Patient blood Management

Erica Wood
Transfusion Research Unit, Monash University
and
Department of Clinical Haematology,
Monash Medical Centre
 Change in focus:
Product safety to patient safety
• Historical focus: infectious safety of blood supply
• Recent focus: clinical governance and practice improvement
• Oversight (e.g. hospital transfusion committee)
• Policies, standards, guidelines
• Patient involvement and patient-centred care
• Haemovigilance, including human factors/process errors
• Patient blood management
 Patient blood management
“PBM is an evidence-based, multidisciplinary approach aimed at optimising the care of
patients who might need transfusion…
It puts the patient at the heart of decisions made around blood transfusion, promoting
appropriate use of blood and blood components and the timely use of alternatives
where available…
This includes application of appropriate indications, minimization of blood loss and
optimization of patient red cells. PBM can reduce allogeneic blood transfusions and
health-care costs, while ensuring that blood components are available for patients…
PBM represents an international initiative in best practice for transfusion medicine.”

www.isbtweb.org/working-parties/clinical-transfusion
 The “three pillars” of patient blood management
Optimise the patient‘s
own blood supplies
• Identify and treat anaemia and
Preoperative
its underlying causes
• Specialist evaluation if necessary
• Avoid elective surgery until
anaemia and bleeding risks
addressed
Intraoperative
• Time surgery for optimal blood
counts & lowest bleeding risks
• Blood conservation measures
• Medications to minimise
bleeding
Postoperative
• Stimulate blood cell production
by bone marrow
• Avoid drug interactions which
worsen anaemia
Adapted from Shander, Hofmann, Isbister
Minimise blood loss
• Identify/manage bleeding risks
• Minimise volume and number of
blood samples
• Plan the procedure
• Meticulous surgical technique
• Blood-sparing surgical and
anaesthetic procedures
• Autologous blood options
• Medications to minimise
bleeding
• Rapid re-warming / maintain
temperature
• Blood salvage measures
• Minimise volume/number of blood
samples
• Monitor/manage post-op
• Medications to minimise bleeding
Improve tolerance
of low blood counts
• Assess & optimise physiological
reserve and risk factors
• Compare estimated blood loss
with patient tolerance
• Formulate patient-specific
management plan
• Restrictive transfusion strategies
• Optimise cardiac output,
ventilation and oxygenation
• Blood conservation measures
• Restrictive transfusion strategies
•
Optimise tolerance of anaemia
• Maximise oxygen delivery
• Minimise oxygen consumption
• Blood conservation measures
• Avoid/treat infections promptly
• Restrictive transfusion strategies
PBM is more than…
...just avoidance of RBC transfusion
...perioperative setting / elective surgery

It is not “anti-transfusion” or withholding transfusion

• In many cases, results in fewer transfusions
• May need more, or different, support
• Timing and coordination to provide right product/s

Individualise therapy – a transfusion/PBM management plan for

• This patient
• This particular circumstance
• With the patient’s active participation
Practice patient-centred care
and
Improve clinical outcomes
Improve stewardship of resources
and
Reduce transfusion risks and costs
• Better blood stewardship
• Costs
• Blood components and products
• Hospital: lab, clinical, administration costs
• Transfusion complications:
• Risks to donors and patients
Need better evidence to guide transfusion practice
• Gaps in evidence including for many clinical
conditions, patient groups
• Implications for clinical trial designs and
interpretation
• Trials should include
• functional outcomes
• health-related QoL/patient-reported outcomes
• health economics analyses
Also supported by:
• Australian Red Cross Blood Service
• Canadian Blood Services
• International Collaboration for TM Guidelines
• International Society on Thrombosis and Haemostasis
• Italian National Institute of Health
• National Blood Authority,Australia
• Sanquin Blood Foundation
• Société Française d’Anesthésie et de Réanimation
International consensus conference on PBM 2018
PICO questions developed and analysed (GRADE) for 3 themes:
• Pre-operative anaemia
• Haemoglobin thresholds for RBC transfusion
• PBM education, implementation and maintenance

• Systematic reviews, evidence synthesis

• Expert panel (methodology, clinical) deliberations
• Audience participation
• Develop and publish proceedings and recommendations
International consensus conference on PBM 2018

Mueller et al
JAMA March 2019
PBM design and implementation
• What do we want to do?
• What needs to happen?
• Who will do it?
• When and how?
• Monitoring and evaluation
www.blood.gov.au
World Health Organization guidance
• Aide-Mémoire
• Promotion of PBM to MoH
• Collaborations and support
• Consultations and other meetings
• Clinical Use of Blood text
• Global Action Framework
RECOMMENDATIONS…

• Requirements for success:

• Management & government support – responsible, engaged, visible
• Professional leadership
• Strengthen clinical governance – HTC/equivalent
• Resources: “Someone who is employed to make things happen…”
Engagement and participation
• Policy-makers and funders
• Hospitals:
• Senior management
• All clinicians (doctors, nurses)
• Perfusion (cell salvage)
• Pharmacy (IV iron, medications)
• Quality/safety (audit, feedback)
• General practitioners
• Blood services
• Professional and educational groups
• PATIENTS
 National PBM framework in Australia
• National policy and oversight
• Government support (reduce risks, save money!)
• National standards and guidelines
• Hospital activities
• Professional societies
• Education
• Collaborations
• Blood service participation

www.blood.gov.au
National standards and accreditation

www.safetyandquality.gov.au
www.blood.gov.au
www.blood.gov.au
www.blood.gov.au
Transfusion practitioners: essential resources
• Staff education and training
• Adverse reaction and event investigation
• Auditing
• Blood utilisation review
• Reporting
• HTC resource and coordinator
• PBM coordinator
• Research
• …
Graduate Certificate in Transfusion Practice
• Transfusion core content
• Critical appraisal
• Change management
• Risk management
• Incident reporting
• Root cause analysis
• Case studies
• Workplace-based assignments
• Examination
 Monitoring and benchmarking: procedural issues

CM, TD
Monitoring and benchmarking: statewide audits

www.health.vic.gov.au/bloodmatters
www.transfusionguidelines.org
UK national comparative audit
 European resources

EC Directorate-General for Health and Food Safety Health, 2017

 Decision-support tools and feedback
Pittsburgh order management and feedback

No alert Hb ≤ 75, alert if >75g/L

Transfusion in OP setting Hb
<8.5

Image: Mark Yazer 2013

Image: Mark Yazer 2013
 Blood utilisation and feedback
• Bubble: individual surgeon; size/number: number of THA
• x axis: frequency of receiving ≥ 1RBC; y: mean no. RBC/patient

Yazer and Waters, Transfusion 2012

www.ontracprogram.com
Defined roles and responsibilities

Patients and carers:

• Partner with organisation and providers to make decisions for service
planning, developing models of care, measuring service and evaluating
systems of care
• Participate in making decisions about own care
• Need to know and exercise their healthcare rights & be engaged in care
and treatment decisions
 Involving patients
Questioning appropriateness of transfusion;
number of units
Assess clinical need
Asking about risks and benefits and (any) Inform patient/ consent Doctors
alternatives; giving consent
Checking: they have wristband (or other ID);
Order product
details on wristband correct; blood sample for Request form
compatibility testing correctly labelled; asked to Nurses/ Doctors/
state their name and DOB Blood sample Phlebotomist
Checking: they have wristband (or other ID);
details on wristband correct; they have been Crossmatching Laboratory staff
asked to state name and DOB; their details
checked against bag of blood Delivery Porters
Asking questions about what they can and
cannot do while receiving a transfusion; asking
Identity check
how they should feel during transfusion and
Administration of product
what to expect, e.g. how often their T and BP Nurses/ Doctors
should be taken
Recording
Making sure observations are taken
Monitoring how they feel Observation
Reporting to staff if they do not feel well or if Nurses/ Doctors/
Respond to adverse event/ reaction
they think there is a complication Laboratory staff
Modified from Davis RE, et al. Transfus Med Rev 2011;25(1):12–23.
 Are we making progress?
• Policies  RBC
• Standards/guidelines 
• Education/training 
• Wastage 
• Issues 
• Costs  PLTS

• Collaborations 
• Research funding 

www.blood.gov.au
 Key points
• PBM = established international best practice
• Team effort:
• Policy (government, hospital, department) and practice
• Accountability of hospital heads of departments, other senior staff = clinical champions
• Awareness/training of all clinical staff
• Transfusion committee
• Partner with other hospitals, Blood Service, DoH
• Use the tools we have – and develop new (better) ones
• Major part of hospital standards/accreditation
• Audit and feedback
• Hospital risk register
• Staff projects
• Wide access to other countries’ tools and reports
How can you get involved?
Be part of the multidisciplinary PBM team in your
blood centre, hospital, national/international society
• Transfusion or PBM committee
• Policy and procedure development/implementation
• Audit and feedback
• Inventory management
• Education
• Careers – transfusion/PBM practitioners
• Research, presentation, publication
ISBT working parties
Open to individual interested members of ISBT

Share experiences
Learn from others around the world
Contribute to projects and activities
www.isbtweb.org/working-parties
Challenges/actions: hospitals, blood services, policy makers

• Take a broad view of PBM

• Implementation in the setting of evidence gaps – not a
reason not to get started and/or keep going
• Support and conduct high-quality research and practice
with clinical, QoL, health resource outcomes
• Sustainable funding models
• Funding for training and TP, medical, scientist roles
• Partner with patients, professionals
• International cooperation, harmonisation, sharing
• Opportunities for new roles/services/research
• Top down and bottom up: “Community of practice”
Acknowledgements
• Monash Health team
• Christine Michael, Terri Dunstan
• Kylie Rushford
• Clinical staff, transfusion registrars
• Blood Matters and BloodSafe
• National Blood Authority
• ANZSBT
• ISBT, WHO, ICC-PBM