Are We Transfusing Too Much Blood?


January 30, 2023

George D. Lundberg, MD

Would you be surprised if I said that nearly half of all blood transfusions administered in hospitals in the United States between 2012 and 2018 were unnecessary?

A recent study used a sample of 15 community hospitals in five populous American states to examine nearly 7000 total adult transfusion events (approximately 100 encounters per hospital) by retrospective anonymized record review, using a blinded internal and external review process. The conclusion? Nearly half (44.6%) of the encounters could have been managed without any transfusion, and 54.6% could have been managed without at least one of the components. No examples of underutilization were found.

In the course of one recent year, 16 million units of blood or blood products were transfused in the United States. Is that how many units that should have been administered? Obviously, judgment is involved on a case-by-case basis. I do not know the answer.

But many authoritative figures and groups believe that far too many transfusions are administered. The Joint Commission names red blood cell transfusion as one of the top 5 overused hospital procedures. Five specialty societies list reducing unnecessary transfusions in their Choosing Wisely campaigns. Patient blood management is an organized, systematic approach to best transfusion practices.

Only 3% of Americans are regular donors and this precious commodity is sometimes in short supply for those who need it most. Such a valuable resource should not be squandered.

Guidelines exist, blood bank medical directors act with their best judgment, transfusion committees meet and review, and accreditation standards are met. Computer order entry systems are functional.

These 15 hospitals described their blood use as "good"; none anticipated findings of overuse. It seems to be an elephant hiding in plain view. They are not seeing the endangered forest for the seemingly healthy trees. It is not that hard to imagine an individual physician choosing to err on the side of over- rather than undertransfusion, yet none of these community hospitals conducted in-house retrospective chart review as a method of controlled guidance for blood product transfusion. Only one of the 15 utilized prospective intervention by a pathologist. All transfusion requests were approved.

The lead author, David Jadwin, is a fellow ex-Army pathologist who has been studying the use of blood and blood products with audit and blind review methods for many years and has endeavored to persuade many institutions to improve their transfusion practices. Retrospective review can be a potent illuminator and educational tool for better patient management.

<<Level 2>>Leadership and Motivation

Motivating changes in physician behavior can be attempted through education, feedback, physician participation, administrative changes, financial penalties, and financial rewards. The "more is better" strategy for blood transfusion use needs to be replaced with one that achieves "right-sizing." But someone must take leadership in each institution.

The study by Jadwin and colleagues is apparently a first. If the data are accurate and generalizable, and if the overuse situation persists, change must follow. These data must motivate community hospitals to look internally at existing practices and strive to improve their patient blood management activities. Reducing the waste of this precious human commodity is worth the effort.

The general need for improvement has been recognized by many medical organizations, and exhortations to reform are common, but it does not happen. Why? What are the motivations, incentives, and barriers to change?

Resistance to change itself can be a barrier. Why do people and organizations resist change? Fear of failure, desire to maintain a present happy situation, territorialism, excess work pressure. Retardants include lack of clarity of need and reasons and plans for change, poor communication, insufficient rewards for change, and failure to involve the affected people in planning and implementing change.

To overcome resistance to change, plan carefully, bring a history of success, and show confident leadership. Without leadership and institutional motivation to improve patient blood management, little is likely to change. Change the "present happy situation" into an unhappy one. Combat territorialism in open sessions. Have good reasons for change and explain them carefully. Involve the people affected in planning and implementing change.

Would these techniques work in individual hospitals? They have in the past in various circumstances. I described such a successful approach for changing the ordering of laboratory tests in JAMA in 1998.

Another recent article demonstrates the leadership needed at a local level and includes a step-by-step strategy to institute improvements. Go for it.

That's my opinion. I'm Dr George Lundberg, At Large at Medscape.

George Lundberg, MD, is contributing editor at Cancer Commons, president of the Lundberg Institute, executive advisor at Cureus, and a clinical professor of pathology at Northwestern University. Previously, he served as editor-in-chief of JAMA (including 10 specialty journals), American Medical News, and Medscape.

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