Blood is in big demand at the University of Alabama at Birmingham (UAB) Hospital, once the fourth largest user of blood among U.S. hospitals served by the American Red Cross. And although blood transfusions can be life-saving during cancer care, trauma, surgery, transplants and difficult pregnancies, supply doesn't always rise to meet demand.
After a 2007 winter storm in the Midwest drove home the vulnerabilities of being dependent on outside sources, hospital officials implemented an aggressive blood-management plan that changed the culture at UAB — leading to less blood use, more blood donations and better outcomes for patients.
In 2006, UAB used nearly 40,000 units of blood from suppliers that often were challenged to meet the need. During that summer, UAB experienced shortages in some blood types 60 percent of the time and rudimentary hospital collection efforts yielded just 168 units. Most of the blood used at UAB was purchased from other states, and hospital officials realized it was time to make changes.
"We began discussions in 2006 to examine how we managed our blood supply," said Marisa Marques, M.D., professor of pathology and medical director of transfusion services at UAB. "The gap between how much we used and how little was donated locally was dramatic."
Then in January 2007, a huge winter storm paralyzed Midwestern states, disrupted blood-donation and supply and caused major shortages at UAB and elsewhere in Alabama. The shortage drove UAB officials to action.
"Under the leadership of then-hospital CEO Mike Waldrum and current interim CEO Anthony Patterson, we partnered with a consultant, Strategic Healthcare Group, to look at ways we used blood and find ways to use it more efficiently," Marques said. "And we partnered with the American Red Cross to look at ways to increase donations to make the hospital and the state more self-sufficient.
"Now, six years later, we've made huge strides," Marques said.
Supply and demand is much more closely aligned now. Blood use at UAB, which topped in 2007 with 40,043 units transfused, is on pace to reach 29,000 units in 2013, officials say. Meanwhile, an aggressive donation program has increased units donated in fiscal year 2013 to 10,694 from 168 in 2006.
"This has been a huge undertaking, that required buy-in from physicians, administration and everyone at UAB Hospital on the one hand, and from donors, patients and the entire community on the other," said Donna Salzman, M.D., associate professor of medicine and associate quality officer for blood management and utilization at UAB. "It has led to a more stable blood supply and better outcomes for patients."
Reducing blood use
The first tenet of success was better management of the blood supply. That required re-thinking some long-established concepts. For years, the accepted practice was for physicians to order the laboratory to prepare two units if a transfusion was needed and transfuse both into the patient; that is changing.
"Transfusing someone else's blood into your body is not unlike an organ transplant," said Tom Gayeski, M.D., Ph.D., professor of anesthesiology and director of cardiothoracic anesthesiology. "A transfusion may be necessary to save your life, but it also puts a great deal of stress on the body."
Gayeski says transfusion suppresses the immune system, increases inflammatory response and might adversely affect coagulation. Recent research confirms that getting the right amount of blood in a transfusion — and no more —leads to better patient outcomes. At UAB, the practice now is to order and transfuse one unit at a time and re-evaluate the patient afterward to see if more is needed.
Guidelines for when to order a transfusion also have changed. Physicians use a measure of hemoglobin level as a trigger to determine when to transfuse. A hemoglobin greater than 12 g/dL (grams per deciliter) is considered normal. For years the accepted practice was to order transfusion when the hemoglobin fell to 10 g/dL. But a 1999 landmark study in the New England Journal of Medicine demonstrated that transfusing only when the hemoglobin level fell to 7 g/dL was safe, effective and reduced side-effects caused by transfused blood.
"Transfusing at 7 g/dL became the new standard at UAB," Marques said. "Coupled with the switch to transfusing one unit at a time rather than two, we've seen an overall 37 percent decrease in blood use at UAB during the past six years."
Just a little stick now
Change also was instituted in the nursing units to reduce the blood volume drawn for laboratory tests.
"We had to become more aware of the cumulative effects of collecting daily blood samples," Salzman said. "A patient in intensive care who has multiple daily blood draws for testing can see their hemoglobin levels drop precipitously during the length of a hospital stay."
That led to new best practices for blood draws, said Marques. For example, a typical test to establish blood type and do a basic screen called for a 10-milliliter tube of blood and a 3-milliliter tube. More efficient techniques now enable the majority of relevant tests to be performed using only the 3 ml tube 99 percent of the time.
The Preoperative Assessment Consultation Treatment (PACT) Clinic, another new initiative at UAB, is undertaking a clinical study of patients scheduled for hip-replacement surgery to screen for and treat pre-operative anemia. It could be expanded to any major elective surgery in the future if the results are encouraging.
"The goal is to see if, by treating pre-operative anemia, we can reduce the need for blood transfusions during and after surgery," said Thomas Vetter, M.D., M.P.H., professor of anesthesiology. "Boosting the concentration of a patient's own blood prior to surgery and potentially reducing the need for transfusion should be better for the patient's well-being and ease demands on the blood supply."
Marques, Salzman, Gayeski and Vetter agree that buy-in throughout the hospital was one of the most essential factors in reducing UAB's blood use.
"It required a coordinated, team approach," Gayeski said. "We examined practices that minimize blood use, chose the ones most appropriate for UAB and then had to get everybody on board — administration, nurses, physicians, lab techs, perfusionists — virtually every facet of the hospital's operations."
"We've been able to create a culture of wise blood use," Salzman said. "Some of the changes implemented have been small but have had a powerful cumulative effect."
Roll up your sleeves
Reducing blood use was only half the battle UAB faced in 2007. Blood donation in Alabama lags well behind other states, and suppliers such as the American Red Cross have to import blood across state lines.
"When we began looking at our blood use, we also looked at blood donations," said Sherry Polhill, laboratory director at UAB Hospital. "Reducing blood use is only one part of the process. We knew we had to increase donations as well."
Beginning in fiscal year 2007, the hospital partnered with the Red Cross to start an aggressive donation campaign. Five major blood drives were planned and held in the North Pavilion lobby. A donor-incentive program was instituted for hospital employees, and a blood-collection room, operating five days a week, was opened. It was an ambitious effort.
"In fiscal year 2007, we collected nearly 3,000 units of blood, a huge increase over 168 units the year before," Polhill said. "We've seen increases every year — with a major jump in 2008 —leading to a peak collection of nearly 12,300 units during fiscal year 2012."
The donor room, near the North Pavilion gift shop, now collects an average 22 units per day — as much in a week as the hospital collected in all of 2006. The five major blood drives have expanded to include drives in UAB Highlands Hospital and other buildings across campus.
The hospital employee-incentive program, called UAB Touch Points, bestows points for each donation that can be redeemed for a pre-paid Visa card. Polhill said a new, improved version to be unveiled will include The Kirklin Clinic employees.
Another incentive program enables departments to compete quarterly for the coveted Top Blood Donor trophy, and departments that reach a certain donation level also receive a free ice cream party.
"We wanted to create a fun atmosphere with this competition," Polhill said. "We've created champions in each unit or department to advocate for blood donation and drive interest in the programs. Many units really want that trophy on their shelf."
The gap has shrunk
The bottom line is a blood-use landscape very different to the dark days of 2006. In 2013, use has dropped 11,000 units a year and on-site collections at UAB have risen by more than 10,000 units. Everybody wins.
"We use blood so much more wisely now, which is better for the patient receiving blood and also reduces the strain on the blood supply," Marques said. "Everyone involved with this effort — hospital employees, patients and visitors, UAB students, faculty and staff, the American Red Cross and our entire community — can take pride in this accomplishment."
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