Patient blood management (PBM) is becoming a household term in the field of medicine. Case in point: the most recent National Blood Collection and Utilization Survey Report has dedicated a full chapter to PBM.1 Anesthesiologists continue to lead this journey, and ASA is front and center.
In July 2011, recognizing the significant risks of transfusions, wide variability and deficiencies in transfusion practices, changing patterns of demand for blood and documented success of PBM programs, the U.S. Department of Health and Human Services (HHS) Advisory Committee on Blood and Tissue Safety and Availability made the following recommendations to the Assistant Secretary of Health, Howard Koh:2
- Identify mechanisms to obtain data on PBM, utilization of transfusion and clinical outcomes.
- Support development and promulgation of national standards for blood use recognizing the value of patient management, blood conservation and conservative blood use.
- Take steps to establish transfusion expertise as integral to transfusion practices in hospitals and other patient care settings.
- Establish metrics for good practices of blood use and PBM.
- Advise the Office of the National Coordinator for Health Information Technology on the need to integrate PBM and blood utilization into electronic health records.
- Promote education of medical students and practitioners on optimizing PBM and use of transfusion and elevate awareness of the essential role of PBM in the quality and cost-efficiency of clinical care.
- Promote patient education about the risks, benefits and alternatives of transfusion to promote their empowerment in transfusion decision-making.
- Support demonstration projects on PBM.
- Support research on non-invasive clinical measures to define indications for transfusion, e.g., ischemia, hemostasis, platelet function and patients’ functional status.
This followed the adoption of declaration 63.12 by the World Health Organization (WHO) addressing the global importance of incorporating PBM into clinical practice as a patient safety measure. In conjunction with these global activities, the AMA Physician Consortium for Performance Improvement (PCPI) and the Joint Commission, under its visionary president Mark R. Chassin, M.D., have been playing a pivotal role in promoting PBM as a means to improve quality of care.
In 2002, The Joint Commission established the National Patient Safety Goals (NPSGs) to help health care organizations prevent or completely eliminate the occurrence of specific medical errors, the most common being patient misidentification and surgical site infection. During a recent evaluation of the need for new NPSG issues, Joint Commission staff identified the overuse of treatments, procedures, and tests in hospitals and critical access hospitals as a potential topic for a future goal. Research shows that overuse occurs with significant frequency in the United States. Based on a 1980 Institute of Medicine (IOM) definition, overuse was described as “the use of a health care service in circumstances where the likelihood of benefit is negligible and, therefore, the patient faces only the risk of harm.” The proposed NPSG was designed to focus on the safety and quality issues associated with overuse, although The Joint Commission recognizes that cost is also a concern.
In late 2011, The Joint Commission circulated a proposed NPSG on reducing overuse of treatments, tests and procedures to the field for comment. Analysis of the results indicated that many believed overuse is an important patient safety issue. The field review also provided a significant amount of information on the complexity of identifying and managing overuse issues. Patient safety has been an important aspect of the culture at ASA for decades. This October at the ASA annual meeting, Charles Denham, M.D., a leading voice on patient safety, will address our membership. He and others have recognized the importance of the issues mentioned here.
Based on feedback from their proposal, The Joint Commission conducted two focus groups comprising field review respondents who had indicated their willingness to be contacted. Focus group participants represented several different disciplines with varying opinions about whether overuse should be considered as an NPSG. Issues identified in the field review and in the focus groups include the following:
- Lack of a widely accepted definition of overuse
- Lack of benchmarks or criteria for making care decisions in these areas
- Limited resources available for measurement
- Insufficient guidance on how to address the issue in the NPSG
- Patients’ requests to receive services they do not need
- Involvement of other organizations, such as payers, in overuse.
The insights gained from these group activities were used to form the Proceedings from the National Summit on Overuse.3 The summit was co-hosted by The Joint Commission and the PCPI in September 2012. The purpose of the summit was to validate evidence and data that certain interventions are overused, review related guidelines and quality measures, and develop strategies for reducing overuse.
The list of “overused” interventions is overwhelming, and as such, the summit limited itself to five areas, including:
- Antibiotics for viral upper-respiratory infections
- Clinical transfusion practices
- Therapeutic approaches toward acute otitis media with effusion (OME)
- Early-term elective delivery
- Elective percutaneous coronary intervention (PCI) procedures.
Accordingly, five multi-disciplinary work groups convened for the summit focusing on each of these five areas to validate the data on overuse of the interventions, review guidelines and quality measures, and develop strategies for organizations and key stakeholders to reduce overuse. The blood management workgroup was represented by surgeons, internists, transfusion specialists, hematologists and two anesthesiologists. This group was led by the COBM chair.
With approximately 15 million units of red cell transfused annually, Hospital Alliance for Resuscitation Quality (HARQ) data report that one out of every 10 patients admitted to an acute care hospital will be transfused. Transfusion is one of the top five procedures in hospitalized patients. In addition, published data reports that as many as 90 percent of blood transfusions may be “overuse” or unnecessary. Moreover, data on extensive variability of transfusion not only corroborate the “overuse” data but suggest that best practices can be achieved by benchmarking low transfusion centers and making them examples of “best practice.” Reported injury may or may not be a direct result of overuse but is estimated to affect 60,000 patients a year with the knowledge that these numbers might be significantly low as a result of underreporting. This is clearly a patient safety issue.
ASA, in conjunction with the Society for the Advancement of Blood Management (SABM) and AABB, has been promoting PBM to its membership via the ASA COBM. Not only will PBM help in improving patient outcome, it will also help in promoting patient safety. As we progress toward value-based health care, defining and addressing modifiable risk of transfusion and poor outcomes, such as anemia, will help furnish the Perioperative Surgical Home concept and increase our repertoire as physicians. A proposal from the COBM to develop a clinical pathway for the detection, diagnosis and treatment of perioperative anemia has been accepted and is in review. Lastly, to conform with advances in this area, ASA should review the committee’s charter and name in light of this advancing concept and consider renaming the committee the “ASA Committee on PBM” (to emphasize the importance of patient clinical outcomes) as well as adopting the current definition and matrix of PBM as developed and adopted by SABM and AABB.4