Strategies

Resources for Establishing a Bloodless Medicine and Surgery Program

Richard Verstraete, RN

Nurse Coordinator of the Bloodless Medicine and Surgery Program at MedStar Georgetown University Hospital, Washington, D.C., USA

Friday, April 26, 2019

What is a bloodless medicine and surgery program?

A Bloodless Medicine and Surgery Program (BMSP) is a multidisciplinary team approach designed to meet the needs of Jehovah’s Witnesses and other patients seeking optimal medical care without the use of blood transfusion. Some patients admitted to your hospital will resolutely object to the use of blood or blood components as a medical treatment option, even in a life-threatening situation. This refusal may be based on religious, personal, or other conscientious reasons.

Why is this important?

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Dick Verstraete, Nurse Coordinator of the Bloodless Medicine and Surgery Program at MedStar Georgetown University Hospital, Washington, D.C., USA, explains the benefits of having a BMSP at your hospital:

There are eight and a half million Jehovah’s Witnesses in the world. There are also a large number of patients for whom blood transfusion is not an option for other reasons, such as blood availability, and a growing number who choose to avoid transfusions due to risk. Healthcare professionals need to provide optimal care for all such patients.

When I first cared for a bloodless patient as a cardiac nurse, I had no idea what to do if the patient’s hemoglobin dropped. Our fallback was blood transfusion, and we had no other plan of care for this patient. So I set out to develop a plan that would help the bedside nurse know how to respond when situations arose that threatened to compromise the care of a bloodless patient in the postoperative recovery period after major cardiac surgery.

It was my concern for the welfare of these patients that led our care team to develop bloodless protocols and strategies.

CD Sharman, writing in the American Journal of Hematology, reported on his experience at the Oregon Science and Health University Hospital in Portland, OR USA: “We have found that medical and administrative efforts in the form of bloodless medicine and surgery programs can be instrumental in helping to reduce risks of morbidity and mortality in [Jehovah’s Witness] patients.”

Since bloodless care requires awareness of the patient’s needs and appropriate training for all members of the healthcare team, a cultural shift within the hospital or other healthcare institution is needed to ensure consistent quality of care. A BMSP helps to facilitate the coordination of care across all disciplines and eases the cultural transformation in our current patient care model.

A significant side benefit to the healthcare institution is that when providers see for themselves the excellent results that can be achieved without incurring the costs and complications of blood transfusion, they readily transition to using bloodless strategies for all their patients, thereby improving quality and safety and reducing costs.

In the words of Stephen R.T. Evans, MD, Chief Medical Officer for the MedStar Healthcare System, “Building a toolbox to manage the Witness community benefits all our patients.”

What are the key features of a BMSP?

The BMSP places the bloodless patient’s autonomy at the forefront of the plan of care, with the goal of honoring the patient’s rights and wishes. Optimal care of the bloodless patient demands a genuine commitment to the process of shared decision-making, which is a fundamental focus of MedStar’s Institute for Quality and Safety. Healthcare providers must have not only a thorough grasp of the tools and techniques of bloodless medicine and surgery, but also a complete understanding of the patient’s personal choices regarding the acceptability of various procedures and pharmaceutical products.

The staff of a BMSP can facilitate the shared decision-making process by providing clarity and comfort for both physician and patient in crafting a care plan that meets the patient’s needs.

Highlighted below are some key elements for establishing a bloodless medicine and surgery program.

1. Administrative support: The program must have an administrative champion with the authority needed to initiate and implement the program.

2. Business plan: Your business plan should describe the program benefits, limitations, and possible rewards (sample business plan included in downloadable documents).

3. Outreach to your local HLC: The local Hospital Liaison Committee (HLC) of Jehovah’s Witnesses is available to make presentations to individual physicians or entire departments. These presentations will help hospital staff better understand the conscientious position of Jehovah’s Witnesses. .

4. Determining level of interest within the hospital: The champion must identify physicians willing to support the program in order to form an effective, multidisciplinary bloodless care team.

5. Expanding your physician base: Engage the medical staff in informal settings to determine level of interest, and discuss any concerns.

The nurse’s role

All nurses involved in the patient’s care should have the skills needed to provide a safe healing environment and advocate for the patient, ensuring that the patient’s wishes and dignity are at the center of the care plan. Throughout the patient’s hospitalization the nurse on duty should act as gatekeeper, being constantly vigilant to make sure the patient does not inadvertently receive a transfusion or other intervention that goes against the patient’s wishes. The nurse should also protect the patient against all attempts, no matter how well intentioned, to convince the patient to accept an intervention other than those agreed upon in the care plan.

Care of the post-surgical patient requires the nurse to be vigilant to recognize signs of covert bleeding and to notify the surgical team immediately. During patient rounds the nurse provides vital information on the patient’s status. The nurse should also ensure that measures are taken to avoid hospital-acquired anemia by recommending the use of small-volume sample tubes for all blood draws and eliminating routine labs.

In addition, with change of shift, it is important to communicate to the oncoming nurse the patient’s care plan, and to be sure that all involved with the patient’s care are aware that the patient in enrolled in the bloodless program.

Lessons learned

Here are some lessons we learned in setting up a BMSP at MedStar Georgetown University Hospital:

Once the decision has been made to develop and implement a BMSP, logistical issues need to be addressed, These include staffing priorities and work space accommodations.

STAFFING

Medical Director: The key element for this position is choosing a physician from the current medical staff who is enthusiastic about the program, committed to its success, and willing to advocate for the bloodless patient.

Program Coordinator: In order to build a successful program, a full-time, dedicated coordinator is required. This position has been staffed in other BMSPs with individuals from varying backgrounds. One of the most important considerations is hiring a Jehovah’s Witness to fill the position. The JW community will be more supportive from the outset and this will provide a level of trust for the new program. Some hospitals have succeeded in finding a Witness program coordinator already working at their institution in another department. You may also ask your local Hospital Liaison Committee if they know of someone who would fit the role.

Nurse Coordinator: The second consideration is hiring an experienced registered nurse or nurse practitioner. Being a former critical care nurse helped in my consulting with physicians on the care of the bloodless patient. As a non-Witness nurse in this position, it was very difficult for me to gain the trust of the Witness community. Over time I have overcome that issue by being caring and a strong patient advocate.

Finally, in my opinion, the ideal candidate for the Coordinator position would be a nurse practitioner who is a JW. My major regret in caring for bloodless patients is not being able to write orders, as this ability would allow me to be directly involved with more aspects of their care.

PROGRAM DESIGN LOGISTICS

Once the program has received the green light, a medical director has been chosen, and the program coordinator has been hired, it is now time to lay the foundation for sustaining a successful program.

In our case a steering committee was formed to provide feedback and advise. Our steering committee consisted mainly of physicians from various hospital departments. The one drawback of our committee was that it lacked strong nursing leadership. Should you decide to have a steering committee, we advise you to include representatives from the following areas: transfusion services, nursing, anesthesia, surgical services, medical services, obstetrics, oncology, and pharmacy. Our committee was chaired by the hospital vice president of medical affairs, who was a strong advocate of the BMSP.

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A BMSP Blueprint - Essential Documents

All of the following essential documents are provided as downloads to assist you in building your own BMSP blueprint. If you have developed a unique blueprint for your BMSP, please share it with us so others may benefit.

Procedures and Job Aids: Policy and procedure

Patient Education Materials

The following short videos and infographics are provided to help your patients in making decisions about procedures and products that may be offered at your hospital:

What is bloodless medicine and surgery?