Perceptions of the Conditions and Barriers in Implementing the Patient Blood Management Standard by Anesthesiologists and Surgeons

Patient Blood Management (PBM) as a multidisciplinary practice and a standard of care for the anemic surgical patient is playing an increasingly important role in reducing transfusions and optimizing both clinical outcomes and costs. The success of PBM implementation depends on staff awareness and involvement in this approach. The main objective of our study was to explore physicians' perceptions of the conditions for implementing PBM in hospitals and the main obstacles they face in detecting and treating anemic patients undergoing elective surgery. This cross-sectional descriptive study includes 113 Romanian health units, representing 23% of health units with surgical wards nationwide. A 12-item questionnaire was distributed to the participants in electronic format. A total of 413 questionnaires representing the perceptions of 347 surgeons and 66 anesthesia and intensive-care specialists were analyzed. Although a lack of human resources was indicated by 23.70% of respondents as the main reason for not adhering the guidelines, the receptiveness of medical staff to implementing the PBM standard was almost 90%. In order to increase adherence to the standard, additional involvement of anesthesia and intensive-care physicians would be necessary from the perception of 35.70% of the responders: 23.60% of surgeons and 18.40% of hematologists.

E-learning/online education in transfusion medicine: A cross-sectional international survey

OBJECTIVES

This survey aims to assess the scope of transfusion e-learning courses in blood establishments and transfusion services internationally.

BACKGROUND

E-learning/online education is increasingly used in the education of medical professionals. There is limited published data on the use of e-learning for transfusion medicine.

MATERIAL AND METHODS

An International survey was designed and distributed to all members of the International Society of Blood Transfusion to assess utilisation of e-learning in their institutions. Descriptive statistics were used to summarise the results.

RESULTS

A total of 177 respondents participated, 68 of which had e-learning modules in their institutions. Approximately two-thirds of the courses were developed in-house (66%), and 63% are available to learners from outside the host institutions. In one-third of institutions, these courses were established during the COVID-19 pandemic, while 15% had used e-learning courses for more than 10 years. The courses target different audiences and topics ranging from blood donation to hemovigilance. The most common audiences were physicians (71%), laboratory scientists/technologists (69%) and transfusion practitioners (63%). Formal assessment of learning outcomes is used in 70% of the programs.

CONCLUSIONS

The survey demonstrates the widespread use of e-learning courses in transfusion education, with a substantial proportion being developed during the COVID-19 pandemic.

How do we obtain and maintain patient blood management certification?

BACKGROUND

The creation of a patient blood management (PBM) certification program by The Joint Commission (TJC) and Association for the Advancement of Blood and Biotherapies (AABB) provides validation of an existing PBM program.

MATERIALS AND METHODS

A team of subject matter experts in PBM formed a working group to develop a structured approach to guide PBM programs through the PBM certification. Program challenges and metrics were reviewed.

RESULTS

Initial steps to establishing PBM certification include a multidisciplinary working group and hospital administration buy-in. Development of policies and procedures individualized to the facility will standardize practice. An institutional transfusion committee can provide PBM oversight including enforcing compliance. Using resources such as TJC and AABB standards and tools including electronic medical records (EMR) can track and trend hospital PBM performance and identify improvement opportunities. A gap analysis tool helps implementation. Challenges might include maintaining a PBM program during a merger, slow responsiveness of information systems (IS) to requests, PBM education for both the Transfusion Safety Officer (TSO) and hospital staff with constant turnover. Available metrics from one hospital system showed good compliance with transfusion thresholds (average all products: 97.9%, 2019, 2020). In 2020, through educational efforts the cost savings were $124,856.70 compared to 2019. Regarding single unit transfusion of RBCs, this was 62.25% (2019), 63.75% (2020), 72.00% (2021), and surpassed the target goal of 60%.

CONCLUSIONS

Obtaining PBM certification highlights the success of an institution's PBM program. Facilities that have achieved PBM certification have seen significant reductions in transfusions and considerable cost savings.

Focused educational intervention improves intern knowledge of perioperative patient blood management principles

A perioperative patient blood management (PBM) educational intervention was implemented for first year postgraduate doctors (interns) at the Royal Brisbane and Women’s Hospital (RBWH) following identification of a perioperative PBM training requirement. This quality improvement activity evaluated the effectiveness of this educational intervention in improving intern knowledge of perioperative PBM principles.

A 15-question perioperative PBM focused multiple choice questionnaire developed from information attained from comprehensive, evidence and consensus-based guidelines regarding PBM practice was distributed to interns immediately before a compulsory perioperative PBM educational intervention and then again 5 weeks later. The perioperative PBM educational intervention was delivered every 10 weeks (five interventions in total) to a different group of interns each time. Statistical analysis determined significance between mean questionnaire score before and after the intervention.

The mean pre-intervention score for correctly answered questions was 7/15 (SD 2.73) and mean post-intervention score was 9/15 (SD 2.99) (p=0.02). Categorisation of questions into core domains of perioperative PBM demonstrated intern scores for correctly answered questions improved in all domains following the educational intervention.

Perioperative PBM education delivered through a dedicated intervention aimed to improve knowledge is associated with objective evidence of educational benefits for interns at RBWH. It is an effective strategy to enact PBM governance and bestow clinical guideline knowledge. This is important given the global health sector’s challenge to improve patient outcomes despite increasingly restricted funding and pressure on doctors to devote more time to service and less to teaching.

Reticulocyte and Erythrocyte Hemoglobin Parameters for Iron Deficiency and Anemia Diagnostics in Patient Blood Management. A Narrative Review

Anemia, iron deficiency and other hematinic deficiencies are a major cause of perioperative transfusion needs and are associated with increased morbidity and mortality. Anemia can be caused either by decreased production of hemoglobin or red blood cells or by increased consumption and blood loss. Decreased production can involve anything from erythropoietin or vitamin B12 insufficiency to absolute or functional lack of iron. Thus, to achieve the goal of patient blood management, anemia must be addressed by addressing its causes. The traditional parameters to diagnose anemia, despite offering elaborate options, are not ideally suited to giving a simple overview of the causes of anemia, e.g., iron status for erythropoiesis, especially during the acute phase of inflammation, acute blood loss or iron deficiency. Reticulocyte hemoglobin can thus help to uncover the cause of the anemia and to identify the main factors inhibiting erythropoiesis. Regardless of the cause of anemia, reticulocyte hemoglobin can also quickly track the success of therapy and, together with the regular full blood count it is measured alongside, help in clearing the patient for surgery.

Physician's Subjective Increase in Awareness towards Perioperative Anaemia, Patient's Blood Resource, and Transfusion after the Implementation of Patient Blood Management: A Nationwide Multicentre Survey

INTRODUCTION

Patient blood management (PBM) is a clinical and multidisciplinary, 3-pillar concept. The aim of this study was to detect the subjective increase in physician's awareness towards perioperative anaemia, patient's blood resource, and transfusion after the implementation of PBM in German hospitals.

MATERIAL AND METHODS

A survey among 56 hospitals from the German PBM Network group was conducted from October 27 to December 19, 2020. An electronic questionnaire with 28 questions was sent to the local PBM coordinator for the distribution at the hospital level. For assessment of the physician's subjective increase in awareness, numeric rating scales (0 [no increase] - 10 [maximum increase]) were used.

RESULTS

In total, 404 clinicians from 56 hospitals completed the survey. The mean (±standard deviation) time of an existing PBM program was 4.8 (±2.2) years. The physician's subjective increase in awareness towards anaemia (8.2 [±2.0]), patient's blood resource (7.6 [±2.5]), and transfusion (8.1 [±1.9]) was the highest in physicians from hospitals with ≥21 implemented PBM measures. In addition, a subjective increase in awareness towards anaemia (6.6 [±3.3]), patient's blood resource (7.0 [±3.3]), and transfusion (6.6 [±3.4]) was the highest in physicians with daily PBM contact.

CONCLUSION

Results suggest that physician's awareness towards perioperative anaemia, patient's blood resource, and transfusion has increased, depending on the hospital's number of implemented PBM measures and physician's PBM contact in everyday clinical practice.

Non-invasive haemoglobin measurement as an index test to detect pre-operative anaemia in elective surgery patients - a prospective study

Non-invasive haemoglobin measurement using absolute values lacks the precision to be the sole basis for the treatment of pre-operative anaemia. However, it can possibly serve as a screening test, indexing 'anaemia' with high sensitivity when values remain under prespecified cut-off values. Based on previous data, non-invasive haemoglobin cut-off values (146 g.l^-1 for women and 152 g.l^-1 for men) detect true anaemia with 99% sensitivity. An index test with these prespecified cut-off values was verified by prospective measurement of non-invasive and invasive haemoglobin pre-operatively in elective surgical patients. In 809 patients, this showed an estimated sensitivity (95%CI) of 98.9% (94.1-99.9%) in women and 96.4% (91.0-99.0%) in men. This saved invasive blood tests in 9% of female and 28% of male patients. In female patients, a lower non-invasive haemoglobin cut-off value (138 g.l^-1 ) would save 28% of invasive blood tests with a sensitivity of 95%. The target 99% sensitivity would be reached by non-invasive haemoglobin cut-off values of 152 g.l^-1 in female and 162 g.l^-1 in male patients, saving 3% and 9% of invasive blood tests, respectively. Bias and limits of agreement between non-invasive and laboratory haemoglobin levels were 2 and - 25 to 28 g.l^-1 , respectively. Patient and measurement characteristics did not influence the agreement between non-invasive and laboratory haemoglobin levels. Although sensitivity was very high, the index test using prespecified cut-off values just failed to reach the target sensitivity to detect true anaemia. Nevertheless, with respect to blood-sparing effects, the use of the index test in men may be clinically useful, while an index test with a lower cut-off (132 g.l^-1 ) could be more clinically appropriate in women.

Patient Blood Management for primary hip and knee replacement. A survey among POWER.2 study researchers

BACKGROUND

Implementation of Patient Blood Management programs remain variable in Europe, and even in centres with well-established PBM programs variability exists in transfusion practices.

OBJECTIVES AND METHODS

We conducted a survey in order to assess current practice in perioperative Patient Blood Management in patients undergoing total hip and knee replacement among researchers involved in POWER.2 Study in Spain (an observational prospective study evaluating enhanced recovery pathways in orthopaedic surgery).

RESULTS

A total of 322 responses were obtained (37.8%). Half of responders check Haemoglobin levels in patients at least 4 weeks before surgery; 35% treat all anaemic patients, although 99.7% consider detection and treatment of preoperative anaemia could influence the postoperative outcomes. Lack of infrastructure (76%) and lack of time (51%) are the main stated reasons not to treat anaemic patients. Iron status is routinely checked by 19% before surgery, and 36% evaluate it solely in the anaemic patient. Hb<9.9 g/dl is the threshold to delay surgery for 61% of clinicians, and 22% would consider transfusing preoperatively clinically stable patients without active bleeding. The threshold to transfuse patients without cardiovascular disease is 8 g/dl for 43%, and 7 g/dl for 34% of the responders; 75% of clinicians consider they use "restrictive thresholds", and 90% follow the single unit transfusion policy.

CONCLUSIONS

The results of our survey show variability in clinical practice in Patient Blood Management in major orthopaedic surgery, despite being the surgery with the greatest tradition in these programs.

The knowledge of transfusion and related practices among doctors at Universitas Academic Complex, Bloemfontein, South Africa

OBJECTIVES

To determine the knowledge of transfusion and related practices among doctors working at Universitas Academic Complex (UAC), Bloemfontein, South Africa. We aimed to describe training history, transfusion knowledge and reported haemovigilance reporting habits.

METHODS

A cross-sectional descriptive study was performed using an anonymous questionnaire distributed at departmental meetings. The study population included doctors working in adult disciplines that frequently transfuse blood from the UAC. Ethics approval was obtained from the University of the Free State, Health Sciences Research Ethics Committee. Permission to conduct the study was obtained from the Free State Department of Health. Results were summarised by frequencies and percentages.

RESULTS

Questionnaires of 152 respondents were analysed. Most of the respondents (31.5 %) were registrars and medical officers with less than 5 years' experience, followed by specialists (19.9 %). Although prescribing habits varied, 43.3 % of respondents prescribe blood at least weekly. Almost a third (29.9 %) of respondents had never received any transfusion training. A haemoglobin-based transfusion trigger is used by 76.2 % of respondents. Almost 80 % of respondents reported using a single unit of blood followed by clinical reassessment before ordering a second unit. Cost of laboratory investigations and lack of human resources were the main reported obstacles to adequately investigating anaemia. Forty percent of respondents involved with the care of patients who suffered a transfusion related adverse event reported the event to the blood service.

CONCLUSION

At the (UAC), where blood is frequently transfused, we note infrequent training, poor knowledge of some basic transfusion principles and poor haemovigilance reporting.

Programmes for the management of preoperative anaemia: audit in ten European hospitals within the PaBloE (Patient Blood Management in Europe) Working Group

BACKGROUND AND OBJECTIVES

Preoperative anaemia is an independent risk factor for a higher morbidity and mortality, a longer hospitalization and increased perioperative transfusion rates. Managing preoperative anaemia is the first of three pillars of Patient Blood Management (PBM), a multidisciplinary concept to improve patient safety. While various studies provide medical information on (successful) anaemia treatment pathways, knowledge of organizational details of diagnosis and management of preoperative anaemia across Europe is scarce.

MATERIALS AND METHODS

To gain information on various aspects of preoperative anaemia management including organization, financing, diagnostics and treatment, we conducted a survey (74 questions) in ten hospitals from seven European nations within the PaBloE (Patient Blood Management in Europe) working group covering the year 2016.

RESULTS

Organization and activity in the field of preoperative anaemia management were heterogeneous in the participating hospitals. Almost all hospitals had pathways for managing preoperative anaemia in place, however, only two nations had national guidelines. In six of the ten participating hospitals, preoperative anaemia management was organized by anaesthetists. Diagnostics and treatment focused on iron deficiency anaemia which, in most hospitals, was corrected with intravenous iron.

CONCLUSION

Implementation and approaches of preoperative anaemia management vary across Europe with a primary focus on treating iron deficiency anaemia. Findings of this survey motivated the hospitals involved to critically evaluate their practice and may also help other hospitals interested in PBM to develop action plans for diagnosis and management of preoperative anaemia.

Patient blood management programs: how to spread the word?

Red blood cell (RBC) transfusions save lives and improve health; however, unnecessary transfusion practice exposes patients to immediate and long-term negative consequences. Indirect consequences of unnecessary transfusions are the reduced availability of RBC units for patients who are in need. Accumulating evidence shows that restricting RBC transfusions improves outcomes and current guidelines suggest limiting RBC transfusion to the minimum number of units required to relieve symptoms of anemia or to return the patient to a safe hemoglobin range (7-8 g/dl in stable, non-cardiac inpatients). Still, studies show that there is over-utilization of RBC transfusion, partly due to low level of knowledge of physicians regarding restrictive RBC transfusion policy across a broad range of professions and specialties. Patient blood management (PBM) programs have been developed to promote clear hospital transfusion guidelines, strive for optimization of patient hemoglobin and iron stores and, most importantly, improve education regarding restrictive RBC policy. Understanding what and where the gaps of knowledge are, as was done in the study by Dr. Koren and his colleagues, is an important step for developing effective PBM programs.