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  • The Internet Journal of Emergency and Intensive Care Medicine
  • Volume 9
  • Number 2

Original Article

Transfusions And Their Costs: Managing Patients Needs And Hospitals Economics

J Basha, R Dewitt, D Cable, G Jones

Citation

J Basha, R Dewitt, D Cable, G Jones. Transfusions And Their Costs: Managing Patients Needs And Hospitals Economics. The Internet Journal of Emergency and Intensive Care Medicine. 2005 Volume 9 Number 2.

Abstract
 

Are bloodless cardiac surgery programs a fallacy? For the most part, the simple answer is yes they are; unless of course, your cardiac surgery program exists only on the healthiest patients, with active lifestyles, few if any co-morbidities, and not on Clopidogrel and Aspirin. Of course, those cardiac surgery programs are also a fantasy. “With rare exceptions,” Bloodless surgery programs do exist, e.g. Jehovah Witness programs, though truly bloodless surgery programs in the general population are rare.

Allogeneic blood transfusions are a necessary staple of any diverse cardiac surgery program. Nevertheless, the scientific literature is replete with irrefutable data showing that allogeneic transfusions, although at times an absolute necessity, are in fact detrimental to short, intermediate, and long term outcomes, increased infection rates, prolonged ventilator times, disease transmission, allergic reactions, cross match errors, lung injury, increased mortality 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 and are very expensive (Tables 1 and 2). It is estimated that a single unit of packed red blood cells (PRBC's), with an acquisition cost of two hundred U.S. dollars ($200.00) has an actual cost of between one thousand six hundred ($1,600.00) and two thousand four hundred dollars ($2,400.00) to transfuse it to the patient 9 . This actual cost includes all of the direct and variable personnel costs (Figures 1 and 2) along with the increased costs to any one patient's hospital stay as a result of a transfusion-associated morbidity (Figure 3). The acquisition cost for a unit of aphaeresed platelets is above five hundred U.S. dollars ($500.00 Table 2). Based on the formula used for PRBC's the actual cost of platelets is also incredibly higher. In addition, platelets have also been associated with serious adverse events in cardiac surgery 10 .

Blood banks and collection centers are also feeling the pinch. With Nucleic Acid Amplification (NAT) testing, irradiation, and other tests and treatments to make the available blood supply safer, an already strained system is becoming more expensive coupled with the fact that the allogeneic blood supply operates on a margin of only about ten percent of supply versus demand (Source – America's Blood Centers). The blood supply is safer than ever before, however emerging pathogens are the new concern. West Nile Virus was recently added to blood testing, Chagas disease has been reported to have been transmitted in the US through transfusion and there is no current test available for T.cruzi.

Today, cardiac surgery utilizes approximately twenty to twenty-five percent of the national blood supply and depending on practice, between forty and seventy percent of cardiac patients receive transfusion during their hospital stay 11 . Based on these facts therefore, the national average for blood transfusions in all cardiac patients, not risk stratified, is 7.6 of any blood component per patient.

Following a review of our practice of about 500 cases per year, as well as, a review of several other similar programs, we identified several areas where tools and techniques employed were the greatest contributors to blood transfusion requirements. What we discovered was that the bypass circuit was one area where we could make the greatest impact. However, we discovered that this alone, would only take us so far. What we really needed was a team approach.

We changed our entire perfusion circuit 12 , added full biocompatibility, vacuum assisted venous return, reduced our circuit prime with our own innovative design, matched oxygenator size to patient size, instituted aggressive hemofiltration, became aware and corrected areas of iatrogenic blood loss in the operating room, added full dose Aprotinin 13 , incorporated platelet quality analysis, and elicited the involvement of the entire cardiac surgical team. Today, our blood utilization is approximately two units of any blood product, averaged over all cardiac patients, e.g. CABG/Valve combinations, Bental procedures, triple valve, and in our primary CABG population (usually on Clopidogrel) to less than 1 unit average during the patients hospital stay.

In today's economy, hospitals cannot ignore the realities of decreasing reimbursement and increasing costs. Reducing blood transfusions is a way to improve patient outcomes and improve the Cardiac Hospital's financial health. By implementing a program similar to ours, a cardiac program performing three hundred cases per year and reducing its average per patient blood use by only one unit, would realize a savings of between four hundred eighty thousand ($480,000.00) to as much as seven hundred twenty thousand dollars ($720,000.00) per year (Table 3). For those programs able to reduce their blood usage by one or more units, the savings can be a lifesaver, both for the patients and for the programs.

Figure 1
Table 1

Figure 2
Table 2

Figure 3
Table 3

Figure 4
Figure 1: (Cantor et al, J Oncol, 1998 16(7)2364-70)

Figure 5
Figure 2: (Cremieux et al, J Clin Oncol 2000 18(14) 2755-2761)

Figure 6
Figure 3

Correspondence to

Gary P. Jones, M.D., FACS: Managing member of Louisiana Cardio-Vascular and Thoracic Institute Gjones@LACVT.COM Joseph Basha, Senior Clinical Perfusionist JBasha@LACVT.COM Louisiana CVT Institute 3311 Prescott Road Alexandria, LA 71301. Telephone: 318-442-0106

References

1. Hovav, T. et al. Alteration of red cell aggregability and shape during blood storage. Transfusion 1999:39:277-81
2. Manoj Kuduvalli. Effect of peri-operative red blood cell transfusion on 30-day and 1-year mortality following coronary artery bypass surgery. European Journal of Cardio-Thoracic Surgery 2005;27:592-598
3. Talor, Robert W. MD. Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient. Critical Care Medicine. 30(10):2249-2254, October 2002
4. Kopko, K Transfusion-related acute lung injury: report of a clinical look-back investigation. 2002 Apr 17;287(15):1968-71
5. Santiago Ramón Leal-Noval, MD. Transfusion of Blood Components and Postoperative Infection in Patients Undergoing Cardiac Surgery. Chest. 2001;119:1461-1468
6. Biddle, C Curr Blood Transfusion is a Tissue Donation with Immunological Consequences. Curr Rev Nurs Anesth 27(10) 2004 109-116
7. Engoren, Milo C. Effect of Blood Transfusion on Long-Term Survival Afert Cardiacv Operation. Ann Thoracic Surg 2002; 74: 1180-6
8. Spiess, Bruce. Blood Transfusion: The Silent Epidemic. Ann Thoracic Surg 2002;74:986-7
9. Hannon, Timothy. The Contemporary Economics of Transfusions. Perioperative Transfusion Medicne Second Edition: Chapter 2, Lippincott Williams & Wilkins 2006
10. Spiess, Bruce. Platelet Transfusions during coronary bypass graft surgery are associated with serious adverse outcomes. Transfusion, Volume 44, Aug . 2004 1143-48
11. Spiess, Bruce. Transfusion and Outcome in Heart Surgery. Ann Thoracic Surg 2002;74:986-7
12. Terumo Cardiovascular Systems; Ann Arbor, Michigan
13. Trasylol Package Insert, 2003, Bayer HealthCare Pharmaceuticals

Author Information

Joseph Basha, CCP
Louisiana CVT Institute

R. Chance Dewitt, M.D.
Louisiana CVT Institute

David Cable, M.D.
Louisiana CVT Institute

Gary P. Jones, M.D., FACS
Louisiana CVT Institute

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