Patient Blood Management: A Professional Guide

SABM’s definition of Patient Blood Management (PBM) The timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis and minimize blood loss in an effort to improve patient outcome.

Let’s look at the evidence

Transfusion Risks Transfusion related immunomodulation (TRIM) Known, and emerging, infections transmitted by blood (bacteria, viruses, unusual things like malaria) Allergic and febrile (fever & chills) reactions Antibody reactions (when the immune system is activated and destroys transfused cells or attacks our own body) Blood transfusion is a liquid organ transplant Human error – transfusing the wrong blood or transfusing the wrong person

Transfusions are Risky Blood transfusions increases the risk for: –Pneumonia –ICU stay –Ventilator Time –Hospital acquired infections –Mortality Hannon TJ. Pharmacotherapy. 2007;27(10):

Transfusions are Risky

CONCLUSIONS: – A restrictive strategy (<7 g/dl) of red-cell transfusion is at least as effective as and possibly superior to a liberal transfusion strategy (<10g/dl) Herbert et al. N Engl J Med 1999;340:409-17

Villanueva et al.N Engl J Med 2013;368: patients with upper GI bleeding Randomized to 2 transfusion strategies: Liberal (9 g/dl) Restrictive (7 g/dl) - Increased Mortality -Increased Re-bleeding -Increased Portal Pressure

Appropriateness of Transfusions The international consensus conference on transfusion outcomes The international consensus conference on transfusion outcomes. Transfus Med Rev Jul;25(3) (1)

The Rising Cost of Blood Health care costs are increasing faster than any other sector of our economy; Americans expect the very highest standard of care As new threats to the blood supply are discovered, more and more tests are required on every unit of blood Enhanced quality control in blood collection ensures the safest possible products, but at increased cost

Cost Analysis of Blood Transfusions

Hospital Economics Blood costs include more than just the cost of collecting products: – Hospitals pay to test patients before transfusion, store blood and dispense it from the blood bank, and give it to patients, with many safety checks at every step – Side effects, if they occur, add costs for treatment and longer hospital stays Avoiding unneeded transfusions saves all these costs and prevents unnecessary side effects

Cost Analysis of Blood Transfusions Data from the Cost of Blood Consensus Conference (COBCON 1), confirmed…”that the cost of blood has been seriously underestimated”. Shander A Transfusion Apr;50(4):

Overused Treatments The National Summit on Overuse on July 8, 2013 identified 5 overused treatments that can harm patient safety and quality. – Antibiotic use for the common cold – Blood transfusions – Ear tubes for children – Early scheduled births – Heart vessel stents The goal of the summit were to reduce risks to patients, improve care and discourage waste of patient and hospital resources.

Helping Patients Become Educated Consumers

Principles of Patient Blood Management Modifiable Risk Reduction

Patient Blood Management Matrix

Patient Blood Management Clinical Strategies

Strategies for Reducing Phlebotomy Blood Loss Eliminate “extra tubes” or rainbow draws Eliminate over draws Individual nursing/phlebotomy education Use testing material with low sample volume Increase point of care testing Reduce unnecessary testing and standing orders Selective use of microtainers

Patient Blood Management Clinical Strategies

Strategy for Early Detection of Anemia Patients who are having an elective surgical procedure with a risk of blood loss are identified and assessed four weeks prior to surgery. – allows sufficient time to diagnose and manage anemia to avoid risk of transfusion Recognition, diagnosis, and initial treatment of anemia as early as possible for a hospitalized patient may help avoid the need for transfusion during that hospital admission as well as after discharge or during a future hospital admission.

Patient Blood Management Clinical Strategies

Strategy to Integrate Patient Values and Autonomy Hospital policy supports and respects the right of competent adult patients to decline blood transfusion. The policy addresses the rights of patients who are minors. The document declining transfusion clearly clinical strategies or alternatives to allogeneic transfusion are acceptable to the patient. – Alternatives include, but are not limited to, autologous transfusion modalities, Procrit, iron, B12, and folic acid for red cell production, factor concentrates, and blood fractions.

Patient Blood Management Clinical Strategies

Strategies to Accurately Assess True Cause of Bleeding Dysfunction Point-of-care (POC) testing for rapid testing of hemostatic function can provide fast and accurate identification of coagulation abnormalities. Use of Platelet function testing Use of Thromboelastometry and thromboelastography measure time and dynamics of clot formation and stability of clots over time.

Implementing PBM Strategies Improves Patient Outcomes The appropriate use of these PBM strategies as part of an evidence-based, multidisciplinary, patient-focused program which addresses modifiable risk factors has the potential to reduce transfusions and improve patient outcomes. PBM aspires to improve patient outcomes by actively managing the patient's own blood and hematopoietic system to reduce the risk for receiving allogeneic blood products.

Patient Blood Management Programs: A Team Approach Pre- Operative Internist Primary Care Physician Surgeon Intra-Operative Anesthesiologist Surgeon Perfusion (CV) Specialists Nursing Post-Operative Surgeon Intensivist Hospitalist Nursing

Patient Blood Management Programs: Administrative and Clinical Essentials Physician leadership and expertise Core patient blood management team Hospital-wide blood conservation policy and protocols Continuing education for physicians and nursing Community and patient education

Patient Blood Management Programs: Administrative and Clinical Integration PBM Programs are more successful when everyone works together:  Administration  Physicians  Nurses  Patients

Patient Blood Management Realities Blood management options should be a part of making good health care choices Building up blood counts before surgery may help patients to avoid a blood transfusion Sometimes, several blood management strategies can be used at the same time to avoid a blood transfusion No single approach (drug, device, technique) is effective for every patient

Patient Blood Management Programs: Why Hospitals Embrace a Blood Conservation Culture? Responsive to public concern over blood safety Sustains the blood supply Improved technology, devices, pharmaceuticals Imperative to reducing hospital costs Increases hospital through-put (fast-track) Improves physician skills Improves patient care Gives recognition as a “Best Practices” hospital Enhances need to be stay on the cutting edge Cardiothoracic and Vascular Anesthesia, Vol 18, No 4 (August Supplement), 2004: pp 15S-17S+

Patient Blood Management Programs A hospital-based philosophy that every drop of blood counts