Bloodless Medicine

TASA ID: 4211

On November 3, 2020 at 3:00 p.m. (ET), The TASA Group, in conjunction with registered nurse, Cassandra Upchurch, presented a free, one-hour interactive webinar presentation, Bloodless Medicine, for all legal professionals. During this presentation, Ms. Upchurch discussed:

• Understanding definition and history of Bloodless Medicine
• Reasons for refusal of Blood Transfusion
• Alternative strategies to avoid blood transfusions
• Acceptable vs. Unacceptable blood fractions
• Role of Bloodless Medicine

About The Presenter:

Cassandra Upchurch has been a registered nurse for 13 years. She currently holds the position of Manager of Transfusion-Free Medicine. Her nursing background includes Trauma SICU/ Critical care, acute care, long-term care, case management, hospice and homecare, adjunct professor at Widener University. She has been a contractor for crisis hospital assignment on the COVID team. She is also the owner of First Aid & CPR Academy. She has several published abstracts, articles, and poster presentations. She is an international speaker. Recently she has managed the merger of the FACT accreditation for the University of Pennsylvania Hospital and Pennsylvania Hospital, and develops policy, workflow, and process improvement in the Penn Medicine system. She is in the last year of her MSN Nursing Administration, and applying for the Nursing Doctoral program.

Note: This webinar is approved for CLE credit in CA, IL, NJ, and PA.

Disclaimer: Please remember that if you are applying for CLE credit you must attend for the full 60 minutes of the LIVE presentation, not the ONDemand version. If a participant is seeking credit in states we are not approved to issue credit and the participating party seeking credit incurs a fee to receive said credit, it is not the obligation of TASA to remit payment for such credit. It is the participant's obligation to remit payment to the state in which they would like to receive credit.

Transcription: 

Interviewer: Good afternoon, and welcome to today's presentation, Bloodless Medicine. The information presented by the expert is not to be used as legal advice and does not indicate a working relationship with the expert. All materials obtained from this presentation are merely for educational purposes and should not be used in a court of law, sans the expert's consent, i.e. a business relationship where she is hired for your particular case. In today's webinar, Cassandra will discuss understanding definition and history of Bloodless Medicine, reasons for refusal of blood transfusion, excuse me, alternative strategies to avoid blood transfusions, acceptable vs. unacceptable blood fractions, excuse me, role of Bloodless Medicine. To tell you a little bit about our presenter, Cassandra Upchurch has been a registered nurse for 13 years. She currently holds the position of Manager of Transfusion-Free Medicine. Her nursing background includes Trauma, SICU, Critical care, acute care, long-term care, case management, hospice, and home care, adjunct professor at Widener University. She has been a contractor for crisis hospital assignment on the COVID team. She's also the owner of First Aid & CPR Academy. She has several published abstracts, articles, and poster presentations. She is an international speaker. Recently, she has managed the merger of the FACT accreditation for the University of Pennsylvania Hospital and Pennsylvania Hospital and develops policy workflow and process improvement in the Penn Medicine system. She is in the last year of her MSN Nursing Administration and applying for the Nursing Doctoral Program.

Attendees who require a passcode, the word for today is MEDICINE. During the Q&A session, we ask that you enter this passcode into the Q&A widget for CLE reporting purposes. The Q&A is located to the left of your screen. Please remember that if you are applying for CLE credit, you must log on to your computer as yourself and stay for the full 60 minutes. You're also required to complete the survey at the end of the program. Please note that CLE credit cannot be given to those watching together on a single computer. Tomorrow morning, I will send out an email with a link to the archived recording of the webinar. The slides can be downloaded from the resource list at the widget at the bottom of your screen. Thank you all for attending today. And Cassandra, the presentation is now turned over to you.

Cassandra: Thank you so much. Best start out, my name is Cassandra UpChurch, and I currently work for a management of Bloodless Medicine program. And the objectives that were already laid out were defining the history of Boodless Medicine, the reasons for refusal of blood transfusions, alternative strategies to avoid blood transfusion, acceptable vs. unacceptable blood fractions, and the role of Bloodless Medicine. And the main reason this is very interesting, especially in the climate of today's world is that we put a lot of emphasis on respecting culture and diversity. And so, especially in healthcare, Bloodless Medicine is a diverse form of care and provides diversity in healthcare, and that we do have patients that decline blood transfusions. So, just an overview with our patients. Pretty much these patients are, again, not declining medical care treatment, they're declining blood transfusions and asking that care be provided without the use of blood transfusions. And so really, the goal of Bloodless Medicine is to identify Bloodless Medicine patients, manage their anemia and medical and surgical strategies, provide education, minimize blood loss without the use of blood transfusion support. And I'll get into that more detail down the line because there's a big difference between telling a patient that as a provider, you honor their wishes and not give blood versus honoring their wishes and provide an alternative strategy to also enhance patient outcomes to ensure that they're safe and have good outcomes despite not using blood even in emergent cases. And so just looking back at the history of Bloodless Medicine and that, you know, it's relatively new compared to most forms of medicine in different departments.

So, it started with a group of patients that will refuse blood transfusions for religious reasons, primarily Jehovah's Witnesses, especially in Europe, where they would go for treatment as we all would, whether it's going to the ED or going for a transplant, or just your routine level of care, and providers would actually turn them away and decide not to treat them because of the liability with these patients. And so doctors felt like even in cases where, you know, maybe there's no indication for blood use or a patient with a risk for blood transfusion, they felt really concerned or that it was high risk to see a patient that you did not have the option of a blood transfusion for in the case that something emergent happened, and this patient lost their lives as a result of not accepting blood. So, that was really a hard concept for a lot of providers to accept. And then even from a conscious standpoint, some doctors feel as though their safety measure is being taken away where they can't provide the best care for their patient. So as a result, these patients will be turned away for care. And so starting this program, the providers and those involved in the program needs to do extensive self-education, understanding the Jehovah's Witness belief system, why they refuse blood, what they would accept instead of a blood transfusion, which, of course, the goal is not to withhold treatment or care but to find a way to plan care without a blood transfusion. And so, it really started over in Europe with Denton Cooley, who was the first surgeon to perform a successful bloodless cardiac surgery on a Jehovah's Witness patient, and then eventually migrated over here. It's become popular to the extent that you have at least 50 to 60 robust Bloodless Medicine programs in the United States that are successful. And so this is just an overview of what's involved for a successful patient blood management. So, Bloodless medicine falls under the category of patient blood management and as a subset or a subgroup.

And so, you have some hospitals or providers that typically will tell a patient, which is very helpful, you know, "That's fine. We know you refuse blood. I as a provider, I'm more than willing to treat you without giving you a blood transfusion." But then that becomes complicated when there's a lack of support throughout the health system because eventually, you change hands through our providers. So your surgeon may see you during the surgical encounter but then when you get to the floor and the recovery phase, you may have a different attendant altogether. And it's not always understood as to whether or not that doctor is even familiar with Bloodless Medicine or even understands what alternatives are available to treat that patient successfully. So just kind of looking at some of the things that go into making a successful program, some of things we talk about is patient identification. So these patients come in, and it's really good to proactively know, who are these patients that are refusing blood? That's something that needs to be established from the door, even if the primary care provider, they need to know that even when the patient is not getting a non-invasive procedure or just being seen routinely. And so, again, making sure that as a provider, we're asking those questions and making sure it's documented that this patient refuses blood transfusion. And that's something that typically should be asked on every visit because patients do change their mind. So, again, knowing their stance on blood transfusions, and keeping it in a chart if they are adamant about refusing it consistently throughout their hospital course. Care providers. So it's very important, of course. You know, you can't have a Bloodless Medicine program because I have a provider that are engaged, that are involved.

They're knowledgeable regarding what that means and how to provide that type of care. And so that goes across the health system, nursing, your surgeons, your medical doctors, you know, your profusionist. So, again, it needs to be from top to bottom, as far as those providers that are involved and being knowledgeable about Bloodless Medicine. And of course, there's organizations that exist, such as the Society for the Advancement of Blood Management, that really allows providers, physicians, and nurses, all healthcare providers to come together on an international level and kind of discuss these advancements in medicine, without the use of blood to ensure that they understand this avenue of medicine that really isn't taught in medical schools, in nursing schools or health sciences as a student, but you learn that kind of on the job as you develop in your career. Research. Again, especially in healthcare, the things to kind of move this forward is its research. So, again, looking and seeing the effectiveness of what we do and if we're doing it in the best possible way. So, of course, most of your robust programs, a lot of times are attached to your academic hospitals. And it makes a lot easier to kind of see, for example, trend your outcomes. So, for example, we may have patients whose hemoglobin is really low, anemic, or in some cases what we call severely anemic, meaning that that number, that hemoglobin number is less than five. And so, you know, it gets really dangerous for our patients as this is a really critical level. And so as a result, with research, what we were able to trend is, on average, how much blood is lost per procedure? So we know if someone has knee surgery, on average, you know, at your safest knee surgery, on average, you lose about, you know, 2.5 grams, or you know, 2.5 points from your hemoglobin. So you anticipate that fall, but you don't know that unless you do the research and you trend that data. And again, when you have those results, it gets published.

And so those are the things that can be taught to other providers, can be shared at these international conferences, so that we learn from each other, we can publish it, and kind of continue to build on it, which is why we have so many advancements in medicine, especially Bloodless Medicine. Evidence-based practice, how we implement that research. So, again, we did the research, are we implementing what we know works best, not just based on what we're used to doing, or what we think makes sense, or what's in the textbook, but are outcomes supporting the practice. And so, that's really important because what we do is almost always gonna be based on evidence-based practice. The outcome shows that this process works better. The outcome shows that this medication works better. Data metrics. Again, trend in those labs, trend in patterns. So, again, looking at the hemoglobin, looking at the platelet count, just kind of looking at all those labs to see the outcomes, for example, when a patient's having surgery, when they have certain disease processes. But again, collecting that data so that we can make a decision and really learn more about how we're practicing as a result of looking at those data metrics, even if it comes to, like, looking at patient volume and things such as that. Education needs to be a formal process where we're doing that constantly throughout the hospital. So even with a Bloodless Medicine program, it's very important that the patients are educated, that the staff is educated. So that's ongoing. So the Bloodless Medicine program has this very unique function where they kind of bridge that gap between the patient and the provider, even though the Bloodless program has providers in it because the Bloodless Medicine program is the one that understands exactly what Bloodless Medicine means and what options can be recommended for these patients. So, again, bridging the gap to keep those providers that are in the hospital or in a facility up to date and also keeping patients updated as far as what their options are as well, and doing those consent forms, and we'll talk about in more detail.

Improve patient outcomes from the things that we'll talk about further in the presentation, is that we do know that the goal of Bloodless Medicine is to have improved patient outcomes without using blood transfusions. So we know there's a lot of benefits, you know, to not using blood, especially with a blood shortage but especially for those patients that are refusing for religious reasons. It's beyond outcomes and more of us respecting their religious decision. And documentation. Again, big thing, especially in healthcare, ensuring that those things are documented. If we did a consult, but those recommendations were that the patient refused, and that we document which alternatives they are willing to accept, being that they're not taking blood and document that they are refusing blood and release in the hospital liability associated with potential poor outcomes as a result of not taking it because we do have patients, because it is a religious decision who will refuse blood even if death is imminent, because again, for them, it's a religious decision. It's a scriptural decision for them. So that's something that needs to be documented and reviewed as well. And law and ethics, again, you know, what's right, what's ethical, what's right for that patient. And we get into a lot of that with patients' family members, and discuss it, you know, how to approach care as providers especially at the end of life as well when those things happen. And administrative support. Again, no bloodless program is successful without the support of administration, whether that comes from funding, whether that comes from providing the necessary staff and those resources that you need to build this program. And so there's a lot of obviously Jehovah's Witnesses worldwide, especially locally. And so we always tell providers, you know, at some point regardless if there is a bias, whatever your thoughts are as to why people refuse blood, whether you agree or not, the reality is, at some point, especially because of the prevalence, you will take care of a Jehovah's Witness patient at some point in your career as a provider.

So it's important that you're at least knowledgeable about patients that refuse blood and the reason they refuse blood. And so, just from a demographic standpoint, patients participate in the program, 90% of our patients are Jehovah's Witnesses refusing for religious reasons. And because, you know, this is one of the religions that, you know, refuses for this reason, the bulk of our volume comes to those patients. But then the remaining 10% refuse for a variety of other reasons, whether it's reasons of conscience. You have different individuals and different religions that will refuse and just clinical research because there's a lot of research that kind of shows the poor outcomes related to patients who take blood. So we're learning that there's a lot of, more complications associated with patients being transfused, especially surgically. And it shows an increased mortality, especially in cardiovascular surgery patients. And so, you know, there are a lot of patients that know this information. They opt not to get a blood transfusion. So with that being said, we do emphasize always that a Bloodless Medicine program as people use interchangeably, they'll often say, "Oh, the Jehovah's Witness program." It's not a Jehovah's Witness program. We just happen to have a larger volume of those patients because they have a religious stance, which means that even if things go south and the numbers are really low, they're typically not gonna change their mind, but that 10% sometimes they will because it's more based on data and clinical information. So if their hemoglobin hits a 2, they may be willing to take blood in these circumstances because it may not be a religious reason behind it. So usually, for these presentations, we focus on the Jehovah's Witness patient because that's the group that's less likely to change their mind, even if the outcome looks poor. And so, typically, there are some service lines in the hospital that see Jehovah's Witness patients more often, that utilize blood more often, but often, we will reach out to the Bloodless Medicine department more often for that reason.

And so hematology-oncology, orthopedics, OB-GYN, and cardiac surgery, are really big on reaching out to Bloodless Medicine department to ensure that they're educated, that their patients are educated and know their options that those consent forms are fine. But most importantly, sometimes, with certain practices, they allow additional facilities like an anemia clinic to be involved in the care for that. For example, if a patient is about to have cardiac surgery and their hemoglobin is about a 12, they may know that because, you know, we've done their research, we've trended that data, we know you're gonna lose about 5 grams of hemoglobin during that procedure. So that patient needs to be... That number needs to be increased to anticipate that blood loss so that when they come out of surgery, their hemoglobin is still around 11 or 12, at a safe number that doesn't put them at risk after surgery. So again, these are typically the service lines that are utilized in Bloodless Medicine and the anemia clinic. So we always go over a myth regarding Jehovah's Witnesses. Again, we focus on this group, often because they make up 90% of most Bloodless Medicine program volumes and are also the least likely to change their mind. But we also have to have these conversations with providers about cultural sensitive care because a lot of times as providers, you know, we talk about diversity and we talk about culture, and we respect people's decisions on every level, but oftentimes, when it comes to the blood issue, it seems like a simple fix, like, you know, "Oh, just take blood and it'll save your life." And so I think people go into it oftentimes with a bias assuming that, you know, this person is Jehovah's Witness. I know exactly what they believe. And so there's certain myths that can impede care in a lot of cases. And so one of the myths are that Jehovah's Witnesses are a cult. Some providers struggle with this because they feel as though, you know, there's one person making this decision for everyone in a religion, as a result, they kind of fall in line, which isn't the case, and that they're extremist.

And if they try to convert people, they're difficult to provide medical care for, and that they have a desire to die due to refusal of blood transfusions. And so, just a brief overview with the idea of a cult. You know, you think about it, it implies that the individual deviates from societal norms, with no regard or respect for government or leadership. And so Jehovah's Witnesses, they make this decision about blood refusal as a personal decision. So even though, you know, they do read the Bible, the Holy Scriptures, they have to make a personal decision about whether or not that's something they wanna do when they come into the hospital as a Jehovah's Witness, you know, will they take blood or will they not? You do have a small percentage that will take blood in the emergency case, but the majority do not based on their scripture observation to abstain from blood. And so it's a very personal decision versus an individual telling the entire organization that they can't and then they're forced in it and disregarding societal norms. And as far as trying to divert people, you know, again, we know typically there's a lot of education that takes place from a Bible standpoint, as far as, you know, sharing their belief system with other individuals, and difficult to provide medical care. So, you know, oftentimes we talk to a lot of our providers and from an outside standpoint, we have a symposium coming up this week. And oftentimes what we hear is some comments, they'll always comment, you know, "Our bloodless patients that are Jehovah's Witnesses are typically easier to provide care for because the group tends to be more proactive." As a result, there is literature that they read that we're reading too as providers, so scholarly articles that we're reading, to kind of see what's up to date as far as care and Bloodless Medicine. They're reading those articles too. They're published in their website in the medical corner on a jw.org website. So we know that they often read related to Bloodless Medicine what we're reading but also because they know they can't take blood.

We often have patients that are coming in every year and updating their consent form that we'll get into, which specifies which alternatives they're willing to take that should they ever have to come to the hospital, it's already document and doctors already know that their bloodless and they are releasing the hospital of any liability associated with any risk of them not taking blood but most importantly, they are leaving a list of the alternatives they're willing to take should they need them. So again, these are patients that typically have their care plant. They have a lot of support. And the most common myth, the desire to die due to the refusal of blood transfusions. So you often hear people... Sometimes I've seen providers get frustrated. So, you know, Jehovah's Witnesses are trying to behave as martyrs and their refusal of blood transfusions. And the reality is, it's actually not the truth. You know, but you get to know that as you get to work with individuals, you know, versus having a bias and assuming it's about a group of individuals. And so the goal is actually to live for these patients. And then one thing we try to clean our providers is a person refusing a blood transfusion is not saying, "This is a DNR, Do Not Resuscitate or, you know, this isn't the decline in medical care?" No, we're saying as much like any other patient, we involve them and say, "Hey, exceptional care planning includes getting a patient's input, meeting with them, letting them know their options, and planning their care around those options." And so it's the same thing for these bloodless patients, like many our other patients, we're tailoring their care. So they're saying, "Can you please provide the same care for me with successful outcome which do not use a blood transfusion." And so a lot of these programs, they have a bloodless program has figured out how to do that without blood.

And in a lot of cases, you know, kind of coincidentally, as a result, they've learned that the outcomes have been better without using blood, which is why you see patients who are not Jehovah's Witnesses utilizing the services and the resources that will be used for a Bloodless Medicine patient because there's long-term effects to being transfused, even in the hospital down the road. And so this is just... I usually put the slide in here just for providers to kind of have as a reference as to reasons why Jehovah's Witnesses do not accept blood transfusions. So we do know that for this population, it's religious. So again, we wanna make sure we respect and honor their decision not to take blood, that we respect their religion, your belief system, and that we also recognize that it's a form of culture for them. And we respect especially, again, as I brought out, and this climate now, we respect people's culture. We talk about diversity. And so we really need to, at this point, it's funny in 2020, understand that this in the same way is all diversity and culture, and we need to respect it. So we don't need to understand it. We don't need to agree with it, do it for ourselves. But if our patient is coming in saying, "Hey, I need this type of care without blood," we should be more than willing to provide it. But we do leave this as a reference for providers to see beyond that their refusal is scriptural so they at least have the scriptures as the reference. So they know exactly why they are refusing a blood transfusion. So again, that's a religious, ethical, and moral decision for them versus a clinical-driven decision, even though there's a lot of clinical benefits to not taking blood. And again, as I highlighted before, we talk about health literacy in healthcare. And we always assume just to be safe as providers that, you know, you see our patients' health literacy is somewhere around, you know, elementary school, such as they're not a provider, just to be safe and make sure that the education is effective.

But the reality is, especially with this group of patients, they're reading a lot of the same literature we're reading. So, again, it's safe to start there. But this is just an example to show you that this diagram itself came out of one of their publications to kind of help provide education as far as which components are refused, which ones are acceptable, and how they break down. So, for the bloodless patients, the four components that they're refusing, and we require it to enroll in the program is they're refusing red blood cells, white blood cells, platelets, and plasma. But then there's derivatives that are taken from those components, that may be acceptable, should the individual decide to accept it. So, again, just highlighting that a lot of our research literature and the clinical breakdown, explanations do come up oftentimes on a post on their website, on their books, and they're also reading a lot of the same journals that we're reading as well as providers. And it's just an example of one of the panels we have for education for our patients to kind of go over the alternative there, an option for them. So we know that they're refusing those four components, the red blood cells, the white blood cells, the platelets, the plasma, but then those possible acceptable derivatives and procedures are typically listed below. So when they meet with a Bloodless Medicine Department, it's their job to sit down with the patient, see if there's any criteria, meaning seeing if they want to be in the Bloodless Medicine program, the patient has to get consent, like any other type of care participant program to be in the program, meaning that now Bloodless Medicine becomes a part of their medical team. As a result, it's not just a verbal agreement. It has to be a signed consent form by the patient.

So either the patient or their power of attorney is going over these forms with the department, they're receiving the education to explain what the department does, what the patient is refusing by enrolling in the program, but also to explain to them which each of these derivatives or fractions are to see what on this list they're willing to accept, or what they want to refuse, that their provider knows what they're gonna put in your toolkit, should they ever need anything emergently since they're not taking blood. And so, again, they need to have consent forms signed enrolling them into the program, but also specify which alternative they're willing to take. And this is just a snippet from one of our generic enrollment form. So for a patient make it very easy to follow or has a list of procedures and products that are listed as alternatives. So again, refusing the red blood cells, white blood cells, platelets, and plasma, then they have these derivatives. So understanding that's medical directive that they get, which is a much larger sheet in the top paragraph, you know, again, specifies refusal of the full component, but also has a statement stand that they release the hospital of any liability associated with poor outcomes related to the patient refusing blood transfusions. So that's on the form as well. But this checklist here, this box, provides a list, and so the patient as we do the education and go through, you know, cryoprecipitate is what it does, is what it's used for. The patient will make a conscious decision as to whether or not they want to accept or refuse. So, again, every individual thinks for themselves. So some patients have looked up the mall and will refuse all of them. And for some patient looks like a checkerboard and they'll take one and not the other just because that's what they want to do. And sometimes it's just based on how they feel. But we make sure they are provided with these options. Our Jehovah's Witness patients typically have this additional form, a durable healthcare power of attorney.

They refer to it as a no blood card because this speaks mainly to the refusal of blood transfusions. Our Jehovah's Witness patients will typically almost always have this DPA, this no blood card. So even if they present to the hospital and they don't do the hospital-specific NS medical directive with those two fractions, they typically have this DPA that's distributed in the congregation. And a lot of times, it's helpful because you'll have patients present, and maybe they didn't put an emergency contact or healthcare agent in their chart when they admitted to the hospital. But if you have this DPA on file, as you can see, they have a healthcare agent listed of primary and a secondary. So in the case where we have patients that can't speak for themselves, it does help provide some direction as far as who they should talk to. But also, I don't know if it's big enough for you to see but in section 4 bill this year, their allergies, their medications that they can say to them or they'll attach it, but they'll mainly list blood fractions that they're willing to accept here as well. So especially for patients that have met with the hospital to specify what they can take on our forum. They typically will write it in here as well. So your Jehovah's Witness Patients will have usually the hospital form that we do with them when we see them and they'll also have this new blood card. Our non-Jehovah's Witness patients, they won't have this no blood DPA, but they'll typically at least have the hospital-specific forms. And just in general, we won't get into great detail about it. But we talked about causes of anemia because in a lot of cases, you know, preventing anemia ensures that the patient has a reduced risk for being exposed to an allogeneic blood transfusion. So, again, preventive care is a huge part of bloodless medicine. So it's not seeing this patient the last minute to say, "Hey, you're in a dire situation, we're not gonna give you blood."

It's really seeing these situations before they happen if you can. We do know that 60% of surgeries are our planned or elective. So in those cases, if we know that these patients are... Sorry. So in these cases, we know that these patients are about to have surgery, then we can, for example, the patient has been in anemia clinic, and we know that hemoglobin was a 9, and they're having surgery in a month, there's no reason that we shouldn't already have a consult for the anemia clinic for that patient to see the hematologist and be treated with certain medications that we know work, such as Epogen and IV iron to increase the hemoglobin before surgery. Disease processes. One of the things with anemia we've noticed 25% of the time patients are anemic before they even hit the hospital and having a surgical procedure increases that number to about 80% after the fact. And so what we do know, in many cases is that we overlook anemia with a lot of patients. We overlook them a lot. And so as a result it's very important that one providers not just but with medicine providers in general, that they screen for anemia, and that they refer to hematologist in the Bloodless Medicine program for support and treating anemia. But most importantly, that in those cases that they identify what's causing the anemia. So sometimes we'll treat a patient and we'll find out and align that maybe there anemia is related to an inflammatory process that's going on. So if they have an infection, that definitely impedes that, if they have an active bleed, if a patient has some type of malignancy and then you have other cases. But in those cases, you know, they wouldn't identify the cause and treat it. Comorbidities, again, you know, we have patients that, you know, have chronic kidney disease. You know, we expect to see anemia in those patients because we know that their kidneys are no longer producing Epogen or Erythropoietin

So the results, they need to be given Epogen to help them build up those red blood cells that they can't build up naturally. So, again, it's really important to understand those other things that are going on with the patient that may be causing their anemia. Also, we talked about invasive procedures and surgeries. We're learning the last year we established an anemia clinic, that a lot of surgeons oftentimes will have a patient and maybe their hemoglobin is 11 or 12 before surgery. Eleven to 12 is okay, for your typical patients and not if you're about a surgery. So, again, because we know that if they have surgery, there's always blood loss. Even the most minimal amount of blood loss is still blood loss. And as a result, those patients will be even more anemic after surgery. So we put them at risk of needing a transfusion after. But if the patient's a bloodless patient, that's not an option. So it's almost as if surgery needs to be very meticulous, very careful for every patient but especially a bloodless patient because, again, these things are rolling in.

Interviewer: Cassandra.

Cassandra: Yes.

Interviewer: Cassandra, sorry to interrupt. Which slide are you on? Yes, I can hear you. Which slide are you on?

Cassandra: I am on... It says causes of anemia.

Interviewer: Okay. So on slide 26? [crosstalk 00:34:48].

Cassandra: Yes.

Interviewer: I was just making sure. Okay. Because I know my screen froze for a second.

Cassandra: Okay.

Interviewer: Okay. Sorry. Thank you.

Cassandra: Thank you. So, in those cases, we really need to plan for as providers because that's not an option for a bloodless patient. So, you know, you have this patient coming in saying, under no circumstances will accept a blood transfusion and we agreed to treat them without blood, then we take them into surgery at an okay number, knowing that that's not an option should they get into trouble. And then they come out, you know, at an eight or something more severe. And so that makes it a lot more complicated. So these are patients that ahead of time because we know there's gonna be blood loss. We know there's gonna be the potential for anemia. They should be seen in the anemic Clinic or hematologist prior and have some type of preventive care to make sure that that number is normal before they go into surgery. I am interested in blood loss. We talk about a lot is essentially anemia me that we call at hospitals and providers. And so pretty much it's blood loss related to blood draws. And so, typically, if you look at your typical day, I used to be a critical care nurse. And so we would draw labs [SP] in our patient. And, you know, we would draw two tubes that were in itself, just a waste to ensure that, you know, they contaminated blood, whether was contaminated by the medication they were getting the IV was tossed first. And then we would take a couple more too that's a sample that you sent away. But we learned that when you take a lab like that every day, that patients drop about one to two grams a week. So you have your typical patient that starts off at 12. They're already in the hospital because they have a disease process going on. That disease process in itself may contribute to anemia. And then on top of that, we're taking blood from them every day. We're making the situation worse and we're putting them in a situation where they may need a blood transfusion. And so we do know that that's a significant cause of blood loss for patients or anemia.

So, when you go to a facility that has a Bloodless program, the whole goal of the whole system being engaged and being involved in care is ensuring that even those guidelines are rewritten. So, for example, blood draw should be taken when these hospitals have these programs, when it's necessary, and only the amount that's necessary. So, typically, unless a patient... Because oftentimes we draw labs, we see the numbers and we don't do anything about them unless it's critical. So there's no point in tracking a normal calcium or potassium every day, if it's normal, all week long, and they continue to get the same blood for the same number, that's not at risk and that's not changed at all, but we're detained to take this blood to watch your number that we're not doing anything about. So, in these cases, you know, taking blood when necessary in only the amount, so we're using pediatric twos and these patients is that much some people have different types of machines where you'll need to drop like you do you check your finger if you're diabetic with a glucometer, to check to see if the hemoglobin is at point of care testing. And in many cases, if the patient is already really anemic, you know, not drawing labs over a longer period of time. So, again, just avoiding taking large amounts of blood on a daily basis for unnecessary reasons is one of the additional features hospitals have if they have a Bloodless program. And we know that malnutrition also is a huge component of causing anemia as well because our patients that are anemic, typically, when we do a heme panel, we noticed that they typically may be deprived of things such as B12, folate, iron, all those things are building blocks to make red blood cells. So if you don't have the building blocks, you're not gonna build a red blood cell or hemoglobin. So that in itself puts our patients at risk. And so we know, of course, seeing patients that refuse blood transfusions, we've learned a lot.

So, you know, of course, these things should have been treated by necessity. We know blood is not an option so let's figure out a way to do it without it. And so as a result, you know, it's really forced a lot of providers to become better providers. Now you don't have this crutch. You have this option, you lose blood. So we have a lot of providers previously that were extremely bloody, you knowm that, you know, good provider, but a little sloppy because they had the option to give blood back. But they're being more careful with how they provide care to surgery and how they plan patient's care. And for a lot of them, it's kind of trickled over into provide care for the non-bloodless patient as well. Because if I can do this surgery for this patient and not lose any blood, he's a cell saver and he's other alternative, why won't I do it for my non-bloodless patient, especially if you consider now even for patients that take blood, we know firsthand looking at reports in the Red Cross that blood stores are down. There's not a lot to go around as needed. So even if people are gonna take blood, why not leave it for those that are going to accept blood, but absolutely need it versus using blood, just kind of unrestrictedly for whoever, when we can prevent it by minimizing our blood loss, being proactive in building those numbers up beforehand, but also using these alternatives. So we do know patients that do receive a blood transfusion, doctors are kind of seeing the benefit because for our patients that do get blood, especially our cardiovascular surgery patients, just in general, hospital saw an increase in TRALI and TACO, which are conditions related to contraindications or as a result of being transfused. But we also know that, you know, when patients are transfused, it increases their length of stay in the hospital, and their recovery, which also exposes them to an increased risk of hospital-acquired infections as well because, you know, the longer you stay there, the more your risk for contracting whatever it's in the hospital,as far as the different types of infections, that may be a risk with the increased cost of healthcare system and to the patient as well.

And then medical errors. Of course, human error in itself contributes a lot to medical error. So it's the third leading cause of death in the U.S., even when administering blood because blood is listed as a medication. So there's issues with that as well, making medical errors when given blood, and then unknown pathogens. In the wake of COVID-19, you know, even transfusion patients with the little that we do know about it, do you really want to be given blood when we have this new pathogen that we really don't know a lot about? And one provider said it so well when they brought out that we talk about social distancing, but how much social distance is there between the recipient and the donor when you can't see blood. So we're a mess, but then gonna give this person this other person's body fluid. We don't have a test to test for that in blood. So there's just so many unknown pathogens and different ways I think are transmitted. And we really don't know the long-term effects of these things right now. So they're basically added benefits. And then the plan to identify blood with patients. So some of the things that these bloodless programs do that's really helpful, especially in protecting the patient, the providers in the hospital, from a care standpoint, from a legal standpoint, from an ethical standpoint, is that they review the protocol for identifying bloodless patients, which is a whole process. If the patient meets criteria and desires to enroll in the program, they'll consent, they'll sign a signed consent form, and they'll have that consultation by the department. The patient has their education packet so they're able to, you know, continue to think about the things that they've learned and make decisions independently because you want to make sure you encourage the patient to feel empowered, and engaged in their own care, and participate in their own care.

And these forms are typically in the chart and scanned into the EMR as well for all of the care providers to see. And so we talk about the anemia clinic because, again, we talk about proactive planning, preventive care, well providers who thinks about it consider all the tools you can use, but you need to transfuse. So, again, be more meticulous about how we provide care. Be in understanding of patients regarding their decision about blood, especially being that we know as providers that there's risk involved anyway, even with patients that don;t want to take blood. There's a lot of liability in that as well, because, you know, they're poor outcomes associated with it. But again, for the providers who really think, you know, have we used all over options, do we need to jump to a blood transfusion? We'll see some providers sometimes in hospitals that don't have Bloodless Medicine programs and they'll already have the blood on standby before the surgery start and ready to be delivered. So, again, how much better if providers if ahead of time, we know our patients' decisions, we're utilizing the anemia clinic. We're using our nutrition console, and all these other alternative strategies to avoid the use of blood transfusions related to risk, related to what we have in storage and just conservation, in general. So, again, early identification is key, which is a huge part of preventive care. And typically your Bloodless Medicine staff, there's a variation to the staff members. So your typical, your most basic structure, sometimes it's just one person when the program is just getting started, and maybe just one person who is the coordinator for that program. And then as that program matures, other FTEs or other employees will be added to that department. But a basic mature robust program has a medical director, a program manager, and that term may vary, you know, operations manager, director.

So, nurse manager, there's a lot of variations to that. There's typically a secretary and a team of coordinators, who are usually not clinical. But that nurse manager, the manager is tasked with the responsibility of knowing the trends, knowing the options, and clinically educating the coordinators to compile that list of alternatives for the patients, create these protocols, these workflows, and given access to the coordinator so that they can educate the patient, complete these forms, have these forms filed so that these patients are identified and documented for providers to know that they're refusing blood and that they are open to a list of alternatives for treatment. And these are just some helpful tips in managing a transfusion-free medicine patient, especially when programs are newer, this is harder to kind of grasp, you know, because it's, you know, one step at a time. But again, the key roles is identification across the board. Identifying his blood list, identifying what their wishes are and then identify and making sure that there's a process in place to honor the decision to refuse blood. So these patients in addition to... And this varies from hospital to hospital, but in most cases, they're doing the hospital-specific form, where they're refusing blood, release the hospital from liability, consent to be the in the program, doing the dose of alternatives that they want, but they're also filling out the blood transfusion consent form, which also when that form, they may be refusing all which would be the red blood cells, white blood cells, platelets, and plasma. And I think... So, that's it from me. I want to leave the last few minutes for Q&A if anybody has any questions.

Interviewer: Yes, we do. Thanks for that Cassandra. If everybody can type in the passcode in the Q&A, that would be great. The passcode is MEDICINE. Okay. Our first question, we're gonna push it to the audience. Are there any groups besides the Jehovah's Witness who have a religious objection to blood transfusions?

Cassandra: Individually, yes. I haven't run into any groups that refuse blood transfusions. There were a few times when we had a few patients that were Muslim. I know there's a couple of different divisions because I have a family member that's Muslim, and I know not every Muslim has the same, you know, belief system. There's different denominations. But that's correct. But we had an influx, where we have more Muslim patients refusing blood transfusions. And you know, you're very careful about asking certain questions that sound judgmental, but it's more so curiosity. It's just kind of asking, you know, just so we would be able to plan around the education piece and the support piece, you know, "Are you refusing for religious reasons or personal reasons?" And oftentimes, they will say both. So I did kind of check-in with a couple of individuals that were Muslim and they did say it wasn't necessarily a belief that they refuse blood transfusions as observed, and, you know, what they read based on their faith, but I think those were just individual personal decision. So besides Jehovah's Witnesses, I haven't known any other religion that refuse as a whole for religious reasons.

Interviewer: Okay. Thank you. Can the use of warfarin or other blood thinners cause or increase the risk of anemia?

Cassandra: It can in different ways. So typically, yes, it can. That's a very good question. So, typically, when we have patients like that, especially if we know they're having surgery, their anticoagulants, their antiplatelets, their herbal medications that may prolong bleeding, we have them stop those medications, especially if they're an active bleeder and they're about to have surgery. We'll typically stop that. And in those cases we'll start on more medications like antifibrinolytic, like Amicar or Tranexamic acid, which makes sure that clots stay in place to stop things from bleeding out. So it can. And so typically, those medications are stopped and they're put on medications to reverse the prolonged bleeding so that they don't bleed out. So yes, that's the answer to your question.

Interviewer: Okay. Here's our next question. Do Jehovah's Witness or other bloodless preferred people typically wear medical bracelets? If not, how do emergency personnel and ER doctors know in a timely fashion not to administer blood infusions fwith transfusions?

Cassandra: That is a very good question. So that is the difference between hospitals that have bloodless programs and hospitals that don't, which is why we tell patients that are bloodless what hospital do you pick to take bloodless program. So if there's no bloodless program, no, they typically do not have a brace that identifies them. It's strictly communication. So you're hoping that the last provider communicates and documents to pass to the next provider. And facilities that have a bloodless program, they do have a bracelet. There's a variation. The colors are different. The wording is different. But typically they all say new blood. Ours specifically say no blood, a list or phone number of the departments if they have any questions. And it also lists the four components they refuse. And so their doctors knpw, you know, no red blood cells, white blood cells with their plasma so that they know right away. So our department kind of owns that responsibility. As soon as they hit the door, we screen them. We do their consent. We put the band on them. And then there's a lot of identifiers that go on the chart that tells every providers all over their medical trends, their bloodless, but it also triggers what we call a soft stop to an insurance that even if someone went in to try to order blood on this patient, it'll flag and remind them, "Hey, this patient involved in the bloodless program, they're refusing blood. Do you want to proceed?" And typically, it'll make them cancel that order. Yeah, so that bracelet actually triggers a lot. So those hospitals with bloodless with programs will have that bracelet.

Interviewer: Okay. Here is our next question. Is there an accepted refusal form for Bloodless patients?

Cassandra: There is. So the snippet that I showed with a little box with the alternative, that was just a portion of the form, that whole form except the refusal form. Yes. So, it's interested is that form is both that, a refusal form and a form of acceptable blood fractions because the top of that form specifies they're refusing those four components. Again, it releases the hospital of any liability associated with poor outcomes if they refuse blood, but it also gives them a checklist of alternatives that they may be willing to accept without check with them, except to refuse those also. And those forums go on the chart. So the providers are typically looking for those forms as well. But we also have them sign the generic hospital blood transfusion form that all patients fill out. And on that form, they'll also refuse, but our form will give more detail as far as if they're refusing those components. But will alternative therapy stepped in. So they'll have two forms for those patients.

Interviewer: Okay. Here's the next question. How do you handle this concern in an ER situation?

Cassandra: They could turn to a patient refusing blood. So in an ER situation and your more robust programs and, again, this always talks about kind of having an engagement from the top down, it makes it easier because you have the buy-in as admissions. So, our program right now is about 26 years old now. And so of course, it gives us a lot of time to kind of, you know, reinvent the wheel and kind of improve as we continue. So the way it works for us is we have a relationship with admissions and we had a setup at every checkpoint, whether it's an outpatient area for your routine visit and the PCP's office, whether surgery, whether you're presenting ED, direct admit. But all those entry points throughout the health system, we've got them to agree facts two very generic questions to all patients. But if patients hit the ED, whether go to or not everybody gets asked the same two questions. And if they say no to both questions meaning that they refuse blood transfusions, you're gonna call to Bloodless Medicine. And they default to a bloodless list and electronic list in our electronic charting system. That has us as a department follow up and follow up with this patient immediately because we're available 24/7, and then we do the science with them or their POA, and we make sure that it makes it to the chart and we kind of help facilitate character we become a part of their medical team. So, again, in the program and a hospital that has a program, that's taken care of very easily. Usually, it's easy transition. If there is no program, it becomes very complicated and a patient typically isn't identified and it becomes very, very difficult.

Interviewer: Here's our next question. Is the Bloodless Medicine program covered by most insurances?

Cassandra: So actually, there's no charge in the Bloodless Medicine programs, believe it or not. So it's considered a non-revenue-generating department, which is interesting because it typically is a huge driver in the health system. So I know our department alone, we see at least 2,000 patients a year. So, we always tell patients, whether you're getting care here or not or you get care of another hospital, you're more than welcome to come in, sit with our team, get the education, do the forms. They don't have to bring their insurance card, they just bring ID. And we do that education with them, give them a copy of their forms. Most of the time, that translates into them, picking one of our providers and making an appointment to have cure at our hospital. And sometimes they stay where they are with their provider, which may be a hassle, but it doesn't have a bloodless program. So we don't... Insurance is't an issue for us because we don't require insurance. It's different if you come to meet with our program, you do the forms, and then you wanna schedule an appointment and have knee surgery with our ortho surgeon. Maybe he doesn't take the insurance, we'll typically help the patient find a provider with a network in the area. But they can still see us and do this forms regardless.

Interviewer: Okay. Next question. Do the religious objections to transfusions preclude the use of a person's own blood that has been banked?

Cassandra: Yes, it does. So, a couple of different things I wanna list that are considered acceptable, such as A for racist, we use that to take a patient's stem cells, manufacture them, and give it back. Carty is a new therapy we have now. Same concept and sell fever was not things but sell favors, you know, the blood leaves, the body is cleaned and the machine is given right back in surgery. But so a patient can... That's considered an acceptable procedure, even though that is a little unique, and it leaves the body briefly and goes right back. But in cases where our patients whole blood, which we don't think it would give whole blood but in cases where this whole blood that's taken store for periods have been given back and autotransfusion. In that case, our Jehovah's Witness patients do not accept that.

Interviewer: Okay. So this was actually a follow-up question, it said, I'm gonna send it to you. Can Jehovah's Witness store their own blood for use in pre-planned surgeries?

Cassandra: No, they cannot. If it's stored, they can't use it. So it's intersting in that they can use manufactured... It's like if it's manufactured like A for recess or Carty but if it's stores, no. They don't use their own store blood. No.

Interviewer: Okay. Here's one. Have you heard that other religious sects refuse blood transfusions from any person other than a member of their own sex?

Cassandra: You know, I heard of that before... No, I haven't had that experience just yet. So the two questions when I talked about avid envisions X to direct questions, generic questions, so they were actually developed, which is why this question is interesting, based on some responses we would hear. So I don't know if this answers your question. But typically, we had a generic question where we would have adverse effects, you know, would you accept a blood transfusion under any circumstances, even if the provider deems it necessary? If they said no... There was another generic question like, you know, would you accept it and, you know, dire situation or something like that. But then we hear patients say no to both, but then they'll be like, "But I'll take it from my cousin or I'll take from my spiritual sister." So then we're like, well, you know, technically patients in this program are refusing all four components, regardless. You know, they're not even taking it from another friend or family member. So now that second question is, would you accept the blood transfusion from a family member or a friend? So if they say no to that, then we offer them their role in the program. If they don't meet criteria, then they kind of default to the option of a patient blood management program where there's still a lot of oversight, but they're not refusing. So that actually created our second question because people would refuse it from anyone but a friend or family member.

Interviewer: Okay. This is our second or last. Do doctors have an ethical duty to test the sincerity of a patient's religious belief or for non-religious lack of consent for use of bloo and the strength of the refusal of blood refusal?

Cassandra: So, I'll answer it in two parts. I feel like it might be two different questions number one. So do doctors have an ethical duty to test this area of patient religious beliefs? So, yes and no. A lot of it is open for interpretation because... So bloodless program kind of does that piece for them. So we kind of have this conversation with the patient. We always tell them, you know, we've had patients that's like, "You know, I'm refusing blood, but I'm not a practicing witness anymore." And I make it very clear to him, you know, that's not a requirement. Like we are a hospital department. So, you know, we don't get into, you know, how active you are and all that information, just that you're infusing blood. So the doctors typically don't proceed down that pathway. However, you will oftentimes, which is harder in programs that don't have a bloodless program, but does come up in hospitals have a bloodless program where we've run across doctors, better newer doctors in new to bloodless medicine and are talking to a patient, get an OB patient and her name Avila 14, which is more than safe. And she says she refused blood. And I kind of walked into the doctor talking to the patient saying, "Listen, you have three kids at home. Are you really gonna leave your kids without a mother is? Do you really think that's fair? You're gonna refuse blood. and then if you bleed out, and then, oh, you're gonna die? Do you wanna die and leave your kids without a mother?" And so that's why that gets tricky. Because even if you do, you know, we talk about that bias, interview in a ping and there's still a way to ask certain things and approach a conversation. So they do but that conversation looks a lot different. So we typically will take care of that part for them. But when they do, it kind of comes out that way. The other pieces for non-religious items consent. I'm not sure if I understand the second part of the question. Do you understand the second part?

Interviewer: No, I was a little confused by the second part as well. I tried to piece it. James, if you can elaborate, that'd be great. But I'm gonna roll over to this last question that's here. Have there been medical malpractice suits or other lawsuits because of Jehovah's Witness or other bloodless preferred patients receiving blood transfusions?

Cassandra: Absolutely. I think it was a big landmark case. We just talked about this last week. I forget where it was. I want to say it was in Seattle, where a patient refused blood received blood. And she didn't sue. Was as of recently in the last year or two for hospitals. We don't have a bloodless program. Not in our hospital. But, you know, affiliates where they'll call over kind of asking, "Hey, what can we do to improve our practice?" And you kind of hear the story of, you know, a patient that came in, everybody knew they were bloodless, they sign a consent form stating they were bloodless. It was documented and somehow, they still gave them blood. And so most of the time to kind of call you freaking out, you know, "Hey, we gave blood. We need to prove to this patient that it won't happen again." Can we see your SOPs? What is your workflow? So you know, that's the point. We see a lot of hospitals, you know, kind of saying, "Hey, we wanna build a bloodless program. Can you help us do that?" So it does happen? It happens very often to hospitals that don't have a bloodless program, and we get those calls a lot. So it actually does happen pretty often not as much as before, but it happens pretty often.

Interviewer: Thanks, Cassandra. I did wanna let everyone know that in order to get your credit, you had to have stayed on for the 60 minutes and you do have to fill out the survey that's gonna pop up on your screen when I end the presentation. I will be sending out the certificates within one to two weeks, but you will get a follow-up email from me tomorrow morning. I do wanna take this opportunity to thank everyone for attending and most especially Cassandra UpChurchfor her time and effort in creating this presentation. If you would like to speak with Cassandra or if you would like to speak with a TASA representative regarding an expert witness court case that you were working on, please contact us at 1-800-523-2319. And this concludes our program for today. Have a great day, everyone. Thank you.

Cassandra: Thank you. Cheers. Bye.

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