BMSI Case Studies

10-1 Victoria Court
Freehold, NJ 07728
(732) 995-2556

[ case studies ]
How To Develop A Center For
Bloodless Medicine and Surgery (CBMS)

"Case studies highlight the variety of methods utilized in the Bloodless field. We will feature studies done at St. Vincent Charity Hospital, as well as, studies submitted by physicians across the United States. Do you have an interesting case? Please contact BMSI for publication information."

Sharon Vernon, RN
Director, CBMS
St. Vincent Charity Hospital, Cleveland, Ohio

[Recommend you print this document and read offline]

Bloodless Medicine and Surgery originated with a few pioneer-spirited physicians more than 30 years ago. Even earlier, physicians had been faced with the challenge of providing adequate medical care without the use of blood transfusions because of the religious position adopted by Jehovah's Witnesses in the mid 1940's. Notable names from the early days of bloodless medicine are Dr. Denton Cooley, Houston, Texas; Dr. Ronald Lapin, Norwalk, California; and Dr. Michael White, Chicago, Illinois. These men became well known leaders in their fields, pioneering techniques that are routinely used today. They also discovered important advantages to bloodless programs, such as lower patient costs, lower mortality rates, less complications in post-op and shorter length of stay in the hospital.
Why has bloodless medicine become the highlighted specialty of the 90's? Can every hospital realize the same benefits from a CBMS program? What makes a CBMS successful? Our discussion will focus around these questions.
Daily, the public is becoming more aware of the dangers of blood transfusions. To a large extent the media has drawn attention to the risk of contracting AIDS from various blood components. However, health care professionals realize that there are even greater problems and dangers associated with the use of blood. For instance, Hepatitis A,B,C,D, and G are major concerns for which we have inadequate responses. Many fear that there may be a whole alphabet of hepatitis descending upon us. Still other threats associated with the use of blood components are immune-suppression, possibly higher recurrence rates of cancer, and yet other unidentified new diseases.
The Patient Rights Act-1991 has repeatedly echoed the same theme Jehovah's Witnesses have sounded for years. Adult patients have the right to decide for themselves what type of medical treatment to accept or reject. Few treatments in modern medicine have the escalating risks of blood transfusions. Usually time, experience, and education have made procedures less risky and more health-building. However, the history of the use of blood components is dismal and does not promise to get better. Is it any wonder that not only Jehovah's Witnesses but the community-at-large demands that physicians and hospitals offer medical and surgical care without the use of blood or blood components. To their credit, many institutions have already risen to the occasion. Currently there are 75 Centers for bloodless medicine in the United States and 115 that we are aware of, around the world.
Success requires a spirit of cooperation. Health centers have found that Jehovah's Witnesses, as a community, have supported the efforts of hospitals to develop bloodless programs because they desire quality medical care. In turn, these hospitals have worked along with the Witnesses to assure that all CBMS policies truly reflect patient rights. One way the Witnesses have given support is by empowering their organization to provide physicians and institutions with current medical information culled from the literature around the world. Many physicians have expressed appreciation for this docent research staff. A practicing health care professional no longer has the time to keep up on everything of import in his field, let alone in related fields that might benefit him, if only he knew about them. Witness patients also make up a ready list of volunteers for new and experimental procedures that might benefit everyone, but which is especially attractive to the Witnesses because of not offending their religious consciences. However, the Witness organization has declined to get involved in promoting the commercial aspects of this very important developing field. Therefore, many hospitals seek the assistance of their colleagues who already have bloodless programs, as well as, bloodless agencies, the Bloodless Medicine and Surgery Institute, or the National Association For Bloodless Medicine and Surgery to get more information on developing a program.
All successful programs begin with dedicated physicians clearly focused on the fact that eliminating blood loss and eliminating blood transfusions is good medicine. Furthermore, physicians need to work as a team with common goals in the care of such bloodless patients if their program is to succeed. Therefore, most programs early on identify a bloodless surgical director and a/or a medical director to oversee the bloodless program team. Obviously, patient consults should be to other physicians within the bloodless program. Networking with experts from other bloodless teams and institutions is possible and desirable. But, it is particularly appropriate to have at least one physician on your bloodless team from every specialty in your institution. This eliminates problems. In times past, a surgeon would agree to operate on a patient without blood components, only to be confronted with an anesthesiologist that would not cooperate. Clearly, anesthesia needs to be as committed to the bloodless approach as surgery. Similarly, the post-op team must also be committed.
All of this can be accomplished only if hospital administrators are actively involved in developing an effective bloodless program throughout their disciplines. Will the hospital benefit? Of course! The key benefits are cost-effective patient care and increased census, both of which translate to the "bottom-line." And, as they say, the bottom line IS the bottom line. Over and over it has been demonstrated that both the Jehovah's Witness community and the general public support a facility that provides bloodless care in the context of a committed bloodless program. Experienced administrators report that a CBMS has very low overhead in relation to the amount of return, both in remuneration and patient satisfaction. Nevertheless, administration involvement and approval cannot be over-emphasized. Only with this kind of commitment will all other departments feel compelled to support the program, also. Therefore, it is wise to have all CBMS policies reviewed and approved by the administration of the facility.
Once administrators and physicians are committed, the next step is to identify a coordinator. A good coordinator will turn out to be the focal point of your success. A strong coordinator makes a strong program. Since the coordinator's job is a liaise between physicians, staff, patients and families in all avenues of patient care, the best coordinators have a medical background and good communication skills. It is important that coordinators be involved in case conferences, in order to facilitate patient's needs and identify resources to maintain high quality care. Likely, the coordinator will be called on to write policies, to inservice staff, to provide on-going education and to keep statistics. Some programs require the coordinator to manage all aspects of the center including marketing and the budget. Successful coordinators make themselves available 24 hours a day, seven days a week for consultations or emergencies. Because such a large part of the patient population within a CBMS is the Jehovah's Witnesses community it is strongly recommended that the coordinator be either, one of Jehovah's Witnesses or, be very familiar with the community and beliefs of this group.
All successful bloodless medicine and surgery programs have essential components. Dr. Richard Spence recently wrote that bloodless medicine is now recognized as a 'specialty.' As with any specialty, policies must exist to define, outline and govern activities within the hospital setting. A CBMS protocol should have an admitting process, laboratory guidelines, a patient referral system, and transfer procedures. All CBMS programs have a general policy stating the reasons for the program's existence and a mission statement highlighting the goal of the program. Nursing and Education need to define the coordinator's role in their departments. Since a large part of a coordinator's role with patients is teaching, it is necessary to outline those responsibilities clearly.
As policies are developed, it becomes apparent that a bloodless program has an impact on many areas of a hospital and that many departments must work together to provide quality patient care without blood components. Hence, successful CBMS's are synergistic. All CBMS programs should institute an 'ad hoc' committee for bloodless medicine made up of representatives of all the affected departments, including nursing, laboratory, pharmacy, emergency services, and pastoral care. This committee can assist in identifying areas in which the coordinator may need to improve patient care. It will be especially valuable if the coordinator is present at ethics meetings, nursing management meetings, and patient education meetings. The coordinator can be of great value to the quality management team, as well.
Every CBMS provides a "letter of intent" to each participating physician, outlining the bloodless principles physicians must observe. This letter should include a statement expressing the physician position to respect a patient's right to refuse blood transfusions and other blood components. To maintain the integrity of the program it is also advisable to have the attending physician agree to turn over to another physician the care of any patient who rescinds his/her non-blood position at any time. A physician signs on to the program by signing this form. Of course, a physician may withdraw from the CBMS program at any time.
Upon admission, a patient who is one of Jehovah's Witnesses is required to sign a "release of liability" form concerning their refusal to accept blood or blood components. Each patient is made aware that he/she must accept the risks related to that decision. The form is signed, dated and witnessed. Members of the general public sign this form only when they specifically state that they refuse blood under any circumstances.
All patients requesting to participate in the bloodless program are uniquely identified by means of a coded wrist band, placard over the head of their bed and coded round stickers on their charts. Some institutions choose to use the international "no blood" sign. Its advantage is that it transcends language barriers. All of these means of identification are designed to protect the patient from unnecessary lab tests, to alert medical personnel of the patient's refusal to accept blood components and to encourage the staff to minimize blood loss by all appropriate conservation modalities. For instance, microsampling is essential for the CBMS patient because iatrogenic blood loss has been a major contributing factor to patient anemia.
Technology to support the bloodless approach to patient care continues to grow. Physicians can now utilize blood salvage equipment, laser and harmonic scalpels, argon beam coagulators, various point-of-care instruments and meticulous surgical technique as blood conservation methods. Also, new approaches to tumor treatment, such as stereotactic radiosurgery, can avoid blood loss. However, all of these new and exciting technologies require surgeons to learn the latest "cutting edge" procedures in behalf of their patients if they are to be part of the CBMS program.
Additionally, pharmaceuticals such as erythropoietin, iron dextran, aprotinin, vasopressin, pentoxifylline, prostacyclin and bombesin can be used to minimize or treat blood loss. Still other new drugs are on the horizon. Efforts are being made to produce sterile products with oxygen-carrying capacity as well as other products that will stimulate internal production of blood cells. As new products become available, institutions having bloodless programs will be the leaders in their use.
A Center for Bloodless Medicine and Surgery brings many benefits to an organization. The community-at-large will recognize the institution as a leader in the field of safe health care practice. Moreover, the Joint Commission on Hospital Accreditation applauds the health care community that makes responsible use of blood components, that integrates patient rights with patient services, and leads the way to a safer, healthier tomorrow. Finally, your patients will thank you for responding to their needs and requests for non-blood medical alternatives.

[Top of page]

To Register: Call Client Services at (732) 995-2556