From Point A to Point B : Packed Cells

Blood Transfusion on CPB

I usually know if I am going to transfuse a patient during the course of cardiopulmonary bypass.

Aside from the obvious co-factors associated with blood product administration (Kg, gender, HgB, age, susceptibility to stroke, estimated hemodilution, platelet count, antiplatelets Rx, and a few others), surgical dynamics also come into play.

But while it is uncomplicated for me- in terms of initiating the process, it is obvious that the entire sequence of events in terms of getting a unit of blood to the patient goes far beyond the $400-$800 that the hospital spent to purchase it.

While the purchase price of a unit of Packed Red Cells is fairly static, the cost to the institution is significantly more sublime and difficult to abstract in terms of tallying the steps and identifying process events, incumbent tests, cost of capital equipment and disposable supplies, and total man hours to achieve the goal.

To process one unit of PRC’s It is broken down as such:

  • Indirect Overhead-  40.6%
  • Total transfusion Process Costs 34%
  • Avg Acquisition Cost  21.5%
  • Direct Overhead  3.9%

So what is the TRUE cost of 1 PRC ?

  • Estimates vary- but it is more in the $1,600 – $2,400 arena.

A brief Review of Packed Red Blood Cells

Red blood cells, or packed red blood cells, are prepared from whole blood collected in one of several approved anticoagulant solutions. The usual 250-300 ml unit of red blood cells (RBCs) has a hematocrit of 55-80%, with some platelets and/or white cells removed during processing. Removal of plasma reduces the risk of adverse reactions.

Collection and Processing

Most frequently, whole blood is collected from a blood donation and is spun in a centrifuge. The red blood cells are denser and settle to the bottom, and the majority of the liquid blood plasma remains on the top. The plasma is separated and the red blood cells are kept with a minimal amount of fluid. Generally an additive solution of citrate, dextrose, and adenine is mixed with the cells to keep them alive during storage. This process is sometimes done as automated apheresis where the centrifuging and mixing take place at the donation site.

Red Blood Cells are sometimes modified to address specific patient needs. The most common modification is leukoreduction, where the donor blood is filtered to remove white cells. The blood may also be irradiated, which destroys the DNA in the white cells and prevents graft versus host disease, which may happen if the blood donor and recipient are closely related. Other modifications, such as washing the RBCs to remove any remaining plasma, are much less common.

With additive solutions, RBCs are typically kept at refrigerated temperatures for up to 42 days.

Point A to Point B

The diagrams below were from a University of Michigan Study and take you down the convoluted pathway a unit of blood takes before I spike it and drop it into my reservoir.

Click on Images Below to Enlarge

Straight to Point B

(For TRUE emergencies some steps may have to be missed )

References

The True Cost of Red Blood Cell Transfusion in Surgical Patients

http://ash.confex.com/ash/2008/webprogram/Paper11293.html

Wikipedia

http://en.wikipedia.org/wiki/Packed_red_blood_cells

Journal of Pathology Informatics

http://www.jpathinformatics.org/article.asp?issn=2153-3539;year=2011;volume=2;issue=1;spage=6;epage=6;aulast=Wong

Acknowledgements

0 thoughts on “From Point A to Point B : Packed Cells

  1. Frank,

    I have heard even high er estimates (~$1,400 per unit), when the cost of increased incidence of infection, ventilator times, and length of stay are factored in to the real cost of transfusion. I will see if I can locate the article that referenced this number and send it to you.

    Carl Schroeder, CCP

      1. This is something I’ve been wrnoikg on in our group. It’s surprising to me how many do not know even after years of surgeries and things happening. The general attitude is not my issue the Drs should know. Seems to be a dangerous attitude when seconds count

  2. The actual acquisition cost of a unit of a blood component is well understood; however, when the costs of testing the blood, storage, tracking, personnel involvement, waste and then the actual transfusion into the patient is added up the costs are not well defined; they vary greatly and the total cost to a hospital and patient is staggering. Blood is considered the most precious and personal substance in the world, and will only become more so in the future.

    Here is a few interesting reads: http://www.mybloodfirst.com/background.html

    Costs have risen due to adoption of improved screening tests for transmissible diseases and government-mandated patient and hospital notification requirements for blood products identified as having increased risk for disease transmission. While such advances improve safety, they also increase the cost of obtaining and processing blood. See, for example:

    •Stokes ME, Ye X, Shah M, Mercaldi K, Reynolds MW, Rupnow MF, Hammond J. Impact of Bleeding-related Complications and/or Blood Product Transfusions on Hospital Costs in Inpatient Surgical PatientsBMC Health Services Research 2011 May;11:135.
    •New Published Study Finds the Cost of Blood Transfusions is Significantly Under-Estimated, Establishes True Cost at $522 to $1,183 Per Unit (5 April 2010)
    •Rising blood costs and safety concerns motivate hospitals to limit use of transfusions (29 Oct. 2009) ◦Tidbit in article: The cost of a unit of blood has more than doubled over the past decade, and hospitals spend an estimated $25 billion to buy, process and transfuse about 30 million units a year.

    •Cost of blood donation | See short video (9 July 2008)
    •Fewer transfusions lowers costs, helps patient (5 May 2008)
    •The business of blood (Lincoln Journal Star, 30 Sept. 2007)
    •Shander A, Hofmann A, Gombotz H, Theusinger OM, Spahn DR. Estimating the cost of blood: past, present, and future directions. Best Pract Res Clin Anaesthesiol 2007 Jun;21(2):271-89.
    •Cost of outpatient blood transfusion in cancer patients (J Clin Oncol I 2000 July;18(14): 2755-61)
    •Comparative costs of blood conservation. Table 12-7 in: ◦Lee LY, DeBois WJ, Krieger KH, Isom OW. Transfusion Therapy and Blood Conservation (Chapter 12). In: Cohn LH, Edmunds LH Jr, eds. Cardiac Surgery in the Adult. New York: McGraw-Hill, 2003:389400.

    •Rueda A. Rethinking blood shield statutes in view of the hepatitis C pandemic and other emerging threats to the blood supply. J Health Law 2001 Summer;34(3):419-58.
    • Crotty B. Blood simple. (article on cost effectiveness by financial manager of capital projects at UK National Blood Services)
    • Wade J. Direct cost to transfuse (slide presentation)
    •Wilson K, and Paul C. Hébert PC. The challenge of an increasingly expensive blood system. CMAJ 2003 Apr29; 168 (9):1149-50.

    Various blood conservation strategies have been used to reduce costs, e.g.,
    •The Society of Thoracic Surgeons Blood Conservation Guideline Task Force; Ferraris VA, Ferraris SP, Saha SP, Hessel EA 2nd, Haan CK, Royston BD, et al. Perioperative blood transfusion and blood conservation in cardiac surgery: the society of thoracic surgeons and the society of cardiovascular anesthesiologists clinical practice guideline. Ann Thorac Surg 2007 May;83(5 Suppl):S27-86.
    •Waters JR, Meier HH, Waters JH. An economic analysis of costs associated with development of a cell salvage program. Anesth Analg 2007 Apr;104(4):869-75.
    •New tactics save blood. Reducing transfusions cuts costs and benefits patients, hospital says (8 Jan. 2007)

    •Cell Washer ATS Waste Calculator & Cost Estimator

    These are just a few but Dr.Shanders COS-COB Activity-based costs of blood transfusions in surgical patients at four hospitals is probably one of the better ones.

    Continued success.
    -Keith Samolyk GBR

  3. Hi Frank,

    I dont believe I know you, but I am very much in tune with blood use and blood management in cardiac surgery, more so than your average perfusionist.
    I have attached an article from Aryeh Shander MD out of Englewood NJ (considered the #1 Bloodless place in the world) which is an interesting read.

    You can also follow some of Bruce Spiess, George Despotis, or James Isbister’ s work on line.

    Let me know how I can donate to your site.

    Continued success,

    Regards,

    -Keith

    Keith Samolyk CEO, CP, LCP
    Global Blood Resources LLC
    P.O. BOX 383 Somers, CT 06071
    Tel (800) 942-9243
    Fax (860) 763-7045
    http://www.mybloodfirst.com

    1. Kieth,

      Thank you for the offer.

      Any sort of post or article you would like to submit would be a great contribution !

      Any idea how hard it is to come up with some of this stuff on a post per day timeline?

      I love it though.

      Frank

  4. Costs have risen due to adoption of improved screening tests for transmissible diseases and government-mandated patient and hospital notification requirements for blood products identified as having increased risk for disease transmission. While such advances improve safety, they also increase the cost of obtaining and processing blood. See, for example:

    NewStokes ME, Ye X, Shah M, Mercaldi K, Reynolds MW, Rupnow MF, Hammond J. Impact of Bleeding-related Complications and/or Blood Product Transfusions on Hospital Costs in Inpatient Surgical PatientsBMC Health Services Research 2011 May;11:135.
    New Published Study Finds the Cost of Blood Transfusions is Significantly Under-Estimated, Establishes True Cost at $522 to $1,183 Per Unit (5 April 2010)
    Rising blood costs and safety concerns motivate hospitals to limit use of transfusions (29 Oct. 2009)
    Tidbit in article: The cost of a unit of blood has more than doubled over the past decade, and hospitals spend an estimated $25 billion to buy, process and transfuse about 30 million units a year.
    Fewer transfusions lowers costs, helps patient (5 May 2008)

    The business of blood (Lincoln Journal Star, 30 Sept. 2007)
    Shander A, Hofmann A, Gombotz H, Theusinger OM, Spahn DR. Estimating the cost of blood: past, present, and future directions. Best Pract Res Clin Anaesthesiol 2007 Jun;21(2):271-89.
    Cost of outpatient blood transfusion in cancer patients (J Clin Oncol I 2000 July;18(14): 2755-61)
    Comparative costs of blood conservation. Table 12-7 in:

    Lee LY, DeBois WJ, Krieger KH, Isom OW. Transfusion Therapy and Blood Conservation (Chapter 12). In: Cohn LH, Edmunds LH Jr, eds. Cardiac Surgery in the Adult. New York: McGraw-Hill, 2003:389400.

    Rueda A. Rethinking blood shield statutes in view of the hepatitis C pandemic and other emerging threats to the blood supply. J Health Law 2001 Summer;34(3):419-58.
    PDF Crotty B. Blood simple. (article on cost effectiveness by financial manager of capital projects at UK National Blood Services)
    PDF Wade J. Direct cost to transfuse (slide presentation)
    Wilson K, and Paul C. Hébert PC. The challenge of an increasingly expensive blood system. CMAJ 2003 Apr29; 168 (9):1149-50.

    Various blood conservation strategies have been used to reduce costs, e.g.,

    The Society of Thoracic Surgeons Blood Conservation Guideline Task Force; Ferraris VA, Ferraris SP, Saha SP, Hessel EA 2nd, Haan CK, Royston BD, et al. Perioperative blood transfusion and blood conservation in cardiac surgery: the society of thoracic surgeons and the society of cardiovascular anesthesiologists clinical practice guideline. Ann Thorac Surg 2007 May;83(5 Suppl):S27-86.
    Waters JR, Meier HH, Waters JH. An economic analysis of costs associated with development of a cell salvage program. Anesth Analg 2007 Apr;104(4):869-75.
    New tactics save blood. Reducing transfusions cuts costs and benefits patients, hospital says (8 Jan. 2007)

    To learn how the Hemobag®can reduce costs, see

    Cell Washer ATS Waste Calculator & Cost Estimator

  5. Dear Frank,

    You bring up an outstanding question and one that I have had a special interest in for quite a few years.

    Mine usually involves the blatant lack of QC on the part of American Red Cross and other “vendors” for harvesting blood…but I digress.

    What I have discovered in traveling the United States is; A unit of blood (RPC’s, FFP etc) is certainly not cheap. There are several states West of Texas that charge the patient (the key word is “charging the patient”…whatever that means)…

    Between $1360.00 to $1470.00/unit.

    There is one state that claimed 73% of all patients undergoing cardiac surgery received at least one “unit” of blood.

    Honestly, this is more 1970’s thought medicine than 2012.

    I sincerely hope all perfusionists become more actively involved in the agents they administer to their patients.

    Thank-you for bringing it up.

    Warm Regards,

    Thomas N. Muziani PA, CP

  6. To support what Mr. Muziani has to say, an abstract by Dr. Shander seems to support this cost range.

    The abstract examined the direct and indirect costs associated with transfusion in a single hospital, and 2,413 surgical patients were prepared for possible transfusion.
    A total of 461 patients received 1368 units RBC (2.97 units/pt). The cost of transfusing each patient was $3,433 for a total expenditure of $1,584,144

    Total cost of one unit of transfused RBC in 2008 was around $1,158

    Shander A, Hofmann A et al: The true cost of red blood cell transfusion in surgical patients
    Am Soc Hematology (50th Annual Meeting), San Francisco, Dec 2008

    Gerard J Myers
    Halifax, Nova Scotia

Leave a Reply