Jump to content
simret

Patient Blood Management

Recommended Posts

Does any of you have a Patient Blood Management program, PBM at your institution? If you do, do you have a dashboard that tracks transfusion, utilization trends (by hemoglobin), wastage by service lines?

Thank you!

Share this post


Link to post
Share on other sites


Patient Blood Management is a comprehensive, multi-modal approach to reduce/prevent anemia prevalence and reduce transfusions to only those that are life saving or absolutely essential.  While the AABB has some materials and interest, they are relatively less likely to explain to you that the primary rationale is that anemia and transfusions are mostly harmful to patients in current practices.  The pre-eminent organization in the USA in this matter is SABM.  The founders of PBM include anesthesiologists such as Aryeh Shander at Englewood Hospital and Tim Hannon at St. Vincents, who saw that (1) Jehovah's Witnesses who refused transfusions actually had better outcomes than similar transfused patients and (2) transfused patients had dose dependent increases in nosocomial infection, thrombosis, multi-organ failure and mortality in the literature and their own practices.  In other words, less is better.  None is best when possible.  Needless to say, the initial reaction in the blood banking and transfusion medicine community was lukewarm at best when these ideas were first put forward a couple of decades ago.  But preventing anemia by doing fewer lab tests, and less frequent lab tests has begun to catch on in some places.  See:

https://www.sabm.org/patient-blood-management-programs/

Good place to get some initial education and join if of interest.

A typical PBM program will include a part-time medical director (often an anesthesiologist, intensivist or hematologist, but also surgeons, transfusion medicine physicians, and other specialties) and one or more full-time nurses or medical technologists who focus on educating practitioners about current practices.  You need a clinical champion at the bedside who other practitioners respect and will listen to. Changing practices is arduous and sometimes rather unpleasant work.  When Bernard Fisher showed that the Halstead radical mastectomy for breast cancer was harmful to patients, the initial reaction was anger, disbelief and pushback. So it sometimes is with PBM.  Physicians change their practices slowly or not at all.  At our institution, PBM is heavily weighted towards collaborations between specialties, including, for example,  an anemia management program prior to cardiac surgery, advocating restrictive transfusion practices where there is evidence (and there is tons of evidence that liberal practices are lethal at worst, wasteful at best).  Happy to answer further questions.

Share this post


Link to post
Share on other sites

And to answer the initial question, yes, one monitors such features as service line specific use of blood transfusions, correcting for case mix and hospital days. Examples of metrics are red cells per admission or platelets per hospital day.  Monitored quarterly or semi-annually. Change is slow so there is no need to monitor things on a daily, weekly or monthly basis in most cases.  Can verify the improvement in clinical outcomes by metrics such as complication rates (central line infections, UTIs, etc.).

Share this post


Link to post
Share on other sites

Thank you Neil. I was going to say that. We have all in place.What I am looking for is a dashboard that someone is using so I can learn from their spread sheet.

Share this post


Link to post
Share on other sites

We are in the early stages. We monitor Hgb at time of transfusion and have a policy with suggested transfusion triggers. Our blood administration order sets reflect those triggers and require a reason for transfusion. The medical staff transfusing the majority of our patients are hospitalists, which does make a difference. We have also initiated minimum blood draws for all inpatient lab work and police that pretty aggressively. We are a small hospital, but this has made a sizeable impact on our transfusion volumes.

I want to start looking at transfusion rates, readmission rates and diagnosis...if we can figure out how to pry that info out of Epic.

Share this post


Link to post
Share on other sites

We recently went live with SafeTrace TX and we are going use the analytics module with that for monitoring. Haven't got it up yet. It is fairly basic but hopefully will give us real time information.

Share this post


Link to post
Share on other sites

I am retired but our corporation had set up a program and dashboard before I retired.   We were using Cerner.  We lowered the acceptable HGB level for transfusion in a non- bleeding patient to 7.  We started physician blood ordering in computer and the physician had to select a reason to transfuse (as above).   They could only order one unit at a time as they were required to do HGBs between units.  At first, we pulled the dashboard and met monthly but, as we became more compliant, we met less often   However, it took daily monitoring to become more compliant. Blood bank techs checked HGBs on all transfuse orders.  We issued blood for fall outs (unless HGB was really high where we called Medical Director), but sent all outlying  patient and doctor info to QA for chart review and follow-up on a daily basis. We also had hospitalists, but some doctors were having nurses enter the transfuse orders, so we started monitoring who was entering the transfuse orders.  It was a lot of work for the techs in Blood Bank and there should be someone who is not working a bench available to control this program in-house and communicate with the nurses and physicians.  For example, our corporation regarded order entry to be under the nursing educator and the Blood Bank had no input into it and was not formally trained, but guess what department the physicians called when they had no idea how to order blood.  That made sense because the nursing educator was usually not available for phone calls and someone was always in the lab.  However, the result of the monitoring wasgood and  our transfusions decreased by 40%. Our numbers looked great on the dashboard after a year or so. 

Share this post


Link to post
Share on other sites

Thanks for the Info Neil.  I appreciate you taking the time for the explanation.  I'm happy to see things moving forward even if I'm no longer actively involved.  It sounds like something I could get behind.

Share this post


Link to post
Share on other sites

As for pediatrics, we have an attached children's hospital, Golisano Children's Hospital of the University of Rochester.  We have a blood management program but it has proven difficult to find evidence based transfusion criteria for the main blood components, red cells, platelets and plasma.  There has been some reluctance to change practice lacking evidence, which is understandable.

Pediatric practice, with perhaps the exception of anesthesiology and critical care, seems based upon older understandings of transfusion that it was "very effective and not very risky."  The reverse is almost certainly true in most clinical settings,  other than life threatening bleeding and/or anemia.  Therapeutic minimalism, rather than maximalism is called for, in my view.

 Witness the use of 20-30 ml/kg of red cells or whole blood in the recent NEJM trial in Africa.  These doses would be fatal to a substantial number of adult patients.  Thus changing practice in pediatrics should probably focus initially on appropriate dosing to start with.  Our typical adult doses for red cells are in the range of 3-5 ml/kg and for platelets and plasma not much more, and certainly not more than 10 ml/kg.  Since there is a dose dependent increase in nosocomial infection, thrombosis, inflation and mortality with red cell transfusion that is in part causal, these practices are likely not in the patient's best interest, despite representing "state of the art 1985 expert opinion."  There is not a shred of evidence that WHO's guideline of 20 ml/kg is effective and safe, to my knowledge.

 The general guidance of hemoglobin 7 and hematocrit of 21 as boundaries for numbers (as opposed to clinically) driven red cell transfusion has reasonably strong evidence based (randomized trials) in children.  Platelet transfusion and plasma transfusion have minimal evidence base, but the prophylactic threshold of 10,000/µl for non-bleeding children with hematologic malignancies seems reasonably evidence based.  There is essentially no evidence to guide plasma transfusion, so my general approach is "don't do it" unless there is life threatening bleeding not treatable by anything other than massive transfusion.

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

  • Advertisement

  • Site Suggestions

    Site Feedback & Suggestions

×
×
  • Create New...

Important Information

We have placed cookies on your device to help make this website better. You can adjust your cookie settings, otherwise we'll assume you're okay to continue.