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By Deborah J. Tolich, MSN, RN; Sheila Blackmur, MSN, RN; Ken Stahorsky, MBA, RN; and Blood Danita Wabeke, BA, RN management: Best-practice transfusion strategies

BLOOD TRANSFUSIONS to treat anemia can have a significant impact on patient outcomes. Because transfusion practices vary among healthcare providers, many clinicians question the best practice for blood product use. Blood management is defined as a patient-centered standard of care in which strategies and techniques are used to reduce, eliminate, or optimize blood transfusions to improve patient outcomes.1 Blood management programs have addressed the variances in healthcare provider practice as they’ve reduced blood use and healthcare costs. This article reviews the evidence and experience gained from formal blood management programs. It identifies and discusses these three areas of blood management: methodology, implementation, and nurses’ direct-care practice. HOTO P

TOCK Putting evidence into practice

3D/iS Anemia isn’t a disease but a sign of an underlying illness or ACK J condition. Anemia falls into three major categories: nutritional LACK B

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Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. deficiency, acute or chronic blood number of red blood cells (RBCs) may cause decreased physical loss, and anemia of chronic disease. carrying oxygen to organs and tissues, performance.1 (For more informa- All three contribute to a limited resulting in signs and symptoms that tion, see What’s anemia?) If evidence shows that reducing allogeneic (donor blood) transfusions What’s anemia? improves patient outcomes while Anemia, an abnormally low hemoglobin level and/or level of circulating RBCs, decreasing costs, how should nurses decreases the blood’s oxygen-carrying capacity. Anemia can be classified according translate this evidence into their to its cause, which is most often excessive bleeding, hemolysis (destruction) of practice? Current research about RBCs, or inadequate RBC production due to either a nutritional deficiency or a advanced anemia management, cost bone marrow problem. accountability, and the negative The effects of anemia can be grouped into three categories: signs and symp- consequences of allogeneic blood toms of impaired oxygen transport and the compensatory mechanisms that transfusions continue to influence result, reduced RBC indices and hemoglobin levels, and signs and symptoms of the pathology causing the anemia. Anemia’s signs and symptoms depend on its nursing practice. With today’s lim- severity, how rapidly it’s developed, the underlying pathology, and the patient’s ited supply of blood products and age and health status. When anemia develops slowly, the body compensates for increasing costs associated with the blood’s decreased oxygen-carrying capacity with increases in plasma volume, transfusions, it’s prudent for health- cardiac output, and respiratory rate. These changes can largely compensate for care institutions to advance their the effects of mild-to-moderate anemia in otherwise healthy people but are less standard of care by adopting blood effective in those with respiratory or cardiac problems. management practices. Anemia causes pallor of the skin, mucous membranes, conjunctivae, and nail Many underestimate the true beds because blood has been redistributed from cutaneous tissues or because of cost of blood. According to a a deficiency of hemoglobin. Patients may experience tachycardia and palpitations recent analysis, the cost of a unit as their bodies try to compensate by increasing cardiac output. of RBCs is between $522 and Anemias caused by premature destruction of RBCs (hemolytic anemias) are as- 2 sociated with hyperbilirubinemia, jaundice, and pigment gallstones. Patients with $1,183. Nurses and healthcare anemias that result from ineffective hematopoiesis (premature death of RBCs in providers have a responsibility to the bone marrow) may have excessively high levels of iron absorption from the exercise good stewardship and take gut, which can lead to iron overload and damage endocrine organs and the heart. measures to reduce waste. Before Lab tests can help determine both the severity and the cause of the anemia. The blood is obtained from the blood RBC count and hemoglobin levels provide information about the severity of the bank, nurses must make sure anemia. The size (normocytic, microcytic, macrocytic), color (normochromic, hypo- they’re following policies and chromic), and shape of RBCs may provide information about the cause of anemia. procedures ensuring safety and The figure shows (A) microcytic and hypochromic RBCs, which are characteristic proper administration of all blood of iron-deficiency anemia; (B) macrocytic and misshaped RBCs, which are char- products. (See Using best practices acteristic of megaloblastic anemia; (C) abnormally shaped RBCs, which are seen for blood transfusions and Practice in sickle cell disease; and (D) normocytic and normochromic RBCs as a comparison. guide for nurses.)

Why blood management? Blood transfusion is the most commonly performed procedure in the United States.3 Labor intensive, it takes more than 75 minutes of A Iron-deficiency anemia B Megaloblastic anemia nursing time from prescription through completion.4 Blood management, a best-practice methodology, evolved from bloodless medicine and surgery, which were developed to address the healthcare needs of those refusing blood prod- C Sickle cell disease D Normal ucts for religious or other reasons. This evolution has broadened the Source: Porth CM. Essentials of Pathophysiology. 3rd ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams and Wilkins; 2011. scope of clinical application and now includes the functions of blood

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Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. utilization, practice variability, and optimal use of blood products. Using best practices for blood transfusions Blood management consists of The AABB provides the following guidelines: prevention, early identification, and • A restrictive transfusion practice in stable hospitalized patients is a hemoglobin treatment of anemia coupled with level of 7 to 8 g/dL. • the best possible transfusion practices. A restrictive transfusion practice in patients with cardiovascular disease is to consider A blood management program trans- transfusion when the hemoglobin level is 8 g/dL or less with clinical symptoms. • The transfusion decision should be based on clinical symptoms in conjunction lates these standards into clinical with lab values. practice. Source: Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline A robust body of evidence supports from the AABB. Ann Intern Med. 2012;157(1):49-58. the need for blood management programs. Paul Hébert and colleagues The efficacy of blood transfusion related to the length of time the conducted a study introducing outside of traumatic blood loss has blood has been stored increase evidence that restrictive transfusion never been scientifically proven. Al- morbidity and mortality.11 Stored practices are as effective in terms of though the blood supply in the United blood undergoes morphologic outcomes as liberal use.5 This land- States is relatively safe, the threat changes that make the cells more mark study demonstrated that of new and emerging transfusion- rigid and less pliable, so it’s harder patients could tolerate lower levels transmitted infections continues.9 for them to flow through small of hemoglobin. Advances in nucleic acid-based test- capillaries. A 2006 study found that The evidence is categorized into ing have improved the ability to ef- mortality increased significantly in supply and demand of blood prod- fectively screen for HIV and hepatitis patients undergoing open-heart sur- ucts, risks and safety of transfusion, B and C viruses. But the FDA in a gery after just one unit of RBCs.19 and outcomes correlated to transfu- public forum demonstrated that the In a landmark study, the Co- sion. The U.S. Department of Health threat of arboviruses such as dengue chrane Collaboration group exam- and Human Services 2009 National and West Nile viruses have the po- ined evidence of the effect of RBC Blood Collection and Utilization tential to become widespread in areas transfusion triggers (recommended by Survey (NBCUS) demonstrated that of the United States. In the absence the AABB as transfusing a patient collections compared with trans- of the ability to eliminate causative with a hemoglobin level of 7 g/dL; fused product produced a 12% agents, the safety of future blood or a hemoglobin level of 8 g/dL for a surplus and that overall number supplies is reduced.10 If blood prod- patient who’s symptomatic or has a of transfused products remained ucts had to submit to FDA scrutiny, preexisting cardiovascular disease) statistically unchanged from 2008.6 they wouldn’t gain approval because on clinical outcomes.5,19 Called the Despite a reported surplus, periodic of safety concerns: The risks of using Transfusion Requirements in Critical local shortages have led to some these products would greatly out- Care (TRICC) trial, it compared out- cancellations of elective surgery. weigh their efficacy.11 comes in 838 critically ill patients Because the population is aging, Much data correlate poor out- who were transfused using two differ- demand is expected to increase and comes to blood transfusion.12-15 ent transfusion thresholds. A liberal donations to decrease.7 A dose- response relationship shows transfusion strategy, in which transfu- The American Association of blood transfusions lead to increased sions were given when the patient’s Blood Banks circular of 2009 pro- postoperative infection, higher hemoglobin concentration fell below vides best-practice guidelines for rates of multisystem organ failure, 10 g/dL and maintained hemoglobin using blood products.8 For example, increased mortality, increased concentrations at 10 to 12 g/dL, was RBC transfusion is indicated only for mechanical ventilator time, and compared with a restrictive transfu- symptomatic anemia or a critical increased length of stay.16 The sion strategy in which transfusions oxygen-carrying deficit. Although the combination of changes during were given when the patient’s hemo- circular doesn’t indicate a specific lab storage and biochemical reactions globin concentration fell below 7 g/dL value for transfusion, it does state leads to complications. and maintained at 7 to 9 g/dL. The that RBC transfusion is contraindi- Decreased immune function in a results showed that the restrictive cated for volume expansion and recipient of a blood transfusion is strategy was “at least as effective as anemia that can be treated using called transfusion-related immuno- and possibly superior” to the liberal hematinics, agents that stimulate modulation.15,17 The intensity of transfusion strategy in decreasing erythropoiesis and increase RBC the immune response varies from mortality in critically ill patients, production. person to person, but the effects with the exception of patients with www.Nursing2013.com January l Nursing2013 l 43

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. acute myocardial infarction and Although these seven PBM core unstable angina. In less acutely ill measures aren’t yet endorsed for use patients younger than 55, the restric- at the national level, they’re an ideal tive strategy was superior to the source to be considered when begin- liberal strategy because it was associ- ning the implementation of a blood ated with a decrease in mortality.5 management program. Maintaining hemoglobin concentrations between 7 and 9 g/dL resulted Implementation tips in a 54% decrease in RBC transfu- Blood management is best imple- sions when compared with the lib- mented by using existing processes eral strategy group. Most research and organizational structure.23 For- concurs with the findings in the mal programs incorporate an inter- TRICC trial; that is, in the absence of disciplinary patient-care approach, cardiac disease, best practice is to use such as nutrition referrals for pa- a restrictive transfusion strategy.20 RBC transfusion is indicated tients with anemia to receive dietary The evidence supports a compre- only for symptomatic instruction and pharmacy-managed hensive approach to blood manage- anemia or a critical anemia clinics.24 Blood management ment. In Ontario, Canada, blood oxygen-carrying deficit. initiatives assimilate standardized management was incorporated into practice, eliminate outlier patterns the care of patients having three such as automatic ordering of two procedures: knee arthroplasty, ab- units of RBCs rather than one, and dominal aortic aneurysm surgery, signifies less healthcare provider vari- enforce evidence-based practice. and coronary artery bypass graft ation in transfusion practice. Before proceeding with formal surgery.21 Patient outcomes included The Joint Commission (TJC) is blood management initiatives, a significant decrease in allogeneic now defining core measures that will organizers need to gain support from blood transfusions, postoperative help set the standard and guide administrative groups. Next, the infection rates, and length of stay. transfusion practice.22 The Blood organization should identify a core Three of the four authors of this Management Performance Measures group of healthcare provider cham- article work for the Cleveland Clinic Project was implemented as a two- pions who’ll drive blood manage- Health System, which comprises 10 phase process from 2007 to 2010. ment into practice among peers.25 community hospitals. When research- During Phase I, a stakeholder meet- Successful blood management ers compared blood use among these ing led to the development of a tech- programs have a dedicated leader, facilities, they found that hospitals nical advisory panel. During Phase such as an RN, who assumes respon- with blood management programs II, this panel identified priority areas sibility for developing and driving had lower blood utilization, which and potential measures for blood initiatives. Many current programs management. These were posted for owe their existence to nurses who public comments in 2008, with final persevered to overcome barriers. If Practice guide for nurses measure recommendations made by creating a new position isn’t feasible Keep these points in mind: the panel in November 2010. These for an organization, undertaking • A blood transfusion is a human final patient blood management blood management initiatives is an tissue transplant. (PBM) measures are: alternative. Regardless of the execution • Anemia tolerance is based on • PBM-01 Transfusion Consent model, high quality and outcome the assessment of signs and symptoms. • PBM-02 RBC Transfusion Indication gains are associated with decreased • Provide clinical information related • PBM-03 Plasma Transfusion length of stay, positive financial to anemia tolerance when reporting Indication impact, and cost-effectiveness in lab values. • PBM-04 Platelet Transfusion transfusion avoidance.21 • Verify blood products at the Indication A three-phase implementation patient’s bedside according to • PBM-05 Blood Administration plan, including a focused planning facility policy and procedure. Documentation phase, practice roll-out, and main- • Transfuse one unit of RBCs at a • PBM-06 Preoperative Anemia tenance phase, has been used time, then reassess the patient. Screening successfully at approximately • Limit phlebotomy and blood loss • PBM-07 Preoperative Blood Type 200 hospitals across the United from lab testing. Testing and Antibody Screening. States.26 Implementation begins

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Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. with analyzing how to incorporate Choosing a delivery model best practices into policies and Published literature provides evi- protocols. A formal proposal or dence that protocols, pathways, and business plan provides a starting algorithms supporting blood man- point and a roadmap for program agement, although simple in design, development. Because barriers are provide significant impact.21 Tools likely to surface, it’s important to to aid in the identification, evalua- identify potential roadblocks in the tion, and treatment of presurgical initial planning phase. and postsurgical anemia, as well as The circumstances surrounding acute and chronic anemias, are transfusion utilization must be iso- essential. Examples include an lated by identifying clinical signs anemia assessment guide, treatment and symptoms, lab values, and pres- process, preprinted prescription ence of active bleeding. Strategies forms, and patient education must be developed to identify and Because storing blood materials. These tools provide the address opportunities for improve- makes cells more rigid and framework for transferring blood ment. This may be done through less pliable, it’s harder for management methodology into healthcare provider-based report them to flow through small clinical practice. cards where transfusion practice and capillaries. An outpatient anemia treatment triggers are compared within medi- center can be established by partner- cal specialties. The Cleveland Clinic ing with an existing cancer center, has developed blood transfusion Empowering stakeholders heart-failure clinic, or outpatient dashboards to make transfusion A multidisciplinary committee can clinic. The outpatient treatment area practices transparent, with focused guide blood management initiatives. can grow by expanding services to plans targeting outlier practice. To The committee should include include treatment for patients with reveal trending successes as well representatives from medical leader- presurgical anemia, acute anemia, as challenges and opportunities, ship, anesthesia, surgery, pharmacy, and chronic anemia.30 Outpatient individual dashboards have been blood banks, and nursing, among volumes can be increased while designed to capture specific bench- others. This group will establish new revenue streams are captured.30 marks such as the following: quality indicators and monitor blood • service-line utilization product administration, healthcare Communication pathways • a drill-down to healthcare provider tracking, and service-line While preliminary measures are provider use blood utilization. Extracted metrics coming to fruition, prepare staff • administration of blood products are used for quality assurance, through education. Instructional by hemoglobin category performance improvement, and plans designed for medical staff, • comparative usage by surgery type. measurements of program success. nursing, and ancillary personnel can Intermittent peer reviews to evalu- First steps include establishing help prepare staff for clinical imple- ate compliance with established transfusion criteria for the clinical mentation. Product vendors are an- standards for blood product utiliza- indications for each blood product other source of educational support. tion provide the basis for behavioral that reflect current evidence and a To make blood management interventions. Simple interventions general hospital policy for blood recognizable in both the hospital such as education and healthcare management. This dedicated team setting and the public sector, it must provider feedback have been effective will implement, promote, and evaluate be described in understandable in changing transfusion practice, initiatives within the hospital.28,29 terms, from its roots in religious according to a review conducted by An effective approach in the conscientious objection through its Tinmouth and colleagues.27 Small clinical implementation of blood evolution to practices. More than measures have a large impact on management is to identify areas of mere transfusion avoidance, blood patient outcomes, and continuing greatest impact that will provide management is a comprehensive education with healthcare providers measurable improvement in patient strategy that conserves the patient’s and nurses is instrumental in main- outcomes with realized cost savings. blood and contributes to better taining positive outcomes and sus- Consider high-volume blood utiliza- outcomes. taining a culture shift by solidifying tion departments such as orthope- Website development can be a new practice habits. dics, cardiac surgery, and medicine.21 successful tool for internal and www.Nursing2013.com January l Nursing2013 l 45

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. external marketing as well as busi- bedside. Iatrogenic anemia resulting Changing habits, elevating ness development. This medium can from lab testing is responsible for pre- standards be instrumental in providing current ventable transfusions.32 Techniques Improving patient safety and delivery and relevant clinical resource mate- to reduce iatrogenic anemia include of care should be top priorities. In rial for staff.31 Use electronic visual minimizing lab draws, using low- striving to provide the very best care screens, posters, and charts depict- volume collection tubes, returning for every patient and do no harm, we ing goals, objectives, and outcomes waste volume from arterial and central must be open to changing the way to heighten awareness. lines to the patient, and documenting we think about blood products in Fostering relationships with lab blood volumes as output.29,33 evaluating the risk versus benefits. By primary care healthcare providers Nurses must pay attention to implementing the measures outlined encourages involvement. An annual patients’ hemoglobin concentrations in this article, nurses can advance the educational event endorsed by ad- on admission. For example, if a pa- standard of care and be in compli- ministrative leadership and health- tient is admitted with a hemoglobin ance with best practices and the care provider champions keeps the concentration of 10 mg/dL or below, forthcoming TJC core measures. program at the forefront. he or she is at risk for transfusion, Individual nurses can implement Focus on program sustainability warranting a more in-depth anemia blood management strategies into throughout the implementation assessment. This includes obtaining nursing practice, but changing phase. Maintain a vibrant and effec- a history of factors contributing habits to elevate the standard of care tive blood management program to anemia, as well as physical assess- requires a multidisciplinary team ap- by continuing engaged committee ment findings. proach. Use this article as the impetus membership, and by understanding A major contributor to anemia is for enacting practice change. ■ and using evidence-based standards, iron deficiency, the most common procedures, and tools developed by nutritional disorder in the world.34 REFERENCES 1. Seeber P, Shander A. Basics of Blood Management. the team. Monitoring outcomes Iron studies, including serum iron, 2nd ed. Chichester, UK: Wiley-Blackwell; 2013. using defined metrics keeps total iron-binding capacity, iron satu- 2. Shander A, Hofmann A, Ozawa S, Theusinger the program focused on goal ration, and ferritin levels, are helpful OM, Gombotz H, Spahan DR. Activity-based costs of blood transfusions in surgical patients at four attainment. Share quality metrics in evaluating iron stores. hospitals. Transfusion. 2010;50(4):753-765. with hospital executives, service-line Nurses play a crucial role in recog- 3. Wier L, Pfuntner A, Maeda J, et al. HCUP Facts divisions, and hospital quality com- nizing the signs and symptoms asso- and Figures: Statistics on Hospital-based Care in the United States, 2009. Rockville, MD: Agency for mittees to drive initiatives for im- ciated with decreased oxygen states Healthcare Research and Quality; 2011. http:// provement. Medical and nursing due to low hemoglobin levels. Nurses www.hcup-us.ahrq.gov/reports/factsandfigures/ 2009/TOC_2009.jsp. leadership must be actively involved are responsible for notifying the 4. Hannon T. Blood management economics. Pre- in endorsing and advancing a blood healthcare provider of a patient’s sented at DeVos Children’s Pediatric Blood Man- management program. hemoglobin and hematocrit, but they agement Conference, Grand Rapids, MI. 2010. 5. Hébert PC, Wells G, Blajchman MA, et al. A Execution of blood management must report the whole patient picture multicenter, randomized, controlled clinical trial of will continue to evolve as new and not just the lab values. For transfusion requirements in critical care. N Engl research is completed and delivery example, if the patient’s hemoglobin J Med. 1999;340(6):409-417. 6. U.S. Department of Health and Human Services. models are tailored to specific is 7.2 g/dL and the hematocrit is The 2009 National Blood Collection and Utilization healthcare systems. A planned and 21.4%, the nurse must assess the pa- Survey Report. http://www.hhs.gov/ash/bloodsafety/ methodical approach with clearly tient’s signs and symptoms and take 2009nbcus.pdf. 7. Casey G. Blood transfusion: the high-risk life- defined metrics will provide direc- into consideration the patient’s medi- saving therapy. Nurs N Z. 2011;17(4):20-25. tion in program development and cal history. This information will help 8. AABB, American Red Cross, America’s Blood data analysis from which to gauge the healthcare provider determine the Centers, Armed Services Blood Program. Circular of Information for the Use of Human Blood and Blood success. The challenge is in concept appropriate course of treatment. Components. 2009. http://www.aabb.org/resources/ implementation, education, and In the past, assessment of anemia bct/Documents/coi0809r.pdf. 9. Hannon T. The bloody truth: 10 facts about blood sustainability. Because blood man- has been based on hemoglobin and transfusions everyone should know. MLO: Medical agement is process and structure, the hematocrit with less emphasis on Laboratory Observer. 2010;43(14):14. http://www. key to long-term success is setting functional ability and quality of mlo-online.com/ebook/201104/resources/16.htm. 35 10. Abbott S. The three “R”s of blood transfusion in up a self-sustaining infrastructure. life. Thinking critically and 2020; routine, reliable and robust. 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Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 12. Eder AF, Chambers LA. Noninfectious compli- Transfusion Coordinators [ONTraC]). Transfusion. erythropoietic-stimulating agent use in hematology- cations of blood transfusion. Arch Pathol Lab Med. 2008;48(2):237-250. oncology patients. J Natl Compr Canc Netw. 2008; 2007;131(5):708-718. 22. The Joint Commission. Implementation Guide for 6(6);577-584. 13. Marik PE, Corwin HL. Efficacy of red blood The Joint Commission Patient Blood Management 31. Rothschild JM, McGurk S, Honour M, et al. cell transfusion in the critically ill: a systematic Performance Measures 2011. http://www.jointcom- Assessment of education and computerized deci- review of the literature. Crit Care Med. 2008; mission.org/assets/1/6/pbm_implementation_ sion support interventions for improving transfu- 36(9):2667-2674. guide_20110624.pdf. sion practice. Transfusion. 2007;47(2):228-239. 14. Corwin HL, Gettinger AG, Pearl RG, et al. The 23. AABB. Best Practices for a Patient Blood Manage- 32. Salisbury AC, Reid KJ, Alexander KP, et al. CRIT Study: anemia and blood transfusion in the ment Program. Bethesda, MD: AABB; 2012. http:// Diagnostic blood loss from phlebotomy and hospital- critically ill–current clinical practice in the United www.aabb.org/resources/bct/pbm/Documents/ acquired anemia during acute myocardial infarc- States. Crit Care Med. 2004;32(1):39-52. best-practices-pbm.pdf. tion. Arch Intern Med. 2011;171(18);1646-1653. 15. Vincent JL, Sakr Y, De Backer D, Van der Lin- 24. Ghiglione M. Blood management: a model of 33. Melmed GM, Hulsey ME, Newhouse M, den P. Efficacy of red blood cell transfusions. Best excellence. Clin Leadersh Manag Rev. 2007; Holmes HE, Mays EJ. Clinical strategies for sup- Pract Res Clin Anaesthesiol. 2007;21(2):209-219. 21(2):E2. porting the untransfusable hemorrhaging patient. 16. Boucher BA, Hannon TJ. Blood management: a 25. The Frankel Group LLC Hospital leadership Proc (Baylor Univ Med Cent). 2009;22(4):316-320. primer for clinicians. Pharmacotherapy. 2007;27(10): perspectives on blood management (U.S.). From 34. Goddard AF, James MW, McIntyre AS, Scott 1394-1411. Insight to Impact-Life Science Strategy Consulting. BB; British Society of Gastroenterology. Guidelines 17. Raghavan M, Marik PE. Anemia, allogenic Cambridge, MA: The Frankel Group; 2009. http:// for the management of iron deficiency anaemia. blood transfusion, and immunomodulation in the www.frankelgroup.com. Gut. 2011;60(10):1309-1316. critically ill. Chest. 2005;127(1):295-307. 26. Tokin C, Almeda J, Jain S, et al. Blood manage- 35. Kupersmith E. Anemia: not just an outpatient 18. Gunst MA, Minei JP. Transfusion of blood ment programs: a clinical and administrative mod- problem anymore. Today’s Hospitalist. 2010. http:// products and nosocomial infection in surgical el with program implementation strategies. Perm J. www.todayshospitalist.com/index.php?b=articles_ patients. Curr Opin Crit Care. 2007;13(4):428-432. 2009;13(1):18-28. read&cnt=969. 19. Loor G, Koch CG, Sabik JF, Li L, Blackstone 27. Tinmouth A. Reducing the amount of blood EH. Implications and management of anemia in transfused by changing clinicians’ transfusion Deborah J. Tolich is the director of blood management cardiac surgery: current state of knowledge. practices. Transfusion. 2007;47(2 suppl):S132-S136. at Cleveland Clinic Health System in Cleveland, Ohio, where Ken Stahorsky is a coordinator and Danita J Thorac Cardiovasc Surg. 2012;144(3):538-546. 28. Moskowitz DM, McCullough JN, Shander A, et Wabeke is a quality nurse. Sheila Blackmur is the 20. Carless PA, Henry DA, Carson JL, Hebert PP, al. The impact of blood conservation on outcomes in education specialist at Southwest General Hospital, McClelland B, Ker K. Transfusion thresholds and cardiac surgery: is it safe and effective? Ann Thorac also in Cleveland, Ohio. other strategies for guiding allogeneic red blood Surg. 2010;90(2):451-458. cell transfusion. Cochrane Database Syst Rev. 2010; 29. Shander A, Javidroozi M, Perelman S, Puzio T, (10):CD002042. Lobel G. From bloodless surgery to patient blood The authors and planners have disclosed that they have no financial relationships related to this article. 21. Freedman J, Luke K, Escobar M, Vernich L, management. Mt Sinai J Med. 2012;79(1):56-65. Chiavetta JA. Experience of a network of transfu- 30. Gilreath JA, Sageser DS, Jorgenson JA, Rodgers sion coordinators for blood conservation (Ontario GM. Establishing an anemia clinic for optimal DOI-10.1097/01.NURSE.0000423955.22755.b1

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