Restrictive transfusion practice improves patient care, quality, safety

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By analysing data from randomised clinical trials comparing blood transfusion approaches, Johns Hopkins experts, along with colleagues at Cleveland Clinic and NYU Langone Medical Centre, endorse recommendations for blood transfusions that reduce blood use to improve patient safety and outcomes. The report also provides a how-to guide for launching a patient blood management programme.

“In summary, there is no benefit in transfusing more blood than necessary and some clinical trials actually show harm to patients,” says Dr Steven Frank, professor of anaesthesiology at the Johns Hopkins University School of Medicine. “All this does is increase risks and cost without adding benefit,” he adds.

As defined by existing guidelines and the clinical trials reviewed, the report reinforces these recommendations: stable adult patients, including critically ill patients, with haemoglobin levels of 7 g/dL or higher should not be transfused; patients undergoing orthopaedic or cardiac surgery, or patients with underlying heart disease with haemoglobin levels of 8 g/dL or higher should not be transfused; and patients who are stable and not actively bleeding should be transfused with a single unit of blood and then reassessed.

The clinical trials that were examined compared so-called liberal versus restrictive blood transfusions. Liberal transfusions are those given to patients with 9 to 10 grams of haemoglobin per one-tenth litre, or decilitre, of blood volume, while restrictive transfusions are those given to patients with 7 to 8 grams per decilitre. Many of the clinical trials examined by this team used the number of patients who died within a 30- to 90-day window post-transfusion as a measure of patient outcome.

Of the more than 8,000 patients included in eight clinical trials that were reviewed, there was no difference in mortality between liberal or restrictive transfusions. One clinical trial found an increased mortality associated with liberal transfusion, and occurrence of blood clots was increased in the liberal cohort in a study that involved traumatic brain injury patients.

“These recommendations don’t apply to patients with acute coronary syndrome, severe thrombocytopenia and chronic dependent anaemia, including sickle cell, because we didn’t see enough evidence for patients with these conditions,” says Frank.

The team also found that the largest randomised trials reduced the amount of blood used by 40% to 65%. Earlier this year, Frank reported the results of a four-year project to implement a blood management programme across the Johns Hopkins Health System, reducing blood use by 20% and saving more than $2m on costs over a year.

“As members of the High Value Practice Academic Alliance, we recognise the importance of promoting evidence-based recommendations for transfusion. Our analysis provides the evidence to reassure providers that restrictive transfusion practice actually improves patient care quality and safety, while yielding substantial reductions in health care expenditure and increasing the blood supply for patients with life-threatening bleeding,” says Frank.

Abstract
Although blood transfusion is a lifesaving therapy for some patients, transfusion has been named 1 of the top 5 overused procedures in US hospitals. As unnecessary transfusions only increase risk and cost without providing benefit, improving transfusion practice is an effective way of promoting high-value care. Most high-quality clinical trials supporting a restrictive transfusion strategy have been published in the past 5 to 10 years, so the value of a successful patient blood management program has only recently been recognized. We review the most recent transfusion practice guidelines and the evidence supporting these guidelines. We also discuss several medical societies’ Choosing Wisely campaigns to reduce or eliminate overuse of transfusions. A blueprint is presented for developing a patient blood management program, which includes discussion of specific methods for optimizing transfusion practice.

Authors
Divyajot Sadana, Ariella Pratzer, Lauren J Scher, Harry S Saag, Nicole Adler, Frank M Volpicelli, Moises Auron, Steven M Frank

Johns Hopkins Medicine material
JAMA Internal Medicine abstract


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