In 1988, I was a third-year anesthesia resident on a casual weekend bike ride with my fiancé and two friends, on the scenic Maryland back roads. The next thing I remember is waking up in the recovery room after a head-on car collision, a helicopter ride to Shock Trauma, and emergency surgery for a ruptured spleen with internal hemorrhage.
Three things saved my life that day: my helmet, which cracked when my head hit the pavement; a series of blood transfusions; and the skilled medical teams providing first class trauma care. By my calculations, I lost 10 units of blood that day, or essentially all the blood in my body (about 5 liters or just over a gallon), so I am no doubt lucky to have survived the accident. My story was one of three patient stories included in a 2020 Report to Congress on the importance of the national blood supply, at a time when we were facing the worst blood shortage in over a decade.
Fast forward 35 years later, and I now direct the comprehensive patient blood management program for the Johns Hopkins Health System, where we like to say that “blood saves lives when you need it, but only increases risks and costs when you don’t.” Since 2008, there has been a 33% drop in blood use across the U.S., where we’ve gone from approximately 15 million to 10 million units a year transfused.
Why is this happening, and if blood saves lives, why are we giving so much less of it? About 10 years ago, the Joint Commission named blood transfusion as one of the top 5 overused medical procedures, right up there with antibiotics for the common cold. This is mostly based on what are now 14 landmark randomized trials published in top journals like NEJM and JAMA, which all show that “less is more” for transfusion, and that giving extra blood to patients results in either the same outcome (in 10 studies) or a worse outcome (in four studies).
At Johns Hopkins, since our patient blood management efforts began in 2012, we launched two distinct programs running side by side synergistically. The first program aims to reduce avoidable transfusions for the roughly 99% of patients who accept blood, while the second program provides optimal care for the remaining 1% of patients who wish to avoid transfusion for personal or religious reasons, the vast majority of whom are Jehovah’s Witnesses. These “bloodless patients” are incredibly grateful when we honor their wishes and treat them with respect when they ask to avoid transfusions.
In fact, we owe them tremendous gratitude for teaching us lessons on “doing more with less,” since what is good for them is good for all patients. For example, treating preoperative anemia with $4 worth of iron tablets to avoid using $400 worth of blood just makes sense. Wouldn’t you rather come to surgery with your own red blood cells, rather than needing a transfusion with someone else’s?
“Keeping the blood in the patient” is the other major concept behind patient blood management. Simple things can reduce bleeding, such as keeping patients warm during surgery; lowering the blood pressure (controlled hypotension); tranexamic acid (an inexpensive medication that reduces bleeding by about 30%); Cell Savers to return surgical blood loss to the patient; and using smaller phlebotomy tubes to send lab tests. All of these strategies can be bundled together to achieve this goal.
After a decade of experience, we crunched the numbers to assess our return on investment (ROI) with our comprehensive patient blood management program, while also looking at patient outcomes. The bottom line was a 7.5-fold ROI, meaning that for every dollar spent on patient blood management, over $7 were either saved or generated in return. This calculation is based on a $3 million annual reduction in blood acquisition cost, along with a $5 million annual net margin on revenue generated by caring for patients under the Center for Bloodless Medicine and Surgery.
At the same time, clinical outcomes were either the same or better while giving less blood. Heart attack, stroke, thrombotic events, and respiratory and kidney problems were unchanged, while the incidence of hospital-acquired infection decreased. This latter finding is very believable based on high-level evidence (meta-analysis of 18 randomized trials) that transfusions predispose patients to infections. Furthermore, by avoiding transfusions for those who do not need them, we make more blood available for those who really do — like trauma victims and cancer patients.
Given the ongoing blood shortages that we are facing, which has been called a “crisis” in the blood industry, patient blood management looks like a giant step towards the triple aim in medicine: improving the patient experience, clinical outcomes, and cost. In this era of healthcare moving from volume to value, patient blood management is another classic example of how “less can be more.”
Steven Frank, MD, is a professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine in Baltimore. He is also director of the Johns Hopkins Health System Blood Management Program and director of the Center for Bloodless Medicine and Surgery.
Frank serves on a scientific advisory board for Haemonetics, a company involved with patient blood management.