 This is Donna Proser, Chief Clinical Officer with the Patient Safety Movement Foundation. I'm excited to bring you a new video today with Dr. Ariya Shanger. He's Emeritus Chief of Anesthesiology and Critical Care at Inglewood Health. And he's coming to talk to us today about blood product transfusions and alternatives that you can implement in your facility. Welcome, Ariya. Thank you so much for joining us today. Thank you, Donna. It's a pleasure and honor. I wonder if you can introduce yourself and tell us a little bit about how you got involved in the assignment management. Thank you, Donna. Well, again, as you heard, I'm the Emeritus Chief of Anesthesiology and Critical Care at Inglewood Health. Been doing clinical practice for over four and a half decades of which about two and a half going almost three decades have been involved in, again, issues associated with patients of blood through the inception of bloodless medicine and surgery, caring for patients for whom blood is not an option. We then developed a concept that really should apply to all patients with use patient blood management. Of interest, this has been one of the topics of patient safety for years. If you look at some of the information we have from ABB as an example, they have a position for hospitals called the Transfusion Safety Officer. Just if you think of the name, the name implies that there's some safety issues a way you need an officer to oversee. So this has been an area that not only been involved in both in development, but clearly have a passion for it. Well, we often think about blood products as that big of a deal. A lot of people think of it almost as an infusion. So to speak. Can you tell us a little bit about what we've learned over the years about the safety of blood products and why we would need a Transfusion Safety Officer? That's a great question. So if you look back at the history of Transfusion Medicine, there was always the notion that if someone was hemorrhaging, that the best way to treat them at that point is to actually give them a replenishment, which is blood. Blood from a transfusion from human to human is actually relatively new. There have been many experiments, if you will, for lack of data work by individual clinicians who have taken blood from animals, tried different substances, including even milk, to see if they could resuscitate the individual. It wasn't till Blondel, who was an obstetrician in the 1800s, who actually thought that human blood was the best way to replenish shed blood. However, if you look at the data that they had, this was a 50-50, meaning that 50% of the individual survived and probably could have survived without transfusion, whereas 50% of the patients actually perished, which suggests maybe this was associated with incompatibility of blood. So it wasn't till the turn of the 1900s where a Austrian physician actually identified the ABO compatibility, the ABO system and the compatibility of blood. This actually propelled blood to become, quote unquote, somewhat safe in terms of the administration because it was matched. But keep in mind, there were a few issues in terms of the matching that wasn't complete. So it wasn't until World War II where the whole process of inventory of blood and being able to deliver blood as a product, if you will, to hospitals, opened the doors to the use of blood. And again, at the time, everyone thought blood was good, you know, and maybe your cheeks rose and people did well. And there was the notion from World War II that those who were severely injured and received blood survived, even though the data, again, was not a randomized controlled trial by any means. So we were sort of checking along with this and everybody was just very happy and we were able to actually advance in medicine by doing procedures just as an example, cardiac surgery and heart transplantation probably could not have been done successfully without the availability of transfused blood. But those were also on the forefront of something that terrible that happened. And what happened was in the 1970s and the 1980s, agents that were deadly, these are viruses that are deadly or created a very prolonged disease entered into blood system. Now that's a principle of safety, if you will. And this is where the safety bell starts ringing. And the reason for that is that blood is a biologic product. And anytime a new agent enters into someone's bloodstream who's a donor, there's a potential that that agent within the bloodstream can actually be transmitted through transfusion and cause disease to the recipient. And again, the recipient may have the consequences of again a deadly disease or high morbidity disease. So again, the safety here is something which is a charter for the blood establishment. So it's not availability of blood only, but now we're talking about also the blood has to be safe. Keep in mind, we will never reach 100% safety. And the reason is just what I mentioned, it's a biologic system. We are now SARS-CoV-2 as a matter of fact and we know that it's in the blood. We don't have any cases that we can point to to say this is transmitted through transfusion and causes the disease, right? But in fact, we're always cautious when that happens. So the rise of HIV and hepatitis C during the 1970s and the 1980s alarmed not just the public, but also the medical community. And since then, I think we have to develop what's called a benefit risk ratio. And that's why safety is so important when we do things. And I think that for everyone around the table today, if you were asked if you would accept a transfusion, I'm sure you would say only under dire circumstances, right? You don't want a transfusion just for the sake of it. And that's because there's concern that you may not get the benefit, only the risk. And there are multiple areas. Again, we don't have time to get into every one of them, but the fact of the matter is that the transfusion safety officer in many ways is one who is educating clinicians in hospitals, not just how to use a transfusion, but also when, and also if there are any alternatives. Now, in the United States, and in some other countries too, a transfusion of blood is considered to be what's called an invasive procedure. Invasive procedure require the consent of the recipient. And that's why we get consent of blood. And the elements of consent are, again, the benefits, the risks, and alternatives. And again, alternatives may actually be the best way of addressing this. I could talk and we could talk about transfusion all the time. Keep in mind that transfusion is a therapeutic intervention. We could talk about this without ever mentioning the disease that we're treating. And the whole interview could be around transfusion. The fact of the matter is that if we were talking about insulin without mentioning diabetes, or chemotherapy without mentoring cancer, it would be sort of a little off the balance here. Why? Because we have developed into a whole industry for the lack of better word or establishment of transfusion as being first, rather than again, what is it that we're treating? Once you identify what the disease is, transfusion may not be the best thing under the circumstances. One example would be iron deficiency andemia. Iron is the therapy for that. And by the way, easy to diagnose, easy to treat, and this has a very high probably when the highest cure rates in medicine. But if you're in a hospital and you have road blood count as a result of iron deficiency, you most likely are gonna get a transfusion. So the patients, not the patient, but the transfusion safety officer is there to educate the medical public on what we just discussed. Now there is data out there, and this is unfortunate, and this is not meant to, again, discourage a scary one, but the data out there shows that the more a clinician knows about transfusion medicine, the less they get. And the less they know about transfusion medicine, the more they get. So we have a work cut out, and this is why we need a safety officer. And you're absolutely right. I think that transfusion safety officers can do such great things in organizations. Tell me a little bit more about that, about the concept of the transfusion safety officer. How many organizations actually have a transfusion safety officer? That's it, an excellent question. Not many do. It is, again, an issue of finances, and the ability to do that. So you may have them in large academic centers, or large hospitals, or you may have one for a chain of hospitals, an example. But it's not one where one is there in every hospital. However, that, again, for those who are watching her in the public, it doesn't mean that the rest of the institutions have a high risk in terms of transfusion, because whether you're a joint commission or any other accrediting organization, a hospital, you're required to have a review process of transfusions, and you create, if you will, a threshold for these reviews, which are based most of the time on guidelines within the institution. So that we're trying to streamline the exposure of patients to transfusions by doing, unfortunately, as a retrospective review, which is no substitute for prospective review, which could be performed, as an example, by a transfusion safety officer. However, it does go back to educating the individuals if they have veered off what we consider to be the standard for that therapeutic intervention. So for organizations that don't have a transfusion safety officer, what alternatives could you recommend for them to improve transfusion safety? So the current requirement for them, as I mentioned, is to have a, what's called a transfusion review committee, right? Or a blood committee, which, again, is part of the accrediting process that they have to have one. They meet and review cases which have, by definition, veered off what we consider to be the floor and the ceiling of guidelines. So that we're given in excess of what they should be doing, and they have to explain that. So the committee may learn from that, but in fact, most of the time, I will tell you that those were probably unnecessary transfusion, and it's who's that committee to educate that clinician individually. And they track who over the years is, falls into the category of violation of these rules, if you will, consistently, and then they have to address them. So it's not a substitute by any means, but it is another safety barrier, if you will, that needs to be there for transfusion. So while hospitals and clinicians are working on improving safety and getting transfusion safety officers in place, what recommendations can you make for patients and families? If they're in the hospital and they're being told that transfusion is recommended, what can they do to help improve their own safety? Well, there are some resources out there for patients in terms of asking the right question for transfusion. Now, despite the fact that I mentioned to you in the 1970s and 80s, there was the HIV and hepatitis C epidemic, we are seeing something called the consumption of safety. Now, the blood establishment has been working very hard to make what are called blood safe, available and safe, which includes, of course, FDA and other governmental agencies such as Department of Health and Human Services. But the fact is, again, that although blood is safer now than it's been in the past because our testing and the testing as well as a quarantine of blood that's been donated really yield a component of blood that probably is safer, as I mentioned, than ever before, barring that there's no 100%, okay? Now, the fact of the matter is that clinicians now may think that blood is safe, not that it's safer, but it's safe. And in fact, because of that, they may say, well, you could benefit from a unit of blood if I give it to you. Now, there's no science behind that statement, I can tell you that right away. But it may be also that they feel the blood is safe, or maybe if you can benefit from it, it would be nice to give you a transfusion. This part of the consumption of safety, if you will, is best illustrated in the motor vehicle industry. So if you were driving a 1957 Chevy on the highway, you have no seat belts, no disc brakes, right? Anti-lock brakes are not there. You have no safety zones in the car if it crashes, right? No airbags, no other restraints. I mean, you're dealing with a heavy machine going at say 60 miles an hour. You're gonna have a lot of distance between you and the person ahead of you. And you're gonna be watching when you need to stop because it's gonna take you a long time. And since you're unrestrained in the vehicle, you're at risk of clearly being severely injured. So you're cautious. But if you get into a 2020 Chevy car, right? You're gonna have all of these things, right? You're gonna have all of these great safety things. However, what are we doing? We're texting while we're driving because we're consuming that safety. And the same, I think, can be applied to individual clinicians who feel the blood is safe and therefore I can give it to you. Rather than what is the absolute indication for this particular unit of blood? And by the way, that's really not the real question. The question is, what am I treating with that unit of blood? And is that the appropriate therapy? And I will submit to you most of the time, it's not. Wow, that's such great information. Thank you so much, Arya, for joining us today. I know that our network appreciates it. It's been a pleasure. Thank you for all the hard work that you all do and the commitment that you have to patient safety. And I think that this is gonna be a lifelong endeavor and we're gonna have to keep our honor in it forever because things do change. As we've just seen over the last few months, our whole life has been turned over. And this will never stop. We're always gonna have these challenges. And in the meantime, we have the small challenges, which is the patient safety during their exposure to hospitals and healthcare. Well, I hope to have you back again in a few months and maybe we could talk about some, more of a deep dive into patient blood management at that time. That would be wonderful. Thank you, Don. Thank you, Arya. Have a wonderful day.