Sherri Ozawa started her career 27 years ago as a critical care nurse at Englewood Health, a small community/academic health system in Englewood, New Jersey, at a time when most of the discussion around the true impact of blood transfusion was met with a lack of understanding – just after the height of HIV and AIDS epidemic. During that period, however, some clinicians and hospitals realized that while they were “forced” to reduce or eliminate the use of transfusion because of HIV, they were actually seeing good or even better outcomes in patients they previously would have transfused, and also found their own medical and surgical skills improving. Finding herself fascinated by this new area of medicine, she and colleagues noticed there wasn’t much published literature on the subject of blood conservation to dive into, and what did exist only said that reducing transfusion might be the right thing to do for patient outcomes and it was “probably a good idea” to reduce transfusion or minimize patient exposure, but nothing was really available to guide good clinical practice.
Although we were a relatively small community/academic hospital, we knew we needed to develop both and organized program and more literature – period. We began multiple education and research initiatives, funded in part with a multimillion-dollar grant from the US Department of Defense. The goal was to create an environment where, no matter who in the hospital was communicating – a patient transporter, someone in the cafeteria, the chief of a service, or someone in the C-suite – everybody would at least have some fundamental understanding of what patient blood management was and why it’s a good thing for our patients, our hospital, our community, and the nation.
Sherri’s work at Englewood has evolved today into the Institute for Patient Blood Management and Bloodless Medicine and Surgery at the hospital, a program that has been featured on Dateline, in Time Magazine, and numerous other media outlets, and continues to receive recognition worldwide. The work at the hospital also resulted in dozens of peer-reviewed medical and nursing publications, establishing the value and essential need for Patient Blood Management from a clinical, economic, and social perspective.
Creating and understanding and culture of blood conservation takes time. It was my goal from the beginning to have a different approach to blood, mentally and clinically, woven throughout the culture of the Institution – from physicians to nursing to all ancillary services. We wanted people to think of blood the way we think of an organ for transplant because blood really is a liquid organ. It’s something that should be used very, very judiciously. Before you transplant a patient with an organ, you try every other possible therapy for them. Looking at blood the same way – blood may be clinically indicated for some patients but should not be our default position.
It was a privilege to be a part of it and exciting to be able to start to change. People didn’t think much about transfusion and its impact on patients, its impact on cost, its impact on society. But to change people’s viewpoint, to at least start to establish some of the science and some of the patient care principles, was really a privilege.
By 2000, Sherri saw the need to bring a much larger and more diverse group of people to the table – people in transfusion medicine, blood banking, and laboratory medicine. There were surgeons, nurses, other physicians, some hospital administrators who thought that these programs were great, but we really couldn’t understand fully what it was to use less blood (or no blood) until we understand how we got to where we did with blood. From this vision, SABM (the Society for the Advancement in Blood Management) was formed as a multi-professional and multidisciplinary organization to promote optimal patient blood management as a standard of care.
Sherri is now the first nurse leader of SABM. Patient blood management is a multidisciplinary team sport. The willingness of an organization with a lot of physicians, physicians that are in very prominent academic centers and large health systems around the world, to be comfortable with non-physicians in leadership roles speaks to the fact that we really are on a mission. My hope is that the equality and equanimity with which we treat one another becomes reflected in hospitals that implement PBM programs.
SABM recently provided a position statement on the role of patient blood management in pandemics as blood conservation became a burning topic, offering a comprehensive look at all aspects of patient blood management and what we should be doing all the time – with or without a healthcare crisis in our midst: managing preoperative anemia, conserving a patient’s own blood, single unit transfusions, careful evaluation of the patient, and transfusing only when there is a true clinical need.
Our reactions to COVID-19, as a healthcare system, reinforced for us that the principles of PBM may become more critical in a pandemic but they’re always there.
It’s hard to believe that the term patient blood management didn’t even exist though the in the nineties. At that time, many clinicians perceived a blood transfusion as something easy, cheap, and quick to order with no consequences. While a lot of progress has made, Sherri shares a few critical areas that still need work.
- Blood in the news. The first thing said in reporting on a tragic event is: go donate blood! I believe in my heart that most people are good, and they want to do something to be helpful in a crisis and that is truly admirable. We need to use every opportunity to educate as to the precious nature of this resource, but transfusion is not always the answer.
- Blood has escaped the scrutiny that other drugs and devices undergo. It’s very easy and still common for people to just transfuse because a hemoglobin test shows a certain number, without any consideration of the true clinical condition of the patient. This would never happen with other types of therapies or treatments. The gap between knowledge, evidence and application is still too wide.
- Understanding that blood is a precious resource. It is not free or cheap, but so easy to order with just a signature or keystroke. Blood components are ordered commonly with no justifiable clinical reason. This is true for Red cells 50-60% of the time and plasma up to 90% of the time. Simple guidelines around ordering practices can improve this level of overuse.
Closing the Gap
There is still a significant gap between the published evidence and transfusion practice. As an example, the persistence of two units of packed red blood cells as a standard order is still common, without concept of monitoring a patient after one unit of blood or even thinking twice if the patient needed any units of transfused blood at all. It’s one of the many metrics we need to think differently about. Look at how the therapeutic pharmacy model changed years ago – suddenly pharmacists were empowered to question or change orders physicians made for particular drugs if what was ordered was not clinically indicated for the patient’s issue, or if there was a more inexpensive option. They were empowered to provide input that is rare in the transfusion world. There is plenty of data that shows transfusion is not always delivering the impact that the clinician thinks it does. Closing that knowledge gap so that they really start to understand the clinical impact to patients, and the economic impact to hospitals, is critical to success.
The United States has some very unique challenges because of our healthcare model. There are few things that you can do in healthcare in which there isn’t a downside. But what is the downside of PBM? There really isn’t one, any way that you look at it. Clinically or economically, from the patient’s viewpoint, from the clinician’s viewpoint, or the hospital and community perspective. There is no reason not to have a program. It’s puzzling to understand why any institution would not want to implement a comprehensive patient blood management program because everybody wins.
As the current COVID-19 crisis unfolded earlier this year, an early concern in healthcare was that the public would not be able to donate blood because they were under stay at home orders, or because many donor sites were closed. And that is indeed what happened. Elective surgeries were postponed but people still had traumatic injuries, accidents, emergent illnesses requiring surgery, and babies were still being born. Hospitals still had the need to supply blood for certain clinical circumstances. Pre-COVID and traditionally, focus immediately turned to the donor – how to increase donors, how to find donors, how to encourage donors – not the supply side. However, COVID compelled hospitals and clinicians to look at blood utilization, not just the donation. Several hospitals and health systems immediately put out guidelines about transfusion thresholds or processes for release of blood from the blood bank to try to better manage the supply they had. We feel this to be huge progress.
We’re also learning every day about the thrombotic and coagulation aspects of COVID-19 and its impact on patients. The conversations about convalescent plasma, quickly assumed to be a potential solution, have also led to other important blood component discussions.
COVID-19 has turned hospitals, hospital systems, and clinician’s attention to the fact that the things we’ve done to manage blood use during this virus were things we should have been doing all along.