The national blood shortage — the worst since World War II, according to the American Red Cross — can be attributed in part to supply and demand. The COVID-19 pandemic brought lockdowns and fears about the disease, fewer blood drives and postponement of nonessential surgeries, but the rescheduling of surgeries and treatment has since dramatically increased the need for blood.
Never has the importance of managing the blood supply wisely been more evident, says Johns Hopkins anesthesiologist Steven Frank, M.D. For the past decade, he’s been helping to guarantee blood for patients who need it by avoiding unnecessary transfusions for those who don’t.
“Blood saves lives when you need it but only increases risks and costs when you don’t,” he says.
Frank is the founder and director of the Johns Hopkins Blood Management Program, which promotes guideline compliance to avoid giving blood transfusions unnecessarily. It was created in 2012, after the Joint Commission held a national patient safety summit. At that time, blood transfusions topped the Joint Commission’s list of the five most overused treatments, tests and procedures. The list also included, for example, prescribing antibiotics for the common cold.
“Blood products can not only be costly for hospitals — they can cause harm for some patients,” Frank says. He explains that blood products can trigger a variety of transfusion reactions, which range from mild to severe and even life threatening.
Frank acknowledges that every surgical procedure involves some degree of blood loss, but there are proven ways to minimize it and hasten recovery. These include taking iron before surgery and the use of cell salvage machines, which wash and recycle a patient’s blood so it can be given back to the patient.
The Johns Hopkins program has decreased unnecessary transfusions, in part, by carefully monitoring how the blood supply is used. Frank says joint replacements, one of the most common elective surgeries, cause a fair amount of blood loss. “But we’ve learned how to do more with less, and have reduced transfusion by over 30% for such cases,” he says.
There’s also a financial incentive to conserve blood products, says Frank. “We spend just over $1 million per month on red blood cells, and about $1 million a month on platelets,” he says, “but during the last four years, we have reduced our overall costs for blood from $28 million to $23 million per year.”
Frank notes that the growth of robotic and other minimally invasive surgical techniques has substantially reduced blood loss and the requirement for transfusions. Additional steps can be taken for elective surgery that reduce the need for blood, including:
· Measuring hemoglobin (a protein that transports oxygen in the blood) a month before elective surgery, to allow diagnosis and treatment of preoperative anemia
· Reducing the amount of blood sent to a laboratory for routine blood tests
· Giving tranexamic acid, a medication that reduces bleeding and transfusion by about 30%
· Taking simple measures such as keeping patients warm during surgery or lowering their blood pressure to reduce bleeding
One thing that sets the Johns Hopkins blood management program apart from many others, says Frank, is its commitment to tracking and sharing information about the institution’s blood use throughout the health system.
“We have data from Epic to generate reports that we send out every month to people who order blood,” he says, and these reports lead to higher compliance rates for blood use protocols. In these reports, green signifies adherence to guidelines, while red indicates concern that guidelines are not being observed and that transfusions could be avoided.
Frank calls this blood use dashboard “one of the best in the country,” noting that it provides information to roughly 700 providers at The Johns Hopkins Hospital alone. “Dashboards help us generate visuals as important reminders about the blood supply and demand, helping to inform decision making to reduce unnecessary transfusions,” he says.
Respecting Patients’ Wishes, Debunking Myths
“Patients whose religious beliefs prohibit blood transfusions need alternatives,” Frank says. For such patients, the Johns Hopkins Center for Bloodless Medicine and Surgery was launched in 2012 — the same year the blood management program began — to provide specialized care without transfusions.
Since 1945, when the legislative body for Jehovah’s Witnesses introduced a policy of blood refusal that says blood transfusion defies divine precepts, some members of the religion have refused transfusions. Others decline transfusions because of safety concerns.
Since the COVID-19 pandemic emerged, Frank says, misconceptions about the safety of blood transfusions have increased. “Rest assured — you can’t get COVID-19 from blood,” he says. “That’s because it’s a respiratory virus. We give 10 million transfusions a year in the U.S., and never has a case of transmitting COVID-19 been documented.”
Recently, Frank and his colleagues had to postpone, for the first time, a cardiac surgery because of the blood shortage, after a weekend during which patients with trauma required massive transfusions. The surgery was eventually rescheduled.
“Every day, we’re checking the numbers, hoping to see a rise in [blood] donations,” he says.
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