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Linström M, Musekwa E, Nell EM, de Waard L, Chapanduka Z. The influence of hematological profiles on the transfusion management and mortality risk of mothers presenting to the obstetric unit of a South African tertiary medical facility. Transfusion 2024; 64:986-997. [PMID: 38661229 DOI: 10.1111/trf.17849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/09/2024] [Accepted: 04/10/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Laboratory results are frequently abnormal in pregnant mothers. Abnormalities usually relate to pregnancy or associated complications. Hematological abnormalities and age in pregnancy may increase the likelihood for transfusion and mortality. STUDY DESIGN AND METHODS Hematological profiles and transfusion history of pregnant mothers presenting to a tertiary hospital, were evaluated over 2 years. Age, anemia, leukocytosis and thrombocytopenia were assessed for transfusion likelihood. Iron deficiency and coagulation were assessed in transfused patients. Anemia, leukocytosis, thrombocytopenia, human immunodeficiency virus (HIV) and transfusion were assessed for mortality likelihood. RESULTS There were 12,889 pregnant mothers included. Mothers <19-years-old had the highest prevalence of anemia (31.5%) and proportion of transfusions (19%). The transfusion likelihood was increased in mothers with anemia (odds ratios [OR] = 6.41; confidence intervals at 95% [95% CI] 5.46-7.71), leukocytosis (OR = 2.35; 95% CI 2.00-2.76) or thrombocytopenia (OR = 2.71; 95% CI 2.21-3.33). Mothers with prolonged prothrombin times received twice as many blood products as their normal counterparts (p = .03) and those with iron deficiency anemia five times more blood products (p < .001). Increased likelihood for mortality was seen in patients with anemia (OR = 4.15, 95% CI 2.03-8.49), leukocytosis (OR = 2.68; 95% CI 1.19-6.04) and those receiving blood transfusion (OR = 3.6, 95% CI 1.75-7.47). DISCUSSION Adolescence, anemia, leukocytosis and thrombocytopenia expose mothers to a high risk for transfusion and/or mortality. These risk factors should promptly trigger management and referral of patients. Presenting hematological profiles are strong predictors of maternal outcome and transfusion risk.
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Affiliation(s)
- Michael Linström
- Division of Hematological Pathology, Department of Pathology, Stellenbosch University, Cape Town, South Africa
- Division of Hematopathology, National Health Laboratory Services, Tygerberg Hospital, Cape Town, South Africa
| | - Ernest Musekwa
- Division of Hematological Pathology, Department of Pathology, Stellenbosch University, Cape Town, South Africa
- Division of Hematopathology, National Health Laboratory Services, Tygerberg Hospital, Cape Town, South Africa
| | - Erica-Mari Nell
- Division of Hematological Pathology, Department of Pathology, Stellenbosch University, Cape Town, South Africa
- Division of Hematopathology, National Health Laboratory Services, Tygerberg Hospital, Cape Town, South Africa
| | - Liesl de Waard
- Department of Obstetrics and Gynecology, Stellenbosch University, Cape Town, South Africa
| | - Zivanai Chapanduka
- Division of Hematological Pathology, Department of Pathology, Stellenbosch University, Cape Town, South Africa
- Division of Hematopathology, National Health Laboratory Services, Tygerberg Hospital, Cape Town, South Africa
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Macedo MCMDA, Biagini S, Montano-Pedroso JC, Ribeiro G, Junior JFCM, Rizzo SRCP, Rabello G, Junior DML. Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Implementation of Patient Blood Management (PBM). Hematol Transfus Cell Ther 2024; 46 Suppl 1:S8-S11. [PMID: 38548507 PMCID: PMC11069055 DOI: 10.1016/j.htct.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/18/2024] [Indexed: 05/07/2024] Open
Abstract
Patient Blood Management (PBM) is a holistic approach to managing blood as a resource of each patient; it is a multimodal strategy that is implemented using a set of techniques that can be applied in individual cases. In fact, the overall result of the implementation of PBM cannot be fully appreciated or explained by simply summing up the effects of the individual strategies and techniques used, since they can only produce the expected ideal result if combined. Implementing a PBM program in healthcare offers several benefits including improved patient safety, better outcomes, cost savings, conservation of resources, evidence-based practice, transfusion alternatives, improved quality of care, compliance with accreditation standards, patient-centered care, and professional education and training.
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Affiliation(s)
| | - Silvana Biagini
- Hospital Guilherme Álvaro e Complexo Hospitalar dos Estivadores, Santos, SP, Brazil
| | - Juan Carlos Montano-Pedroso
- Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil; Instituto de Assistência Médica do Servidor Público Estadual (Iamspe), São Paulo, SP, Brazil
| | - Glaciano Ribeiro
- Hospital das Clínicas da Universidade Federal de Minas Gerais (HC UFMG), Belo Horizonte, MG, Brazil; Grupo HHEMO, São Paulo, SP, Brazil
| | | | | | - Guilherme Rabello
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Incor - HCFMUSP), São Paulo, SP, Brazil.
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De Santis GC, Costa L, Brunetta DM, Magnus MM, Benites BD, Rodrigues RDR, Alves SDOC, Rizzo SRCP, Rabello G, Langhi DM. Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Anemia tolerance. Hematol Transfus Cell Ther 2024; 46 Suppl 1:S67-S71. [PMID: 38604928 PMCID: PMC11069063 DOI: 10.1016/j.htct.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 02/18/2024] [Indexed: 04/13/2024] Open
Abstract
Anemia is a pathological condition in which the hemoglobin and red blood cell mass decrease; it is mainly defined by the concentration of hemoglobin in the blood. The World Health Organization guidelines establish specific values to define anemia in different population groups. Early detection of anemia can also be a valuable indicator of underlying medical conditions. Clinical studies have explored the relationship between perioperative anemia and morbidity, highlighting the need for more judicious therapeutic strategies, such as the use of Patient Blood Management, which aims to prevent and treat anemia in a personalized and effective way. Patient Blood Management emerges as a promising approach to dealing with anemia, recognizing that its correction through transfusion always carries risks and that personalized prevention and treatment can offer better outcomes for patients.
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Affiliation(s)
- Gil Cunha De Santis
- Hemocentro de Ribeirão Preto, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Ribeirão Preto, SP, Brazil
| | - Lorena Costa
- Universidade de Pernambuco (UPE), Recife, PE, Brazil
| | - Denise Menezes Brunetta
- Faculdade de Medicina da Universidade Federal do Ceará (FM UFC), Fortaleza, CE, Brazil; Centro de Hematologia e Hemoterapia do Ceará (HEMOCE), Fortaleza, CE, Brazil; Complexo Hospitalar da Universidade Federal do Ceará (EBSERH UFC), Fortaleza, CE, Brazil
| | - Mariana Munari Magnus
- Centro de Hematologia e Hemoterapia da Universidade Estadual de Campinas (Hemocentro UNICAMP), Campinas, SP, Brazil
| | - Bruno Deltreggia Benites
- Centro de Hematologia e Hemoterapia da Universidade Estadual de Campinas (Hemocentro UNICAMP), Campinas, SP, Brazil
| | - Roseny Dos Reis Rodrigues
- Hospital Israelita Albert Einstein são Paulo, São Paulo, SP, Brazil; Faculdade de Medicina da Universidade de São Paulo (FM USP), São Paulo, SP, Brazil
| | | | | | - Guilherme Rabello
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (Incor - HCFMUSP), São Paulo, SP, Brazil.
| | - Dante Mario Langhi
- Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM UNIFESP), São Paulo, SP, Brazil
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Wise R, Hood K, Bishop D, Sharp G, Rodseth R. Analysis of a 5-year, evidenced-based, rational blood utilisation project in a South African regional hospital. Transfus Med 2024; 34:154-164. [PMID: 38152867 DOI: 10.1111/tme.13025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/26/2023] [Accepted: 12/09/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Blood products are a lifesaving but limited resource, particularly in resource-limited settings. Evidence-based transfusion criteria tailored to local hospitals have shown great promise in reducing costs, minimising shortages, and ameliorating the morbidity and mortality associated with liberal blood product usage. We implemented the "Saving Blood, Saving Lives" project to: promote responsible blood product use and reduce blood product ordering inefficiencies and expenditure. METHODS A comprehensive change management programme, preceded by 3 months of clinical department consultation and training, was implemented. A new evidence-based protocol for blood product utilisation was developed, together with an accountability form. This form was used in monthly audit meetings to refine policies, identify new problems, improve communication, and to drive hospital staff accountability and training. The primary measure of the programme's success was the change in the number of red cell concentrate units ordered. RESULTS Project implementation required minimal time and no additional budget or staff. Annual red cell concentrate usage reduced from 7211 units in year one to 4077 units in year 5 (p < 0.001). Similar reductions were seen in freeze-dried plasma and platelet usage, as well as administrative costs. Total project saving, adjusted to baseline admission numbers, amounted to over R46 million ($2.5 million). CONCLUSIONS As a change management programme centred the "Saving Blood, Saving Lives" project, was able to significantly reduce blood product-related administration and expenditure by implementing evidence-based transfusion criteria. The programme is simple, replicable and cost effective, making it ideally suited for use in resource-constrained environments.
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Affiliation(s)
- Robert Wise
- Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
- Adult Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Faculty Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Kirsten Hood
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - David Bishop
- Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Gary Sharp
- Statistics Department, Nelson Mandela University, South Campus, Port Elizabeth, South Africa
| | - Reitze Rodseth
- Department of Anaesthetics, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg, South Africa
- Netcare Limited, Sandton, South Africa
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Kazamer A, Ilinca R, Vesa S, Lorenzovici L, Stanescu-Spinu II, Ganea I, Greabu M, Miricescu D, Biczo A, Ionescu D. A Potential Indicator for Assessing Patient Blood Management Standard Implementation. Healthcare (Basel) 2023; 11:2233. [PMID: 37628431 PMCID: PMC10454481 DOI: 10.3390/healthcare11162233] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/13/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
(1) Background: Patient blood management (PBM) program as a multidisciplinary practice and a standard of care for the anemic surgical patient has an increasingly important role in reducing transfusions and optimizing both clinical outcomes and costs. Documented success of PBM implementation is not sufficient for implementation of recommendations and correct use at hospital level. The primary objective of our study was to define a composite patient blood management process safety index-Safety Index in PBM (SIPBM)-that measures the impact of screening and treating anemic patients on the efficiency and effectiveness of the patient care process undergoing elective surgery. (2) Methods: We conducted a retrospective comparative study in a tertiary hospital by collecting data and analyzing the Safety Index in PBM (SIPBM) in patients undergoing major elective surgical procedures. (3) Results: The percentage of patients from the total of 354 patients (178 in 2019 and 176 in 2022) included in the study who benefited from preoperative iron treatment increased in 2022 compared to 2019 from 27.40% to 36.71%. The median value of the SIPBM was 1.00 in both periods analyzed, although there is a significant difference between the two periods (p < 0.005), in favor of 2022. (4) Conclusions: Measuring the effectiveness of PBM implementation and providing ongoing feedback through the Safety Index in PBM (SIPBM) increases the degree to which opportunities to improve the PBM process are identified. The study represents a first step for future actions and baselines to develop tools to measure the safety and impact of the patient blood management process in the surgical field.
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Affiliation(s)
- Andrea Kazamer
- CREST Association, 48 Alexandru Odobescu Street, 440069 Satu Mare, Romania
- Department of Anaesthesia and Intensive Care I, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; (S.V.); (D.I.)
| | - Radu Ilinca
- Discipline of Medical Informatics and Biostatistics, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 4-6 Eforie Street, 050037 Bucharest, Romania
| | - Stefan Vesa
- Department of Anaesthesia and Intensive Care I, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; (S.V.); (D.I.)
| | - Laszlo Lorenzovici
- Faculty of Technical and Human Sciences, Sapientia Hungarian University of Transylvania, 4 Matei Corvin Street, 400112 Cluj-Napoca, Romania;
| | - Iulia-Ioana Stanescu-Spinu
- Discipline of Biochemistry, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Street, 050474 Bucharest, Romania; (I.-I.S.-S.); (M.G.); (D.M.)
| | - Ionela Ganea
- Department of Modern Languages, Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Street, 050474 Bucharest, Romania;
| | - Maria Greabu
- Discipline of Biochemistry, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Street, 050474 Bucharest, Romania; (I.-I.S.-S.); (M.G.); (D.M.)
| | - Daniela Miricescu
- Discipline of Biochemistry, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Street, 050474 Bucharest, Romania; (I.-I.S.-S.); (M.G.); (D.M.)
| | - Andras Biczo
- Department Hamm 2 Manufacturing and Production Technology, Hamm-Lippstadt University of Applied Sciences, Allee 76-78, D-59063 Hamm, Germany;
| | - Daniela Ionescu
- Department of Anaesthesia and Intensive Care I, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania; (S.V.); (D.I.)
- Outcome Research Consortium, Cleveland, OH 44195, USA
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Iatrogenic blood loss in critical care: A prospective observational study conducted at Universitas Academic Hospital in the Free State Province, South Africa. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2022; 38. [PMID: 36176738 PMCID: PMC9512050 DOI: 10.7196/sajcc.2022.v38i2.539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2022] [Indexed: 11/17/2022] Open
Abstract
Background
Prevention of iatrogenic blood loss is an essential component of patient blood management (PBM) in intensive care units (ICUs).
The amount of iatrogenic blood loss from diagnostic phlebotomy in the ICUs at Universitas Academic Hospital, Free State Province, South
Africa, is unknown.
Objectives
To quantify diagnostic phlebotomy volumes, and volumes submitted in excess for diagnostic testing in the ICU.
Methods
We conducted a prospective descriptive observational study on adults who were admitted to ICUs at a single centre over a period of
14 days. The weight of each filled phlebotomy tube was calculated using the specific gravity of blood and averages of empty phlebotomy tubes,
establishing the total volume.
Results Data from 59 participants with a median length of stay at the ICU of 3 days were analysed. The median phlebotomy volume was
7.0 mL day and 13.6 mL/ICU admission. The volume of blood required for analysis daily and ICU admission was 0.7 mL and 2.2 mL,
respectively. The median phlebotomy volume in excess of the amount required for analysis daily and ICU admission was 5.05 mL and 12.11
mL, respectively.
Conclusion
While the median excess daily phlebotomy volume in this present study may seem insignificant and underestimating the true
excess of phlebotomy volume, interventions to reduce phlebotomy volumes and development of a PBM guideline for appropriate phlebotomy
volumes and preventing wastage of patients’ blood in the ICU is required.
Contributions of the study
We determined blood volume requirements for laboratory instrumentation, which allows phlebotomists to be cognisant of the true requirements
for diagnostic tests to be undertaken accurately. We established diagnostic blood loss volumes in critical care units at a tertiary hospital in South
Africa and we advocate for the introduction of patient blood management practice guidelines at local institutions.
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Rambiritch V, Verburgh E, Louw VJ. Patient blood management and blood conservation - Complimentary concepts and solutions for blood establishments and clinical services in South Africa and beyond. Transfus Apher Sci 2021; 60:103207. [PMID: 34353706 PMCID: PMC10399285 DOI: 10.1016/j.transci.2021.103207] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Blood transfusions come with risks and high costs, and should be utilized only when clinically indicated. Decisions to transfuse are however not always well informed, and lack of clinician knowledge and education on good clinical transfusion practices contribute to the inappropriate use of blood. Low and middle-income countries in particular take much strain in their efforts to address blood safety challenges, demand-supply imbalances, high blood costs as well as high disease burdens, all of which impact blood usage and blood collections. Patient blood management (PBM), which is a patient-focused approach aimed at improving patient outcomes by preemptively diagnosing and correcting anaemia and limiting blood loss by cell salvage, coagulation optimization and other measures, has become a major approach to addressing many of the challenges mentioned. The associated decrease in the use of blood and blood products may be perceived as being in competition with blood conservation measures, which is the more traditional, but primarily product-focused approach. In this article, we hope to convey the message that PBM and blood conservation should not be seen as competing concepts, but rather complimentary strategies with the common goal of improving patient care. This offers opportunity to improve the culture of transfusion practices with relief to blood establishments and clinical services, not only in South Africa and LMICs, but everywhere. With the COVID-19 pandemic impacting blood supplies worldwide, this is an ideal time to call for educational interventions and awareness as an active strategy to improve transfusion practices, immediately and beyond.
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Affiliation(s)
| | - Estelle Verburgh
- Division of Clinical Haematology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Vernon Johan Louw
- Division of Clinical Haematology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
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van den Berg K, Vermeulen M, Louw VJ, Murphy EL, Maartens G. Undisclosed HIV status and antiretroviral therapy use among South African blood donors. Transfusion 2021; 61:2392-2400. [PMID: 34224581 PMCID: PMC8355170 DOI: 10.1111/trf.16571] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/24/2021] [Accepted: 04/24/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Undisclosed antiretroviral drug (ARV) use among blood donors who tested HIV antibody positive, but RNA negative, was previously described by our group. Undisclosed ARV use represents a risk to blood transfusion safety. We assessed the prevalence of and associations with undisclosed ARV use among HIV-positive donors who donated during 2017. STUDY DESIGN AND METHODS South African National Blood Service (SANBS) blood donors are screened by self-administered questionnaire, semi-structured interview, and individual donation nucleic acid amplification testing for HIV. Stored samples from HIV-positive donations were tested for ARV and characterized as recent/longstanding using lag avidity testing. RESULTS Of the 1462 HIV-positive donations in 2017, 1250 had plasma availability for testing of which 122 (9.8%) tested positive for ARV. Undisclosed ARV use did not differ by gender (p = .205) or ethnicity (p = .505) but did differ by age category (p < .0001), donor (p < .0001), clinic type (p = .012), home province (p = .01), and recency (p < .0001). Multivariable logistic regression found older age (adjusted odds ratio [aOR] 3.73, 95% confidence interval [CI] 1.98-7.04 for donors >40 compared with those <21), first-time donation (aOR 5.24; 95% CI 2.48-11.11), and donation in a high HIV-prevalence province (aOR 9.10; 95% CI 2.70-30.72) compared with Northern Rural provinces to be independently associated with undisclosed ARV use. DISCUSSION Almost 1 in 10 HIV-positive blood donors neglected to disclose their HIV status and ARV use. Demographic characteristics of donors with undisclosed ARV use differed from those noted in other study. Underlying motivations for nondisclosure among blood donors remain unclear and may differ from those in other populations with significant undisclosed ARV use.
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Affiliation(s)
- Karin van den Berg
- Translational Research Department, Medical Division, South African National Blood Service, Roodepoort, South Africa
- Division of Clinical Haematology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
- Division of Clinical Haematology, University of the Free State, Bloemfontein, South Africa
| | - Marion Vermeulen
- Division of Clinical Haematology, University of the Free State, Bloemfontein, South Africa
- Operations Testing Department, Operations Division, South African National Blood Service, Roodepoort, 1715, South Africa
| | - Vernon J Louw
- Division of Clinical Haematology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Edward L Murphy
- Departments of Laboratory Medicine and Epidemiology/Biostatistics, University of California San Francisco, USA
- Affiliate Investigator, Vitalant Research Institute, San Francisco, California, USA
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, South Africa
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Hofmann A, Spahn DR, Holtorf AP. Making patient blood management the new norm(al) as experienced by implementors in diverse countries. BMC Health Serv Res 2021; 21:634. [PMID: 34215251 PMCID: PMC8249439 DOI: 10.1186/s12913-021-06484-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 05/06/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Patient blood management (PBM) describes a set of evidence-based practices to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This concepts aims to detect and treat anemia, minimize the risk for blood loss and the need for blood replacement for each patient through a coordinated multidisciplinary care process. In combination with blood loss, anemia is the main driver for transfusion and all three are independent risk factors for adverse outcomes including morbidity and mortality. Evidence demonstrates that PBM significantly improves outcomes and safety while reducing cost by macroeconomic magnitudes. Despite its huge potential to improve healthcare systems, PBM is not yet adopted broadly. The aim of this study is to analyze the collective experiences of a diverse group of PBM implementors across countries reflecting different healthcare contexts and to use these experiences to develop a guidance for initiating and orchestrating PBM implementation for stakeholders from diverse professional backgrounds. METHODS Semi-structured interviews were conducted with 1-4 PBM implementors from 12 countries in Asia, Latin America, Australia, Central and Eastern Europe, the Middle East, and Africa. Responses reflecting the drivers, barriers, measures, and stakeholders regarding the implementation of PBM were summarized per country and underwent qualitative content analysis. Clustering the resulting implementation measures by levels of intervention for PBM implementation informed a PBM implementation framework. RESULTS A set of PBM implementation measures were extracted from the interviews with the implementors. Most of these measures relate to one of six levels of implementation including government, healthcare providers, funding, research, training/education, and patients/public. Essential cross-level measures are multi-stakeholder communication and collaboration. CONCLUSION The implementation matrix resulting from this research helps to decompose the complexity of PBM implementation into concrete measures on each implementation level. It provides guidance for diverse stakeholders to design, initiate and develop strategies and plans to make PBM a national standard of care, thus closing current practice gaps and matching this unmet public health need.
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Affiliation(s)
- Axel Hofmann
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
- University of Western Australia Faculty of Health and Medical Sciences, Perth, Australia
| | - Donat R. Spahn
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
| | - Anke-Peggy Holtorf
- Health Outcomes Strategies GmbH, Colmarerstrasse 58, CH4055 Basel, Switzerland
- Faculty of the College of Pharmacy, University of Utah, Salt Lake City, UT USA
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Adedayo T, O'Mahony D, Adeleke O, Mabunda S. Doctors' practice and attitudes towards red blood cell transfusion at Mthatha Regional Hospital, Eastern Cape, South Africa: A mixed methods study. Afr J Prim Health Care Fam Med 2021; 13:e1-e8. [PMID: 34212740 PMCID: PMC8252156 DOI: 10.4102/phcfm.v13i1.2889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/28/2021] [Accepted: 04/01/2021] [Indexed: 01/28/2023] Open
Abstract
Background Unnecessary blood transfusion exposes recipients to potential harms. Aim The aim of this study was to describe blood transfusion practice and explore doctors’ attitudes towards transfusion. Setting A hospital providing level 1 and 2 services. Methods A mixed-methods study design was used. In the cross-sectional descriptive component, a sample was taken from patients transfused over a 2-month period. Blood use was categorised as for medical anaemia or haemorrhage, and appropriate or not. The qualitative component comprised a purposeful sample for focus group and individual semi-structured interviews. Results Of 239 patients sampled, 62% were transfused for medical anaemia and 38% for haemorrhage. In the medical anaemia group, compliance with age-appropriate transfusion thresholds was 69%. In medical anaemia and haemorrhage, 114 (77%) and 85 (93.4%) of recipients had orders for ≥ 2 red blood cell (RBC) units, respectively. In adults ≥ 18 years old with medical anaemia, 47.1% of orders would have resulted in a haemoglobin (Hb) > 8 g/dL. Six doctors participated in focus group and eleven in individual interviews. There was a lack of awareness of institutional transfusion guidelines, disagreement on appropriate RBC transfusion thresholds and comments that more than one RBC unit should always be transfused. Factors informing decisions to transfuse included advice from senior colleagues, relieving symptoms of anaemia and high product costs. Conclusion Most orders were for two or more units. In medical anaemia, doctors’ compliance with RBC transfusion thresholds was reasonable; however, almost half of the orders would have resulted in overtransfusion. The attitudes of doctors sampled suggest that their transfusion practice is influenced more by institutional values than formal guidelines.
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Affiliation(s)
- Temitope Adedayo
- Department of Family Medicine and Rural Health, Faculty of Health Sciences, Walter Sisulu University, Mthatha.
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11
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Shead DC. Drop for drop: A descriptive analysis of blood product usage in a South African tertiary care setting during the Covid-19 pandemic. Afr J Emerg Med 2021; 11:171-174. [PMID: 33083210 PMCID: PMC7561332 DOI: 10.1016/j.afjem.2020.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/21/2020] [Accepted: 09/30/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The Covid-19 pandemic has had a drastic effect on the global community. Blood products are precious resources especially in the African context and this has been especially compounded during the Covid-19 pandemic. Concurrent to this during the Covid-19 level 5 lockdown in South Africa from 26 March - 30 April 2020, a decrease in trauma admissions to state hospitals was noted. The aim of this data collection was to assess whether lowered blood product issuance was seen during the Covid-19 pandemic lockdown. METHOD Areas at Tygerberg Hospital with trauma patients were identified, namely: the A1W intensive care unit (Surgical ICU), Trauma Front Room (Trauma Admissions), Trauma Resuscitation unit (Trauma Resus Area) and J7(Trauma Ward). Data of blood product issuance (red blood cells and fresh frozen plasma) for these 4 areas was provided by the Western Cape Blood Service for the period 26 March-30 April 2018, 2019 and 2020. This included the stage 5 Covid-19 South African lockdown, as well as Easter for all three years which is traditionally associated with raised trauma admissions. This data was quantitative. RESULTS 201 products were issued in 2018 versus 103 for the same period in 2020 for the 4 trauma areas in Tygerberg Hospital. The surgical ICU received the most products over 3 years with 183 of the product issuances. DISCUSSION As expected there was a significant decrease in blood product (red blood cell and fresh frozen plasma) issuance during the 2020 period which paralleled the lowered trauma numbers. This represented a significant cost saving of over R150 000 despite increased yearly costs for blood products over the same period. This data collection did not consider the reasoning for these blood transfusions or the clinical appropriateness thereof. The author acknowledges the wide variability of transfusion thresholds and protocols within various centres around the world, including Tygerberg and was not seeking to prove commentary on the appropriateness thereof in this research.
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Affiliation(s)
- Danielle C. Shead
- Department of Anaesthesia and Critical Care, Tygerberg Hospital, Cape Town, South Africa
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12
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Wise R, Bishop D, Gibbs M, Govender K, James MFM, Kabambi F, Louw V, Mdladla N, Moipalai L, Motchabi-Chakane P, Nolte D, Rodseth R, Schneider F, Turton E. South African Society of Anaesthesiologists Perioperative Patient Blood Management Guidelines 2020. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Anaesthesiologists regularly request and administer blood components to their patients, a potentially life-saving intervention. All anaesthesiologists must be familiar with the indications and appropriate use of blood and blood components and their alternatives, but close liaison with haematologists and their local haematology blood sciences laboratory is encouraged. In the last decade, there have been considerable changes in approaches to optimal use of blood components, together with the use of alternative products, with a need to update previous guidelines and adapt them for anaesthesiologists working throughout the hospital system.
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Affiliation(s)
- R Wise
- University of KwaZulu-Natal
| | | | | | | | | | | | | | - N Mdladla
- Sefako Makgatho Health Sciences University
| | | | | | - D Nolte
- University of the Witwatersrand
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13
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Al-Riyami AZ, Louw VJ, Indrikovs AJ, Nedelcu E, Bakhtary S, Eichbaum QG, Smit Sibinga CT. Global survey of transfusion medicine curricula in medical schools: Challenges and opportunities. Transfusion 2020; 61:617-626. [PMID: 33091965 PMCID: PMC7894143 DOI: 10.1111/trf.16147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/13/2020] [Accepted: 09/20/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Physician's knowledge in transfusion medicine (TM) is critical for patient safety. Therefore, ensuring that medical schools provide adequate education in TM is important. The aim of this study was to assess the status of TM education at a global level. STUDY DESIGN AND METHODS A comprehensive anonymous survey to assess TM education in existing medical school curricula was developed. The survey was distributed to deans and educational leads of medical schools in a range of low-, medium-, high-, and very high-human development index (HDI) countries. It included 20 questions designed to assess specific domains including structure of TM curriculum and teaching faculty. RESULTS The response rate was 53%. The majority of responding schools from very-high-HDI countries offered a 6-year curriculum after high school or a 4-year curriculum after college education, whereas most schools from medium-HDI countries offered a 5-year medical curriculum. A formal teaching program was available in only 42% of these schools in contrast to 94% of medical schools from very high-HDI. Overall, 25% of all medical schools did not offer structured TM teaching. When offered, most TM teaching was mandatory (95%) and integrated within the third and fourth year of medical school. Formal assessment of TM knowledge was done in 72% of all responding medical schools. More than half of the deans considered the TM education in their medical schools as inadequate. CONCLUSION Despite its limitations, the current survey highlights significant gaps and opportunities of TM education at a global scale.
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Affiliation(s)
- Arwa Z Al-Riyami
- Department of Haematology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Vernon J Louw
- Division of Clinical Haematology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Alexander J Indrikovs
- Division of Transfusion Medicine, Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Elena Nedelcu
- Division of Transfusion Medicine, Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA
| | - Sara Bakhtary
- Division of Transfusion Medicine, Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA
| | - Quentin G Eichbaum
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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14
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Nadar K, Hardy A, Alphonsus CS. Blood transfusion related to procedure in adult patients undergoing cardiac surgery. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.2.2321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- K Nadar
- University of KwaZulu-Natal
- Groote Schuur Hospital
- University of Cape Town
| | - A Hardy
- University of KwaZulu-Natal
- Groote Schuur Hospital
- University of Cape Town
| | - CS Alphonsus
- University of KwaZulu-Natal
- Groote Schuur Hospital
- University of Cape Town
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15
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Barrett C, Mphahlele K, Khunou I, Mkwanazi T, Moshoeshoe P, Mabine M, Wessels PL, Setlogelo O, Joubert G. The knowledge of transfusion and related practices among doctors at Universitas Academic Complex, Bloemfontein, South Africa. Transfus Apher Sci 2020; 59:102739. [PMID: 32093966 DOI: 10.1016/j.transci.2020.102739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/11/2019] [Accepted: 01/26/2020] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Claire Barrett
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Free State, PO Box 339, Bloemfontein, 9300 South Africa.
| | - Khutso Mphahlele
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Free State, PO Box 339, Bloemfontein, 9300 South Africa.
| | - Ipeleng Khunou
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Free State, PO Box 339, Bloemfontein, 9300 South Africa.
| | - Thenjiwe Mkwanazi
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Free State, PO Box 339, Bloemfontein, 9300 South Africa.
| | - Palamang Moshoeshoe
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Free State, PO Box 339, Bloemfontein, 9300 South Africa.
| | - Malefane Mabine
- Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Free State, PO Box 339, Bloemfontein, 9300 South Africa.
| | | | - Otlile Setlogelo
- South African National Blood Service, Bloemfontein, 9301, South Africa.
| | - Gina Joubert
- Department of Biostatistics, School of Biomedical Sciences, Faculty of Health Sciences, University of the Free State, PO Box 339, Bloemfontein, 9300, South Africa.
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16
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Bloch EM, Hull J, Green-Thompson R, Ingram C, Crookes RL, Fawcus S, Anthony J, Courtney L, Roubinian N, Jauregui A, Hilton JF, Murphy EL. Antenatal blood transfusion in South Africa: indications and practice in a high-HIV-prevalence setting. Transfusion 2020; 60:479-487. [PMID: 31909499 DOI: 10.1111/trf.15661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/16/2019] [Accepted: 11/17/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Globally, data on antenatal blood transfusion practices are scarce. We sought to characterize the epidemiology of antenatal transfusion in South Africa. STUDY DESIGN AND METHODS A cross-sectional study was conducted of women who were transfused during pregnancy (>48 hr before anticipated delivery) at two hospitals in Durban and Soweto in 2014 to 2015. Medical record data on demographics, obstetric history, anemia, HIV status, and indications for blood transfusion were abstracted. RESULTS The records on a total of 560 transfused pregnant women were evaluated; mean age was 28 years, 98% were of black African ethnicity, and 28% were HIV positive. At time of transfusion, one-half were in the first trimester. Hemorrhage was noted in 76% of women, most of which was associated with abortion (67%) or ectopic pregnancy (27%). Most women were transfused with red blood cells (RBCs; median, 2 units); 14% of women were transfused with plasma and 2% with platelets. Median pre- and posttransfusion hemoglobin levels were 6.9 g/dL and 9.2 g/dL, respectively; the latter differed by hospital (8.7 g/dL vs. 9.5 g/dL; p < 0.01). Hemorrhage was associated with missing HIV status, lower gestational age, and transfusion of 3 or more RBC units (all p < 0.01). In contrast, diagnoses of anemia (Soweto only) were associated with HIV infection, later gestational age, and lower (<3 units) RBC dose (all p < 0.01). CONCLUSION Abortion and ectopic pregnancy with associated hemorrhage were the leading indications for antenatal transfusion and were concentrated in early gestation. By contrast, anemia was associated with HIV infection and transfusion in the third trimester.
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Affiliation(s)
- Evan M Bloch
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer Hull
- Department of Obstetrics and Gynecology, Chris Hani Baragwanath Hospital, Soweto, South Africa
| | | | - Charlotte Ingram
- South African National Blood Service, Johannesburg, South Africa.,South African Bone Marrow Registry, Cape Town, South Africa
| | | | - Susan Fawcus
- Department of Obstetrics and Gynecology, Mowbray Maternity Hospital, Cape Town, South Africa.,Department of Obstetrics and Gynecology, Groote Schuur Hospital, Cape Town, South Africa
| | - John Anthony
- Department of Obstetrics and Gynecology, Groote Schuur Hospital, Cape Town, South Africa
| | | | - Nareg Roubinian
- Kaiser Permanente Northern California Division of Research, Oakland, California.,Vitalant Research Institute, San Francisco, California.,Department of Laboratory Medicine, University of California San Francisco, San Francisco, California
| | - Adam Jauregui
- Vitalant Research Institute, San Francisco, California
| | - Joan F Hilton
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California
| | - Edward L Murphy
- Vitalant Research Institute, San Francisco, California.,Department of Laboratory Medicine, University of California San Francisco, San Francisco, California.,Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California
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