Reducing Blood Transfusions Through an Effective Laboratory Test Management Program
It is well known that the longer a patient stays in the hospital, the more likely one is to develop anemia. This could be due to the fact that patients who stay longer in the hospital tend to be sicker and more vulnerable to developing anemia. However, the longer the length of stay, the more phlebotomy events patients will have as well. In other words, it is common to see patients who come to the hospital with normal hemoglobin levels and then experience hemoglobin drops during hospitalization without a clear explanation, or evidence of bleeding. Critically ill patients are particularly at risk. Excessive blood draws in the ICU result in increased mortality and are major contributors to anemia.1 A study in 2011 found that even for conservative estimates of blood loss – for every 50 mL of blood drawn, a patient’s risk of developing moderate to severe hospital-acquired anemia increases by a whopping 18%! 2
What are some consequences for patients who develop anemia while in the hospital?
A recent study has shown that hospital-acquired anemia increases risk of mortality, length of stay as well as increases the use of hospital resources.3 Also, performing routine, daily laboratory tests such as a chemistry panel, complete blood count, or arterial blood gas, can increase the incidence of central line associated blood stream infections. Additionally, Salisbury and colleagues illustrated routine phlebotomy is independently associated with the development of hospital-acquired anemia in those with acute myocardial infarction – which is associated with worse health status and greater mortality.1,4 Furthermore, hospital-acquired anemia greatly increases the risk for transfusion. It is well established that transfusion of blood products is associated with higher mortality, infection and longer intensive care unit length of stay.
What steps can hospitals take to reduce the incidence of hospital-acquired anemia?
The easiest way to reduce the risk of anemia is to reduce the number and frequency of blood draws, or to bundle blood draws, or use of micro or pediatric tubes to reduce blood volume for lab tests. Another proposed tactic to reduce blood product utilization is through improved reflexive laboratory testing. Mayo Clinic Laboratories recently reported on local pilot study for hematology outpatients undergoing chemotherapy who were being considered for red blood cell transfusion.5 Prior to the change, the blood type, antibody screen and CBC were all ordered, collected and performed at the same time. To change this practice, a reflex test was created in which the blood type and antibody screen tests were only performed if the CBC was abnormal – more specifically if the hemoglobin was less than 8.0 g/dL. The additional tests would be performed using the CBC specimen; therefore no additional blood would need to be collected. They estimated this reflexing scenario would save 76.6 liters of phlebotomy blood volume and $1,467,139 in cost savings yearly. As evidenced by this one example, reducing the frequency of blood draws results in not only improved clinical and quality outcomes but also has beneficial financial outcomes. Additionally, patient and provider satisfaction, although difficult to measure, is also improved.
Our patients have the right to care that is efficient, equitable, effective, timely and patient-centered. But they also have the right to care that is safe. With a laboratory test management program and implementation of appropriate reflexive laboratory testing, hospitals can improve patient care by avoiding unnecessary transfusions!
- Rhagavan M. Chest 2005;127(5):295-307
- Salisbury JAMA. 2011;171(18):1646-1653
- Koch CG. J Hosp Med 2013; 8(9):506-512
- Salisbury AC. Circulation 2010;3:337-346
- Mayo Clinic Communique. Sept. 1st 2015
Author: Sarah Daccarett, MD, FCAP