How Allina Health saved $4 million from blood use management
One day in the fall of 2012, Dirck Rilla, director of clinical perfusion operations for Allina Health, walked into a physician lounge at the system's flagship Abbott Northwestern Hospital in Minneapolis. Some physicians were watching a staff-made "Dragnet"-style video called "The Blood Police," which was streaming on monitors throughout the hospital. The video, written by Lauren Anthony, MD, laboratory medical director for Allina, showed a physician ordering two units of blood to "tank up" a post-op knee replacement patient prior to rehab. "Uh-oh, watch out; he's in trouble," said one of the physicians watching the show. "Why order two when one will do?"
The anecdote serves as confirmation of the success of a major project at Allina, which has rolled out what may be the most ambitious effort in the nation aimed at reducing the use of banked donor blood. The video was a centerpiece of its educational outreach to staff.
With 12 hospitals, 90 clinics and three ambulatory care centers; 105,000 inpatient and 1.2 million outpatient admissions; and 35,000 inpatient surgical procedures a year, Allina uses a lot of blood. For the system, blood conservation is about improving patient safety and quality of care. A relatively new and quiet movement, blood conservation saves lives, prevents patient harm and saves money — good outcomes in an era of health reform and cost control.
A liquid organ transplant
Recent research shows that donor blood transfusions, even when properly matched, stored and handled, are far from benign, even as they save lives when patients have lost needed volume. Large, multi-center studies have found significantly higher rates of death, kidney failure, heart attacks, surgical-incision infections, post-operative bleeding and other complications among transfused patients compared with those who didn't receive blood. Administering banked donor blood is essentially a liquid organ transplant. Through that transplant, the recipient's own immune system is altered for some period of time.
"You should only give blood when it’s needed; you can cause a lot of harm when it's not," says Dr. Anthony, who leads the Allina Transfusion Care Council, the entity that is carrying out the blood conservation effort. "Doctors don't get much education on this in the field, because it's kind of its own subject area. You learn about it in the lab, but not so much in areas like OB/GYN or general surgery where they aren't so focused on transfusions."
The effort to get physicians to understand and embrace blood use protocols at Allina has paid off. Overall blood utilization is down 25-30 percent across the system. Red blood cells, which account for 70 percent of transfusions, have fallen from 300 units per 1,000 admissions to 200, with direct blood center charges running $1 million lower annually. When overhead is added in, the system saves roughly $4 million per year from lower use of red blood cells and other blood products, including plasma and platelets, both of which help blood to form clots.
Blood use beyond benchmarks
The effort began in 2010, when leaders at Allina, including Chief Clinical Officer Penny Wheeler, MD, and Dr. Anthony, began discussions on how to reduce the use of blood products across the system. Dr. Wheeler had been intrigued after attending an American Hospital Association conference where she heard presentations on the value of blood management.
According to benchmarked data provided by a consultant, Allina had a transfusion rate that was 25 percent to 40 percent above average, depending on DRG code and patient mix. "We were using 2 to 3.25 units of red blood cells per cardiac case. The benchmark at that time was 0.8 or 0.9," says Mr. Rilla, clinical perfusionist and director of operations for the perfusion team that runs heart-lung machines during open-heart surgeries at the Allina system. (The service is provided by SpecialtyCare, a Nashville-based company that employs Mr. Rilla and the perfusion team.) "There was not really any effort to conserve blood during and after surgeries," he said.
Dr. Anthony had arrived at Allina earlier in 2010 from Bronson Methodist Hospital in Kalamazoo, Mich., where she was involved in a successful blood management program, so she was a natural for leading the project. She knew that pathology could not just mandate new practices through the system. She needed allies among the providers who used the most blood products. That meant surgeons — especially cardiac surgeons — and other clinicians.
Among others, Dr. Anthony credits John Grehan, MD, attending cardiothoracic surgeon at Allina's United Hospital in St. Paul, Minn., for being a force for clinical integration on blood conservation. "A lot of doctors don't care about other hospitals, other specialties, but he has really worked across the system to implement guidelines," she said.
She also cites an anesthesiologist at Allina's Mercy Hospital in Coon Rapids, Minn., Joshua Martini, MD, as a key champion. Blood management as a movement started with anesthesiologists, who perform transfusions after complex surgeries. (In the video, Dr. Martini plays the physician mindlessly ordering too much blood.)
System-wide approach
Once the physician champions had been identified, they gave Dr. Anthony surprising feedback. In their view, the transfusion effort should be rolled out systemwide, rather than piloted at one hospital and introduced only gradually at the others.
"Some of the high-level champions, like a cardiovascular surgeon and a liver surgeon, said, 'This is only going to work if you do it at the system level, because we have a single electronic medical record,'" she says. "They said, 'You can't be making changes to order sets and transfusion guidelines if you don't include all the hospitals as you move forward; it's not going to work.'"
By July 2012, the transfusion council had succeeded in revising and launching the transfusion electronic order set to make it more difficult for physicians to order two units of blood (single-unit transfusions are best in non-bleeding patients, data show).
At the same time, another working group led by Dr. Grehan and comprised of cardiac surgeons, anesthesiologists and perfusionists, focused on implementing blood conservation guidelines from the Society of Thoracic Surgeons. The group shortened the cardiopulmonary bypass circuit to reduce the length of exposure of the blood to the surfaces within the heart-lung machine, which can provoke an inflammatory response that can cause the patient to dilate and lose fluid from blood vessels to body tissue. That leads to a need to give patients extra fluid volume in the form of a crystalloid solution, but at the risk of having the red blood cell count fall, necessitating a transfusion. Another change to bypass procedures allowed for the use of the patient's own blood instead of a solution for priming the bypass pump, again to reduce risk of diluting the blood.
During surgeries, post-operative blood loss is minimized by collecting blood from incision sites and concentrating and washing it prior to reinfusing it back into the patient.
Even small amounts of wasted blood, such as blood draws for lab tests, were addressed. With patients who have arterial or central lines, a certain amount of blood must be removed prior to getting a clean sample, as it has mixed with a solution that keeps the artery unclogged. So Allina began using blood-conserving arterial line systems that allow that initial blood draw to be re-transfused rather than discarded. Also, every effort is made to group blood draws for lab work, reducing the total amount collected.
“Saving small amounts of blood in all these procedures adds up to a lot of blood saved, blood we used to just throw away,” Dr. Anthony says.
'The Blood Police'
Educating staff about the blood management project has proved to be a challenge. The transfusion council has members from each hospital and clinical specialties, but Allina facilities are spread out across Minnesota and Wisconsin, making in-person education problematic. The transfusion council has turned to videoconferences called transfusion medicine grand rounds, "focusing on topics the doctors want to hear about," Dr. Anthony says. "We are using every means we can find to spread this message of using less blood."
The awareness campaign began with a logo — a simple drop of blood containing the word "Think." It is used on posters, brochures, lapel pins — anywhere it is visible to staff.
"Our message is not, 'Don't transfuse,' it is 'Think,'" Dr. Anthony says. "There is a lot of folklore around blood, and people who would otherwise order the minimum effective dose of any medication automatically order two units of blood. We are asking them to stop and think first."
"The Blood Police" was the main educational effort. "When I made up the dialogue, I used all the objections I have heard in all the meetings and presentations on the blood program," Dr. Anthony says. "I had heard the phrase, 'the blood police,' so many times, I thought we should use it to our advantage. Administrators who would be totally bored with blood management watch this video and they get it," she added. "It has enabled us to get more buy-in from leadership."
The video includes "evidence" such as a screenshot of the transfusion guidelines from the American Association of Blood Banks, which recommends:
- Make transfusion decisions for all patients based on symptoms as well as hemoglobin levels.
- Use a hemoglobin level of 7 to 8 grams per deciliter as a threshold for hospitalized patients who are stable. Many clinicians still use 10 or higher, despite clear evidence to the contrary.
The film, produced and directed by Allina's media services department, has been a hit not only within the system but at national medical conferences as well. And the slogan from the video, "Why order two when one will do?" has been heard from clinicians' lips many times.
Next steps
With nearly all the major changes to blood use made, the effort has come down to "a game of inches," Dr. Anthony says. A more recent initiative is a systemwide transfusion dashboard that shows which blood products are being transfused, how often and in what quantities.
This dashboard is aimed at persuading holdouts of the value of restrictive transfusion strategies. It shows outcomes such as length of stay and complications by type of procedure, hospital and physician. "A surgeon can no longer say, 'My patients are sicker and older than others' because we can use the dashboard to see the ages of the patients, the comorbidities, the complications,” Dr. Anthony says. "You can show them the trend line for the patients who didn't receive transfusions and the trend line for the patients who did."
Meanwhile, the cardiovascular team is working on new dashboards that join data on blood use with outcomes and performance data. "Now, we want to move beyond just meeting the benchmarks to all best practices," says Dr. Grehan.
Todd Sloane is a freelance writer and communications consultant based in Highland Park, Ill.