A History Student Makes an Impact in the Operating Room at Penn
It’s not only physicians and nurses who can make a difference in health care. Sometimes it takes a history major and some careful observation to help effect positive change.
That was the case with Nicholas Savino, a senior at the University of Pennsylvania, who devoted a summer to examining the magnitude of blood wastage in the operating room. His independent research project, which entailed a detailed tracking of blood products from blood bank to operating room to patient, a subsequent survey of surgical staff and a final report with concrete recommendations, helped lead to changes that have significantly reduced wastage at the Hospital of the University of Pennsylvania.
Growing up in Moorestown, N.J., Savino initially wanted to pursue medicine as a career, but he came to feel differently as his college years approached. A gifted athlete, he was recruited to play soccer at theUniversity of California, Santa Barbara. But, after a shoulder injury his freshman year, he reconsidered his decision to attend college so far away.
“I loved my time out in California, but I wanted to come home,” Savino says.
His father attended Penn, as did his older twin brothers, Michael and Andrew, the latter now a student at Penn’s Perelman School of Medicine. Savino found Penn was a good fit for him, not to mention he was offered an opportunity to join the Penn soccer team. He transferred to Penn after his freshman year at UCSB.
Like his brothers before him, Savino decided to major in history in the School of Arts & Sciences, concentrating in economic history. Yet Savino was still drawn to the health-care field. For the independent project following his sophomore year, Savino was introduced to Daniel Dempsey, chief of gastrointestinal surgery and the assistant director of Peri-operative Services at Penn Medicine, who served as Savino’s advisor. Along with co-advisor Marc Schmidt, an associate professor of biology in Penn Arts & Sciences, Savino and Dempsey identified the issue of blood wastage as a fruitful subject for study.
“It was a nice fit for me because it is an economic problem as well as a moral problem,” Savino says.
Not all blood that is donated finds its way to patients, Savino explains. A portion of donated blood products is discarded because it expires or is mishandled. The wastage of blood on a national level is significant and is considered by some the “price of doing business.” But reducing blood wastage can benefit patients, save money and help conserve a limited and precious resource.
“Elimination of blood wastage was a goal of the HUP periop team, and Nick came along exactly at the right time,” says Dempsey.
During his research, Savino learned that surgeons rely on four different types of blood products: packed red blood cells, cryoprecipitate, fresh frozen plasma and platelets. Each has a specific role in the care of patients, and each has a defined protocol for storage and expiration. Once ordered and released from the blood bank, blood products have a short shelf life. If not transfused within a specified period of time, for example, five hours for cryoprecipitate, they have to be discarded. In practice, it’s impossible for a surgeon to know exactly how much of a blood product will be required. Instead of risking not having enough, it is common to order more than is anticipated.
“What would happen is doctors would order too much because they know it takes 45 minutes or so for the blood to be defrosted in the blood bank,” Savino says. “They’re thinking of the worst case scenario, and they don’t want to be caught short handed in a patient that is bleeding and needs a blood transfusion.”
But Savino and his advisors suspected that the amount of blood being wasted could be reduced. To attempt to quantify and track the wastage, Savino obtained clearances to analyze records of surgery patients at HUP between July 2013 and May 2014. He also sat in on surgeries, taking careful note of the blood products ordered, transfused and wasted and also how they were handled. In addition, he sent a survey to operating room staff, including attending physicians, residents, nurses and technicians, garnering more than 200 responses on such subjects as how long it takes to obtain blood, how blood was stored in the OR and who was responsible for returning unused products to the blood bank when appropriate.
His analysis of patient records revealed that, in the course of 10 months, 833 units of blood were discarded — that is, units that were ordered and were not able to be returned to the blood bank for reallocation to another patient. This blood was defined as “wasted.” The estimated cost of this wasted blood was $184,000.
The quantity surprised, but national data suggest this problem is not specific to Penn Medicine. It is ubiquitous in many medical centers in the United States.
“I’ve donated my own blood before,” Savino says, “and to think it might be going in the trash is really demoralizing.”
The survey results and his OR observations found that no one person was designated to return unused blood to the blood bank, and some blood products were wasted because the blood products were being mishandled. For example, platelets, once pooled, must be kept at room temperature. Packed red blood cells must be kept cold. If red cells were kept at room temperature or platelets were kept cold, the products would need to be discarded.
Savino and Dempsey brainstormed practical steps the hospital could take to reduce wastage, some of which HUP has since implemented. Among them, the blood bank decreased the number of units of cryoprecipitate in a bag from 10 to five so less is wasted if a bag is prepared and not used. And a new blood-returning system has been adopted with a designated technician responsible for retrieving and returning blood products between the ORs and blood bank, a system designed to return unused blood before the expiration time.
Savino spent this past summer again working in service to the health-care system, this time in patient accounting for Thomas McCormick, associate vice president for patient accounting for Penn Medicine. He foresees a possible career in health-care administration or consulting.
But first, he’s taking on his senior year, complete with 6 a.m. soccer practices, history major requirements and a sports business course.
“To become a doctor is a long road; it’s a bright light at the end of it, but I don’t think it’s for me at this time,” Savino says. “But the part where I can help people, that part I like.”
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