By Dr. Aryeh Shander MD, FCCM, FCCP, FASA, Emeritus Chief Department of Anesthesiology, Critical Care and Hyperbaric Medicine Englewood Health, Director of TeamHealth Research Institute
Transfusion of blood components has been a default therapy for hospitalized patients for more than a century. After World War II, the availability of blood components made it extremely easy to prescribe this therapy with little to no understanding of the complete risks or benefits. Regardless of this, as a therapeutic endeavor, it never underwent any rigorous evaluation by the U.S Food and Drug Administration (FDA) or academia. Most if not all clinicians regarded transfusion as being beneficial both in terms of clinical outcomes and quality of life. It was not until the hepatitis C (HCV) and human immunodeficiency virus (HIV) epidemic in the early 1980’s, that the Centers for Disease Control and Prevention (CDC), few blood bank physicians and transfusion specialists recognizing blood as the vector, the FDA was ‘forced’ to initiate warning about blood transfusion as well as establish new standards for safety of blood. In 2010-2011, the health sector recognized that transfusions of blood were one of the most common medical activities in hospitals that when coupled with high costs of transfusions and risk with ill-defined benefits, re-examining of this practice was needed. This led to including transfusion as part of the overuse in healthcare conference and the proceedings published in 2012 by the American Medical Association–Physician Consortium for Performance Improvement, The Joint Commission and the American Heart Association. In short, overuse is defined as “any medical intervention where the benefit is at best questionable and therefore the patients are only exposed to potential risks and harm,” and is a clear patient safety issue that needs to be addressed.
To improve on a condition, one must be able to screen, diagnose and treat appropriately while making sure that this approach improves patients’ outcomes including quality of life. Of interest, more than 2.3 billion people on earth have some level of anemia. That includes our population too. The largest group with anemia is pre-school children followed by pregnant and non-pregnant women. This social problem highlights our responsibility to respond to whenever we can and wherever we serve, in the operating rooms, hospital wards (including children) and emergency departments.
There is a growing recognition that all patients including the surgical population are at risk. Depending on the type of surgery, colorectal, cardiac orthopedic and more, anemia may be present in 30 percent to as high as 70 percent of this population. Large cohort studies have demonstrated anemia as an independent risk for both morbidity and mortality in this population. Setting up a system that will identify patients going for surgery, screen for anemia, diagnose it if present and offer therapy before surgery is scheduled, will not only reduce the impact of anemia but has been definitively shown to reduce or eliminate the need for transfusions with their inherent risks. For hospitalized patients, transfusion is a default action rather than approaching the disease, the way we do with medical conditions. Close to three out of four patients admitted to our hospitals have some level of anemia. With illness and repeated unnecessary phlebotomy, more than 90 percent of patients are discharged with some level of anemia. Data, both previous and current, demonstrate that anemia is an independent risk factor for general health, quality of life and mortality. We generally ignore anemia as being a silent disease and usually feel confident that if needed, we can always transfuse the patient ignoring the risks of both anemia and transfusion.
In response to identifying the above as an unmet medical need, a few clinicians that included physicians and nurses, blood bankers and public advocates, gathered to initiate the Society for the Advancement of [Patient] Blood Management (SABM) in 2000. The evolution of the default position to becoming patient-centered took a while but Patient Blood Management (PBM) is now a global effort with far-reaching consequences as measured by improved patient outcomes, patient experience and lower healthcare costs. This strategy aligns with The IHI Triple Aim, which is a framework developed by the Institute for Healthcare Improvement that describes an approach to optimizing health system performance. In 2019, several PBM societies lead by SABM and the European Union organization called NATA, came together to produce a single global definition of PBM. Currently, we use the SABM definition of PBM that is listed below:
“The timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis and minimize blood loss to improve patient outcome.”
Today we are at a crossroads. We can continue with the status quo or adopt a better approach to our patients. At TeamHealth, our culture is adopting the best clinical practice regardless of the challenge we face. Our journey to improve patient outcomes is now starting to adopt PBM across all service lines.