Risk-adjusted clinical outcomes in patients enrolled in a bloodless program.

Providing medical care to patients without the use of allogeneic blood transfusion (ABT) is an aspect of patient blood management (PBM) that has been referred to as “bloodless” medicine. This specialized care was initially developed to provide necessary treatment to patients of the Jehovah’s Witness (JW) faith, who decline transfusion due to religious beliefs. By providing bloodless care to patients, valuable lessons can be learned that facilitate blood conservation in general and thus the advancement of knowledge in the field of PBM. The methods employed in providing bloodless medical care are an example of the paradigm shift that has been described in the field of transfusion medicine, away from the component-centric model, toward the patient-centric approach.1,2 To understand bloodless care, it is helpful to understand the background behind the JW doctrine and why they do not accept ABT. The JW faith has more than 8 million members worldwide with an estimated 1.2 million members in the United States who, based on their interpretation of the Bible, do not accept ABT. The avoidance of blood products has its origin in the Old and New Testaments of the Bible (Genesis 9:4, Leviticus 17:10–14, Deuteronomy 12:23–25, Acts 15:29, and Acts 21:25). In Leviticus 17:14 it is stated in the Bible: “For the soul of every sort of flesh is its blood by the soul in it. Consequently I said to the sons of Israel: You must not eat the blood of any sort of flesh, because the soul of every sort of flesh is its blood.” The prohibition of transfusion officially became part of the church doctrine in 1945, when it was determined that the apostolic decree as set forth in the Bible book of Acts holds true for JWs, which prohibits accepting the “major fractions” of blood. JW patients will not accept whole blood, red blood cell (RBC), plasma, platelet (PLT), or white blood cell transfusions. They will not predeposit autologous blood for transfusion; however, it is acceptable (but a personal choice) to accept autologous salvaged blood, as well as the “minor fractions” derived from blood (e.g., albumin, cryoprecipitate, clotting factors, and hemostatic agents such as thrombin). When JWs present for medical or surgical care, they challenge their medical providers to provide appropriate care that optimizes their clinical outcomes. Specialized treatment that includes multidisciplinary coordinated care is often required for these patients, especially when they present with multiple comorbidities or for high-risk surgical procedures. As a result, some hospitals have developed bloodless programs, but only a few centers have systematically reported their clinical outcomes. Previous studies that have reported outcomes in patients who decline ABT (bloodless patients) have focused primarily on patients undergoing cardiac surgery,3–13 and only a few studies have reported on non-cardiac surgical patients or nonsurgical (medical) patients.14–19 When outcomes are reported in patients requesting bloodless care, the focus is often on easily measured outcomes, such as mortality and length of stay,3,8,12,14,17 rather than on relatively common morbid outcomes such as infection or respiratory, cardiac, renal, and thrombotic events. Moreover, most prior studies are limited by lack of a control group6,7,9–12,20 to which the bloodless patients can be compared. After recently establishing a bloodless medicine and surgery program to care for such patients at our institution, we assessed a variety of clinical outcomes for patients who choose to avoid ABT and compared these outcomes to those in patients who accept ABT. Furthermore, we report these outcomes in a risk-adjusted fashion for both medical and surgical patients. In addition, we describe the multidisciplinary specialized care rendered to these patients, which incorporates various principles of PBM to maintain hemoglobin (Hb) concentration and optimize clinical outcomes.