February is always a good month to talk about blood utilization oversight because it is the anniversary of the Transfusion Requirements in Critical Care (TRICC) trial, published in the New England Journal of Medicine on February 11th, 1999.1 In this study, 838 anemic critically ill patients were prospectively randomized into one of two treatment strategies: transfuse at a hemoglobin level of 10 gm/dL, a very traditional approach to these challenging patients, or transfuse at a hemoglobin level of 7 gm/dL, which was a very radical departure from common practice in 1999.
The results of this study were shocking and changed the practice of transfusion medicine because the patients who were transfused at the more liberal “trigger” of 10 gm/dL had substantially worse outcomes than those transfused at the more conservative trigger of 7 gm/dL, particularly cardiopulmonary outcomes such as pulmonary edema, ARDS and myocardial infarction. Further, hospital mortality rates were also higher in those patients transfused more liberally. The conclusion of the authors back in February of 1999 was that “a restrictive strategy of red cell transfusions is at least as effective as and possibly superior to a liberal strategy in critically ill patients, with the possible exception of patients with acute myocardial infarction or unstable angina.” Of great interest, even the exception to the rule noted by the authors, those patients with acute coronary syndromes (ACS) have now been shown to also have higher mortality rates when transfused liberally.2,3,4 The results of the TRICC trial coined the phrase “less is more for transfusions,” a concept whose evidence has grown even stronger over the past decade. An editorial comment that I regularly make from the podium is that although the TRICC trial is ranked as the #1 landmark study that has changed transfusion practice worldwide,5 how many physicians who regularly order blood products within our hospitals are familiar with this now 11 year old study?
Before you get the impression that I’m throwing physicians under the bus, let me explain that they are not entirely quote to blame. It turns out that most physicians who order blood products, including anesthesiologists like myself, have never received formal training in blood component therapy. Most medical schools do not have a curriculum in transfusion medicine, and most residencies don’t cover the subject at all. Absent standardized training, what medical students and residents get is on-the-job training, which is only as good as the person doing the training and of course varies greatly from institution to institution. For that reason, transfusion practice is essentially inherited from the institution where a physician trained and is therefore shrouded in habits, misconceptions and myths. To put this issue into greater perspective, blood transfusions are the second most common procedure in U.S. healthcare, second only to live births, with 30 million units of blood products a year being ordered mostly by physicians not formally trained to do so, and administered mostly by nurses who lack training in transfusion administration and transfusion safety. As if this gap in basic training isn’t serious enough, physicians are often slow to integrate new information into their practices, particularly for issues which they may view as peripheral, e.g. blood transfusions. The Institute of Medicine has stated that it takes physicians an average of 12- 14 years to incorporate advances in evidence-based medicine into their clinical practices, and in the case of more conservative transfusions, the IOM seems to be correct.
With that preamble about the current state of transfusion education and transfusion practice in the U.S., it should be self evident that hospitals need strong and effective blood utilization committees to develop, promote and monitor evidence-based guidelines for blood component therapy. My counsel to clinical and administrative leaders is that they should assume that doctors and nurses arriving from the finest medical schools, residencies, and nursing schools have no idea how to properly order and administer blood products; if it turns out they know what they are doing, it can be a pleasant surprise. The assumption that physicians and nurses lack competency for a therapy that is hazardous in the best of circumstances is the safest bet for our patients, and completely changes our view of the importance of blood utilization committees that are effective.
I hope that you’ll be able to join me for our upcoming Blood Management UniversityTM Live Learning webinar, “Building Effective Blood Utilization Committees” on March 15th at 1 PM EST. Topics for discussion will include the regulatory requirements for blood utilization oversight as well as the Joint Commission’s push for Blood Management Performance Measures, which are mainly centered around measures of the effectiveness of this oversight. More importantly we’ll explore the practical aspects of building effective blood utilization committees, which I believe to be the heart of blood management programs. In addition to discussing important resources for the development of blood utilization committees,6 I’ll detail the three characteristics that I attribute to committees that actually make a difference: multidisciplinary, representative and activist. A multidisciplinary approach is required since blood and blood related resources cross so many hospital departments, including nursing, lab, perfusion, quality, risk management, pharmacy, IT and finance. Representative implies that the committee looks like the departments that actually use blood, meaning there is strong representation of both physicians and nurses from the “bloody” specialties such as cardiac surgery, anesthesia, critical care, orthopedics, oncology and hospitalists. I believe that it is also best practice to have a physician who actually transfuses blood to chair this committee, adding both insight and credibility to the proceedings. The final attribute is that this be an activist committee, on a mission to improve blood utilization and transfusion safety 24/7/365. This is as opposed to a committee that punches the clock once a quarter to meet the minimum regulatory requirements. What we need now, more than ever, are blood utilization committees with the energy and passion to ensure the quality and safety of transfusion therapy while promoting stewardship of the blood supply.
- Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled trial of transfusion requirements in critical care. NEJM 1999;340(6):409-68.
- Rao SV, Jollis JG, Harrington RA, et al. Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. JAMA 2004;292(13):1555-62.
- Aronson D, Dann EJ, Bonstein L, et al. Impact of red blood cell transfusion on clinical outcomes in patients with acute myocardial infarction. Am J Cardiol 2008; 102: 115-19.
- Shishebohr MH, Madhwal S, Rajagopal V, et al. Impact of blood transfusions on short-term and long-term mortality in patients with ST-elevation myocardial infarction. J Am Coll Cardiol Intv 2009;2(1):46-53.
- Blajchman MA. Landmark studies that have changed the practice of transfusion medicine. Transfusion 2005;45:1523-30.
- Hannon TJ. Transfusion guidelines: development and impact on blood management. In: Saxena S, Shulman IA. eds. The transfusion committee: putting patient safety first. Bethesda,MD: American Association of Blood Banks Press, 2006:115-29.