Program reduces need for blood transfusions
Patient safety, cost, preference drive needs
With only 5% of the U.S. population serving as blood donors,1 it is easy to see that blood is a limited resource. There is no guarantee that donations will increase to keep up with the demand that is required by older patients who undergo complex surgical procedures that result in large volume blood loss.2 Although great strides have been made to ensure the safety of the blood supply, it is unlikely that the risk of infection from transfusions will be completely eliminated.3
The limited supply, as well as concerns about safety, cost, and patient preference, has made the development of a bloodless surgery program an important move for many same-day surgery programs.
"The term bloodless’ is a misnomer when you are talking about surgery because most surgeries mean the loss of some blood," says Sherri Ozawa, RN, director of The New Jersey Institute for the Advancement of Bloodless Medicine and Surgery at Englewood Hospital and Medical Center in Englewood. "A bloodless medicine or surgery program has a focus on minimizing exposure of patients to allogenic blood transfusions." Ozawa’s facility became interested in a bloodless surgery program because of the large Jehovah’s Witness population served by the hospital and its physicians. The religious tenets of Jehovah’s Witness do not allow for blood transfusions or acceptance of any other type of blood product, she says.
"There is no magic formula to reduce the number of transfusions, but we have discovered, out of necessity for our patients who refuse transfusions of any kind, how to minimize the need for blood," she says. The first step is to boost the effectiveness of the patient’s own blood, Ozawa says. "The key is to start weeks ahead of a procedure, and that is usually possible with same-day surgery procedures," she points out.
By administering erythropoietics to promote increased red blood cell production before surgery, a patient can tolerate blood loss without a need for transfusions, Ozawa explains.
At Good Samaritan Regional Medical Center in Phoenix, patients of the Transfusion-Free Medicine and Surgery Program visit the same-day surgery center three to four weeks prior to surgery to be tested for anemia, says Richard Melseth, director of the program. "We begin treatment of anemia with erythropoietics, and we often administer intravenous iron," Melseth says. Patients return to the center for follow-up visits as needed to monitor hemoglobin levels prior to the surgery, he adds.
The Good Samaritan and Englewood programs are patient-driven. "Any patient can request a physician who participates in the transfusion-free program," Melseth says. When a patient calls his program, Melseth and his staff refer to a list of physicians that includes internists, family practitioners, and specialists. Once the patient sets up the first appointment with the physician, the patient notifies Melseth’s department. "At that point, we review the procedures, options, and types of medications the physician might prescribe with the patient. We serve as the patient education component of the process," he explains.
At Englewood, patients learn about techniques that will be used to minimize blood loss during surgery and how the operating room team will replace lost blood with other fluids, Ozawa says.
Patients can choose no transfusion in any event or transfusion only in a life-threatening situation, Melseth says. Patients sign the appropriate forms and wear wristbands that indicate no blood or restricted blood use, he explains.
Patients sign release-of-liability forms that indicate their refusal of transfusions at any time during their care, Ozawa says. "Our experience is that patients and their families don’t litigate if we’ve respected their right to refuse transfusions," she says. The hospital has not experienced any increase in claims or any change in their insurance coverage, she adds.
While many same-day surgery programs do not handle procedures with significant blood loss, there are some procedures such as orthopedics and gynecological procedures that carry the risk of unexpected blood loss, Melseth says. "Also, with gynecological procedures, you are working with female patients who are often anemic or borderline anemic," he adds. These patients benefit from preoperative treatment of anemia because then they go into surgery with a greater capability to sustain blood loss without transfusion, Melseth points out.
A bloodless medicine and surgery program can benefit a same-day surgery program because it might keep more procedures in the SDS program, he says. "In our facility, a surgeon will schedule a typical same-day procedure in the inpatient operating room if he or she anticipates a potential need for transfusion," Melseth says. If these patients are evaluated and treated for anemia or other blood-related issues prior to surgery, they can remain same-day surgery patients, he adds.
"Many same-day surgery programs already use techniques to reduce blood loss during surgery," Ozawa points out. "Endoscopic and laparoscopic surgery, electrosurgical and harmonic scalpels, and laser surgical techniques all help create a bloodless field of surgery," she says.
For other cases that present a potential for blood loss, hemodilation, volume expanders, and cell washers can be used, says Ozawa who points out that these are techniques more likely to be used in an inpatient surgery program.
Setting up a transfusion-free program requires time and the support of key medical personnel, Melseth says. Finding physician-champions who are top-rate physicians respected for their skills by other surgeons is important, he suggests.
Educating physicians, staff members, and administrative personnel is a lengthy process, Ozawa says. "It took us at least one year to develop the program and have the support we needed to get started." Not only did Ozawa point out the patient safety issues related to blood transfusions, she also talked about the cost. "Donated blood and all the costs related to getting it to a patient costs $1,003 to $1,043 per patient," she says.4 "This doesn’t take into account the costs when a patient experiences complications related to the transfusion," she adds.
There are resources to help same-day surgery managers who want to develop a bloodless medicine and surgery program, Melseth says. Professional associations, books, and articles are available to offer tips on rationale and support for the program, and development of the policies and procedures needed, he adds. (See resources at the end of this article.) Be patient, Melseth suggests. "You have to realize that you are asking physicians to change their behavior, and that takes time," he says. "You are also developing a customer-driven program that requires a lot of education for everyone."
References
1. Nucci ML, Abuchowski A. The search for blood substitutes. Sci Am 1998; 278:72-77.
2. Ozawa S, Shander A, Ochani TD. A practical approach to achieving bloodless surgery. AORN J 2001; 74:34-47.
3. Chamberland ME, Epstein J, Dodd RY, et al. Special issue: Blood safety. Emerging Infectious Diseases 1998; 4:3.
4. Blumberg N. A cost analysis of autologous and allogenic transfusions in hip-replacement surgery. Am J Surg 1996; 171:324-330.
Sources and resources
For more information about their experience with bloodless surgery programs, contact:
• Sherri Ozawa, RN, Director, The New Jersey Institute for the Advancement of Bloodless Medicine and Surgery, Englewood Hospital and Medical Center, 350 Engle St., Englewood, NJ 07631. Telephone: (888) 766-2566 or (201) 894-3935. Fax: (201) 541-2268. E-mail: [email protected].
• Richard Melseth, Director, Transfusion-Free Medicine and Surgery Center, Good Samaritan Regional Medical Center, 1111 E. McDowell Road, Phoenix, AZ 85006. Telephone: (877) 815-3114 or (602) 239-6070. E-mail: [email protected].
The following offer information about the development of bloodless medicine and surgery programs:
• The Society for the Advancement of Blood Management, 350 Engle St., Englewood, NJ 07631. Telephone: (866) 894-3916 or (201) 894-3916. Fax: (201) 894-0585. Web: www.sabm.org. The web site contains a variety of articles related to blood management, news updates on new techniques and products, and information on educational meetings.
• The Network for Advancement of Transfusion Alternatives, Paris. Web: www.nataonline.com. This web site provides links to presentations and articles related to blood management as well as information about new products, educational meetings, and surgical and anesthesia techniques.
• www.bloodlessprograms.com. This web site provides a list of hospitals that offer bloodless programs as well as links to bloodless program publications distributed by the web site’s sponsor, BloodlessMedia, 1018 E. Magill Ave., Fresno, CA 93710. Telephone: (559) 432-5259.
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