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Ozawa believes this type of practice should stop. “This is contrary to everything in medicine and nursing. We go on evidence with everything else, but with blood, it’s completely arbitrary. Instead, we need to look at the patient. Blood should be given based on a constellation of factors [hemodynamic instability uncorrectable by volume replacement, heart rate and other vital signs, and blood count] and only after other treatment has not worked.”

Alternatives to blood

Techniques designed to conserve blood and to be used as alternatives to blood are widely used at the N.J. Institute for the Advancement of Bloodless Medicine and Surgery at Englewood Hospital, particularly in the OR, Ozawa says. These include —

• Intraoperative Cell Salvage: A “cell-saver” machine recovers blood lost from the operative area, spins, washes, and filters it, and returns the patient’s own red blood cells back to his or her body.
• Normovolemic Hemodilution: Before surgery, the patient’s blood is “thinned” by draining blood out through a closed system and replacing it with fluid. When the patient loses blood during surgery, it is “thinned” blood. Fewer blood cells are lost. At the same time, the anesthesiologist returns the patient’s own whole blood through a closed system in constant contact with the patient’s own circulatory system.
• Postoperative Blood Salvage and Reinfusion: This allows the patient’s blood to be collected postoperatively and returned to the patient. Blood flows from the operative site into a device that filters the blood, which is then returned to the patient through an intravenous line.

A decade of success

The bloodless program at Englewood was started in 1994, initially to serve Jehovah’s Witnesses. Ozawa was asked to be the director because she is both a critical care nurse and a Jehovah’s Witness, with firsthand knowledge of the medical and religious issues many patients would face. She stresses that it is not a religious program, and this became particularly apparent when, after a short time, health care professionals at Englewood came to believe the Witnesses they thought were getting substandard care were actually getting a higher standard of care, according to Ozawa. Their health status was being bolstered before surgery and the alternatives to blood transfusions worked well, allowing them to thrive while avoiding the risks of blood transfusions. For that reason, the bloodless approach was adopted throughout the hospital.

Not every institution, however, is interested in adopting a bloodless program. Ozawa admits that many health care professionals are philosophically uncomfortable with caring for people who won’t accept blood. Cost is also an issue.

Edna Cadmus, RN, PhD, CNAA, senior vice president for patient care services, believes that the transition from a traditional to a bloodless approach was successful at Englewood because everyone was committed to having one standard of care across the institution. To accomplish this, nurses, physicians, and staff from every clinical department had to be trained in new techniques.

Staff nurses were educated to —

• Use more IV iron in conjunction with erythropoietin to ensure adequate iron supplies when stimulating blood cell production
• Identify which patients would absolutely refuse blood transfusions
• Educate patients about risks, benefits, and alternatives to blood
• Question orders for routine blood work, when it might not be necessary (to avoid iatrogenic blood loss)
• Know the science of blood and bloodless medicine

Robyn DeSantis Ringler, RN, Esq., is a frequent contributor to Nursing Spectrum.

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