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Summary

Red blood cell (RBC) transfusions are one of the most frequent procedures in every hospital and can increase risk to patients and costs to hospitals. Many transfusions are considered unnecessary, so there is a growing recognition of the need to reduce RBC transfusions. Laboratory hemoglobin values are used as a primary indicator for RBC transfusions, are only available intermittently, and are often delayed — leading to suboptimal transfusion decisions.

Masimo has invented noninvasive and continuous hemoglobin (SpHb®) monitoring, which helps clinician optimize transfusion decisions by providing real-time trending in hemoglobin status. SpHb has been shown to help clinicians reduce blood transfusions in both low and high blood loss surgery,1,2 and has demonstrated its lifesaving potential to help clinicians detect occult bleeding in places like intensive care units and labor and delivery wards.3

Blood Transfusion Related Cost Reduction Guarantee

To help hospitals improve patient care and reduce cost of care, Masimo has initiated a program called Blood Transfusion Related Cost Reduction (BTR-CR, "Better Care"). BTR-CR guarantees that a hospital's blood transfusion related cost reductions will be greater than their cost of SpHb monitoring.*

Contact us at 888-44BTRCR to learn more about BTR-CR.

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Risk and Costs of Red Blood Cell Transfusions

RBC transfusion is one of the most frequent procedures performed in U.S. hospitals, with one in ten inpatients receiving one or more blood units.4 While blood loss during surgery is a known risk factor, RBC transfusion overuse can increase patient risk and cost of care. Meta-analysis of pooled results from multiple observational studies, each of which adjusts for risks between patients, shows patients receiving RBC transfusions have an 88% higher mortality, 69% higher infection rate, and 250% higher rate of ARDS.5 Multiple randomized controlled trials indicate that restrictive transfusion practices — those in which significantly lower hemoglobin triggers are used to determine need for transfusion - are safe.6 In addition, the cost of each RBC unit is estimated between $522 and $1,183 per unit, without including morbidity-associated costs.7 Beyond the cost of transfusion, each RBC unit transfused is associated with increased cost of care and transfusions that occur at higher hemoglobin levels increase the cost of care more than those given at lower hemoglobin levels.8

With the growing recognition of the need to reduce transfusions, noninvasive and continuous hemoglobin (SpHb) can be a key tool to help overcome the limitations of existing approaches.

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The Growing Recognition of the Need to Reduce Transfusions

Many transfusions are unnecessary. A systematic, expert review of 494 studies for positive impact on health outcome showed that 59% of RBC transfusions are "inappropriate".9

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Figure.
494 studies were evaluated by an expert panel in a systematic method to assess appropriateness of RBC transfusion, revealing a significant opportunity to reduce unnecessary transfusions.9

Given the risks and costs of RBC transfusions, there is a growing recognition of the need to implement strategies to reduce RBC transfusions. The Joint Commission has introduced Patient Blood Management Measures that encourage hospitals to evaluate appropriateness of transfusions as a continuous quality indicator.11 The American Medical Association and The Joint Commission also recently identified RBC transfusions as one of the top five overused procedures in medicine, defining overuse as "circumstances where the likelihood of benefit is negligible or zero, and the patient is exposed to the risk of harm".10

Limitations with Existing Approaches to Assess Transfusion Need

Hemoglobin concentration is used as a primary indicator for RBC transfusion, but laboratory measurements are only available intermittently and results can be delayed in the period between blood draw and laboratory analysis. This time gap of information can lead to sub-optimal transfusion decisions.12

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Figure.
The process to obtain laboratory hemoglobin measurements has multiple steps that delay results.

The most universally available information about whether a transfusion is needed during surgery is estimated blood loss, which is often overstated. Visible blood and fluid lost appears to tell one how much blood has been lost, but in a recent study at Duke University, anesthesiologists estimated blood loss at 40% more than it actually was.13 The implication is that the need for transfusion may appear to exist, when in fact it does not.

How SpHb Monitoring Helps with Transfusion Decisions

Masimo's solution provides hemoglobin both noninvasively and continuously. The noninvasive aspect makes the technology easy to apply to the patient, and the continuous aspect assists RBC transfusion decision making. While SpHb monitoring is not intended to replace blood draws, it identifies significant changes in hemoglobin and lack of significant changes in hemoglobin between invasive blood sampling and laboratory analysis.14

Continuous hemoglobin means you can determine the directional trend of hemoglobin — whether it is stable, rising, or falling. This can help avoid unnecessary transfusions when the SpHb trend is stable and the clinician may otherwise perceive hemoglobin is dropping, or when the SpHb trend is rising and the clinician may otherwise perceive it is not rising fast enough. Inside and outside the operating room, a dropping SpHb trend may also allow clinicians to identify internal bleeding and permit earlier interventions.

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Figure.
Real-time SpHb trend showing stable, rising, and dropping hemoglobin.

Clinical Evidence that SpHb Monitoring Helps Reduce Transfusions

There are now two studies showing that SpHb monitoring helps clinicians reduce RBC transfusions.

SpHb monitoring has been shown in a randomized controlled trial in low blood loss surgery (orthopedic surgery) to reduce RBC frequency by 87% (from 4.5% to 0.6%) and the average number of RBC units transfused by 90% (from 0.1 to 0.01 units per patient).1

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Figure.
Randomized controlled trial in 327 orthopedic surgery patients.
p<0.0001 vs. Standard Care Group.

Image Study Abstract:
Impact of Continuous and Noninvasive Hemoglobin Monitoring on Intraoperative Blood Transfusions

SpHb monitoring has also been shown in a prospective cohort study in high blood loss surgery (neurosurgery) to reduce the percent of patients receiving three or more RBC units from 73% to 32% and reduce the average number of RBC units transfused by 47% (from 1.9 to 1.0 units per patient).2 In this study, the researchers also showed that patients who needed RBC units received them sooner by 41 minutes on average.

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Figure.
Prospective cohort study in 106 neurosurgery patients.
p<0.001 vs. Standard Care Group.

SpHb also helps clinicians decrease the time to transfusion, when a transfusion is truly indicated2

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Figure.
Prospective cohort study in 106 neurosurgery patients.
** p<0.001 vs Standard Care Group

Image Study Abstract:
Reduction in Red Blood Cell Transfusions during Neurosurgery with Noninvasive and Continuous Hemoglobin Monitoring

Projected Cost Savings from SpHb Monitoring to Reduce Transfusions

To project the potential savings from SpHb monitoring, the range of published cost estimates for RBC transfusions ($522 to $1,183) can be multiplied by the expected reduction in RBC transfusions per patient. In lower blood loss surgery, the 0.09 lower RBC units per patient with SpHb monitoring is projected to reduce RBC costs by $47 to $106 per patient monitored.1 In higher blood loss surgery, the 0.90 lower RBC units per patient with SpHb monitoring is projected to reduce RBC costs by $470 to $1,065 per patient monitored.2 These estimates do not take into account the expense of SpHb monitors or sensors, or the other costs associated with over transfusion or delayed care.

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Cost Savings Model from Capgemini

Capgemini, a leading supplier of global consulting and technology services, released a study showing that a typical 500 bed hospital incorporating Masimo rainbow® Pulse CO-Oximetry into its clinical standards and care pathways could generate nearly $500,000 in net annual cost savings and financial gains. Capgemini reported that significant financial benefits could be derived from incorporating noninvasive total hemoglobin (SpHb) by helping clinicians prevent unnecessary blood transfusions, identify internal bleeding, and increase patient throughput. The study concluded that "whether considered on a per-patient, department, or hospital-wide analysis, there are significant clinical and financial benefits to implementing Pulse CO-Oximetry technology."

The Capgemini whitepaper explains the study findings and cost savings calculations by care area. The Capgemini calculator allows a hospital to create customized calculations for the cost savings from SpHb monitoring by using their own inputs for surgery, intensive care, and the emergency department.

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Case Studies

Image Balangoda Hospital, Sri Lanka
Image SpHb Initiates Lifesaving Intervention
Image Declining Hemoglobin Status Pre-Empted Before Routine Tests: Masimo SpHb Alerts Nurse to Patient's Unexpected Post-Op Hemoglobin Drop
Image Masimo SpHb® Alerts Surgical Team to Potentially Deadly Hemoglobin Drop: SpHb Proves Indispensable in High Blood Loss Surgery
Image Unsuspected Anemia Discovery Leads to Shocking Diagnosis: Random SpHb® Screening Prompts Cancer Diagnosis & Lifesaving Treatment

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References

* This is not an offer. Participating in the guarantee requires a contract with agreed-upon terms and conditions.

  1. Ehrenfeld JM et al. American Society of Anesthesiologists. 2010. LB05 (abstract).
  2. Awada WNFM et al. Anesth Analg 2013; (117 suppl): 50 (abstract).
  3. Case studies at www.masimo.com/guarantee
  4. AHRQ. Inpatient Sample. 1997-2007.
  5. Marik PE.et.al. Crit Care Med. 2008;36(9):2667-74.
  6. Carson et al. Cochrane Database Syst Rev. 2012 Apr 18;4:CD002042.
  7. Shander A et al. Transfusion. 2010;50(4):753-765.
  8. Murphy G J et al. Circulation. 2007;116:2544-2552.
  9. Shander et al. TransMed Rev. 2011. 232-246.
  10. http://www.jointcommission.org/patient_blood_management_performance_measures_project/
  11. Joint Commission Perspectives. The Joint Commission Continues to Study Overuse Issues. Volume 32, Number 5, 2012: 4-8(5).
  12. Friedman MT et al. Arch Pathol Lab Med. 2006 Apr;130(4):474-9.
  13. Hill SJ et al. ASA. 2011 (abstract).
  14. Frasca D et al. Crit Care Med. 39(10); 2011; 2277-2282.