Blood and red ink: Hospitals perform fewer transfusions and blood banks feel the pain
|By Alan Bavley, The Kansas City Star|
|McClatchy-Tribune Information Services|
Its donors provided a record number of units of red blood cells for area hospital patients that year, and the blood center opened a gleaming new state-of-the-art laboratory about a mile from its midtown headquarters to swiftly test donor blood for infections.
As the Great Recession took hold that year, people started worrying about their jobs and health insurance, and they canceled elective surgeries.
More important, hospitals across the country -- including
Research had been mounting for years that most hospital patients stayed healthier when they received little or no transfused blood. They faced less risk of infection, lung complications, even death.
From 2008 to 2011, transfusions nationwide dropped 8.2 percent, according to the most recent data from the
Declining demand is forcing a lot of belt-tightening by blood collection organizations that less than a decade ago faced chronically short supplies.
In 2012, the
"It's a new world," said
Collecting all the blood needed has always been difficult, Menitove said, and the blood center still needs people to donate regularly. But, he added, "this is a paradigm change from blood shortages to an adequate supply."
Blood centers across the country have been merging, laying off staff and looking for other ways to economize. In 2010, the two blood centers serving most of
"It's ugly. You see yourself as the good guys and you're laying people off," said
As blood centers merge, America's Blood Centers has seen its membership drop. Last year, it held a training session on mergers and acquisitions for its members.
Plummeting demand caught some blood centers off guard, Katz said, but "we had a lot of warning. The handwriting's been on the wall for a while."
To be sure, blood transfusions remain an essential part of medicine. Donated blood is usually processed into component parts that are transfused separately depending on a patient's needs -- red blood cells that carry oxygen, for example, or platelets that stop bleeding.
Transfusions can be lifesavers for people who are bleeding from traumatic injuries or who have illnesses that leave them severely depleted.
But since the early 1980s, researchers have been showing that for patients who aren't in immediate danger from blood loss, fewer transfusions are at least as good, and maybe better, for their health.
Studies linked transfusions in cancer patients to the reappearance of their disease. Other studies found death rates after heart surgery were higher in patients receiving transfusions. Report after report found associations between transfusions and pneumonia, stroke, heart attack, lung injury, delayed wound healing and organ failure.
Researchers issued warnings that transfusions temporarily depress the immune system, leaving patients vulnerable to potentially deadly infections. They called these infections "a silent epidemic."
A landmark Canadian study published in 1999 in
But most doctors were slow to pick up on what was becoming overwhelming evidence.
From 1994 to 2008, red blood cell transfusions climbed 40 percent in
The nation's burgeoning blood use didn't seem to follow any general standards. Transfusion rates for heart bypass surgery were up to 12 times as high at some hospitals as at other hospitals. The chances of receiving a transfusion varied significantly from one region of the country to another.
Overall, transfusions were far more common here than in other countries with advanced medical systems such as
"We're using too much blood in
In 2012, the
And last summer, the
Recycling blood, reducing loss
St. Luke's was an early adopter of what initially was called "bloodless medicine" and is now called patient blood management.
Often these programs were developed to serve Jehovah's Witnesses and others who declined transfusions. Eventually, hospitals began adopting the techniques for other patients as well.
"The biggest thing we've learned is just because someone's blood level is low, we don't have to give them blood," said St. Luke's heart surgeon
"Cell saver" machines in the operating room recycle the patient's blood. As the surgeon cuts, a member of the surgical team suctions up the blood with a tube that leads to the cell saver. When enough blood is collected, the machine's centrifuge puts the blood through a spin cycle to wash and separate out the red blood cells. The blood cells are pumped into a plastic transfusion bag and go back to the patient.
"We've always used (cell savers) in heart surgery. Its use in orthopedic surgery in the past couple of years has been a big improvement," Davis said.
Surgeons use a variety of techniques to minimize bleeding. They squirt a material called BioGlue into sutures to seal repairs, for example. Something as simple as moving a heart-lung machine closer to the operating table means less blood is needed to prime the pump.
The trend toward minimally invasive surgery -- slipping catheters and laparoscopes through small incisions -- also is cutting down on blood loss.
"We will continue to become more and more minimally invasive," Davis said, "and the smaller the incision, typically, the less the blood."
Transfusions also are avoided by taking steps before surgery. Anemia from illness, poor diet or chronic bleeds in the digestive tract is common among elderly patients. Not having an adequate supply of healthy red blood cells puts them at greater risk of requiring a transfusion during or after surgery.
At St. Luke's, anemic patients go onto a treatment plan, often receiving intravenous infusions of iron, before they ever reach the operating room.
Even something as innocuous as the blood tests that hospitals run can increase the chances that patients will get a transfusion. Researchers at St. Luke's found that so much blood was being drawn from patients, they were becoming anemic. That's led to less blood being taken.
St. Luke's expanded its patient blood management program in 2011 after many meetings of physicians in various specialties and small studies that tested the benefits of treating patients' anemia before surgery.
"It sounds easy, but in medicine there's cultures and subcultures. To change a culture is very difficult," said
"I was interested in patient safety. I thought, 'This is the right thing to do,' " he said.
Two units of red blood cells was the typical order doctors would give, Tilzer said, even when one unit would do.
"This was the tradition. This is what everyone would say."
Things started to change about five years ago after heart surgeons and other physicians and nurses from St. Luke's who were used to limiting transfusions moved to KU.
"It's a little difficult for other surgeons to say no when high-blood-loss cardiac surgeons do it," said
Thorpe estimates that since 2009, blood use at
The St. Luke's system also has seen savings. The St. Luke's flagship hospital on the
When all the costs of transfusions are added in, St. Luke's estimates that its four metro hospitals saved about
'The right thing'
Blood demand nationwide is likely to decline another few years before bottoming out at levels 20 to 30 percent lower than in 2008, according to
Over time, population growth and the aging of the baby boom generation will increase the need for blood, he said in testimony last June to the
But AuBuchon didn't expect demand to rise again to the level of 2008 before 2022, and maybe not until 2030.
"It's going to be some time before blood centers recover their economic footing," he said.
But the nonprofit blood center lost nearly
Menitove, 68, is guarded about the blood center's future, and his own.
He wouldn't say whether the blood center is seeking a merger partner or plans to soldier on independently.
"We'll get the job done in
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