quiz, it’s PowerPoint slides. But the response [to the film] has been: ‘This is really creative. I actually watched that, I remember the information, I understand it better now.’”
Dr. Tierney agrees. “The film was done in a way that had enough evidence behind it so that physicians were engaged and didn’t just blow it off,” he says. “And it was appealing to nurses, who probably are responsible for many more transfusions being given than anyone realizes, because they call at 2 AM and say, ‘This patient’s hemoglobin is low; should we transfuse?’ The doctor who answers the call, and doesn’t know the patient, says, ‘Well, sure.’”
Rilla, who played the part of the “blood cop,” calls the film “light, comical, but full of fact.” “You really did get to know what the evidence says, but it wasn’t presented in an overly academic way, and I think that really helped,” he says. “My favorite reaction to the movie was during Blood Conservation Awareness Week. We had it playing in the cafeteria and in some of the doctors’ lounges. I happened to be walking through one of the lounges, and two surgeons were walking by. In the film, the doctor had just ordered two units of red blood cells, and one surgeon said, ‘Watch this. He’s going to get in trouble.’ I got a kick out of that.” A follow-up film, this one focusing on plasma, was introduced last month.
As a result of all these efforts, red blood cell use dropped 20 to 25 percent between mid-2011 and mid-2012. In the quarter after July 2012, when the new order set was implemented, that number decreased an additional 10 to 15 percent. At this point, Dr. Anthony says, it’s time to look more closely at variation between individual physicians and departments.“If there’s a significant outlier, we can start asking why and unmask some of that variation.”
That’s why a systemwide transfusion dashboard is being introduced. It shows which blood products are being transfused, how often, and in what quantities. “We also have all of the Joint Commission requirements for blood that we’re tracking,” Dr. Anthony says. “All those quality indicators, such as: Were vital signs taken? Was informed consent verified? All those types of documentation, as well as the actual utilization data, like how many transfusions are one-unit versus two-unit in non-bleeding patients. It shows each hospital how they’re trending.
“We know right now that we’re pretty close to best practice,” she continues. “So what we can do is look for trends, if things start going back up or if they remain stable. The data analysis is really robust, so that we can measure metrics such as red blood cell units per 1,000 discharges.”
This dashboard, she hopes, will help convince holdouts of the value of restrictive transfusion strategies. “You might have one physician say, ‘I’ve been doing this for 40 years, and I’m not going to change,’” she says. “But now you can show them: Here’s this other hospital that’s also doing this type of surgery, and their patients have a shorter length of stay than yours. Then they might say, ‘Well, their patients must not all be over 80 years old.’ But you can use the dashboard to see the ages of the patients, the DRGs, the complications. You can show them the trend line for the patients who didn’t receive transfusions, and the trend line for the patients who did.”
Dr. Tierney joins Dr. Anthony in predicting that the dashboard will be a powerful force to change physician behavior. “You can do all the order-set modification and communication you want, but if a physician doesn’t understand the why of it, things may change for a while, but will change right back,” he says. “I think it will be a permanent change here.”
Meanwhile, the physician champions are still working to educate their colleagues one-on-one. “For instance, one liver surgeon presented to his own hospital group why the transfusion guidelines should be moved from a hemoglobin of eight to seven,” Dr. Anthony says. “It wasn’t the lab presenting that; it was him. And he has a lot at stake there, because he takes care of patients who have high blood loss. That carries a lot of weight.”
|Dr. Anthony wrote the script for the film in which Dirck Rilla, above, plays the blood cop. It’s “light, comical, but full of fact,” he says of the film. The “Think” logo is on everything from lapel pins to posters to council agendas.
From a nurse’s point of view, getting physicians to comply with the new transfusion guidelines takes “a lot of repetitive, respectful discussion,” Zinken says. “So far the physicians I’ve interacted with have all been relatively positive. I’ll say, ‘Are you sure that’s what you want to do?’ And they’re like, ‘Yeah, you’re right. Let’s hold off. Let’s give only one unit.’ Now, there have been some physicians who say, ‘Well, I’m still going to give two units,’ but at least you’re starting to gently nudge them in the direction of the new guidelines. I expect to see that by the end of this year, we’ll have a lot more compliance.”
What about from the patient’s point of view? “Some of the patients have been thrilled,” says hospitalist Dr. Terzian. “A lot of times people are grateful that they didn’t get blood, because there’s a certain stigma associated with getting it.”
As for next steps, “getting that dashboard out and in use amongst the different services is going to make the biggest changes,” pathologist Dr. Katz says. “This momentum—we need to hand some of it over to the actual clinical services and their groups and departments with our continued encouragement and support. The educational awareness will just continue to grow.” In addition, a preoperative anemia management pilot is underway at one site as a preventive care measure.
In Rilla’s view, additional things still need to be done. “I think we could be doing a little better on raising awareness, getting this to the front of everybody’s thought processes.” He’d like to have blood conservation as a trending topic on the home page of Allina Health’s intranet: “what our utilization has been, what our quality improvements have been—have it up front and in everybody’s face constantly. We could step this up a little by getting into everybody’s face a bit more. Because believe me, if I put two different surgeons’ blood utilization numbers up side by side, I can tell you, they’re going to get competitive, and they’re going to want the best numbers.”
Though there’s plenty left to do, the Allina Health team is proud of all it has accomplished so far. “I couldn’t, as an individual, make the changes that we’ve been able to make at a system level,” Dr. Martini says. “At Mercy Hospital alone, we were able to decrease our red cell transfusion by 24 percent, saving the hospital millions of dollars in the process. How often can you say: ‘I can spend less money and give better care, just by following the evidence?’”
Anne Ford is a writer in Evanston, Ill.