SCGH Patient Blood Management Transfusion Guidelines 1 • Red blood cell transfusion should not be dictated by Haemoglobin alone but based on assessment of the patient’s clinical status. • In patients with iron deficiency or depleted iron stores, replacement iron therapy is indicated. Is the patient actively bleeding? • Transfuse 1 unit then reassess • For haemorrhagic shock, activate MTP Hb >100g/L: Transfusion is likely to be unnecessary and inappropriate unless the patient is actively bleeding Transfuse to relieve clinical signs and symptoms of anaemia. Transfusion may not be required in well compensated patients Is Hb <70g/L Is Hb 70-100g/L Surgical Patients: Hb 70-100g/L Post op patients with acute MI or cerebrovascular ischaemia: transfuse 1 unit RBC and reassess. Is the patient symptomatic? e.g. angina in pts with Acute Coronary Syndrome and Hb <80g/L, transfusion is likely to be appropriate. Transfuse 1 unit and reassess. Medical Patients: Hb 70-100g/L RBC transfusion is not associated with reduced mortality. Transfuse to relieve sign and symptoms of anaemia. There is no evidence to warrant a different approach for patients who are elderly or who have respiratory or cerebrovascular disease. Component Clinical Code Indication for Transfusion RBC 1 Active bleeding 2 Symptomatic anaemia 3 Bone Marrow Suppression Platelets 4 Bone Marrow Failure Plt count < 10x10 9 /L in absence of risk factors 5 Bone Marrow Failure Plt count < 20x10 9 /L in presence of risk factors: fever, sepsis 6 Plt count < 50x10 9 /L with invasive procedure planned 7 Surgical/invasive procedure: maintain Plt count > 50x10 9 /L 8 Platelet dysfunction: medical or drug related 9 Massive Haemorrhage/Transfusion FFP 10 Liver Disease in the presence of bleeding or at risk of serious bleeding 11 Multiple coagulation deficiencies: use specific coagulation factors when available 12 Plasma exchange procedure 13 Massive Haemorrhage/Transfusion 14 2 Warfarin reversal in clinically significant bleeding: in addition to Prothrombinex Cryoprecipitate 15 Disseminated Intravascular Coagulopathy (DIC) 16 Fibrinogen Deficiency 17 Coagulation factor deficiencies Other 18 Albumex / IVIg / other plasma derived products Consider consultation with Transfusion Haematologist via Switch, PathWest Transfusion Medicine Unit, Transfusion CNC page 4815, Patient Blood Management CNC page 4179. 1 Adapted from National Blood Authority, Patient Blood Management Guidelines: Module 2 Perioperative and Module 3 Medical. (2012) www.nba.gov.au 2 Refer to Warfarin Reversal Guidelines in Transfusion Policy Manual Yes No No Yes Yes Yes Yes Patient / Product I.D W In Pt name/DOB/URMN check: Blood product: Date: Time: 3 Patient / Product I.D Witness Witn Initial In Pt name/DOB/URMN check: Blood product: Date: P Re reco trans Fresh 15 min Platelet following Cryopreci 15 minutes More freque transfusion e • RBC transfusion should not be dictated by Haemoglobin alone but based on assessment of the patient’s clinical status. • In patients with iron deficiency or depleted iron stores, replacement iron therapy is indicated SCGH Patient Blood Management Transfusion Guidelines 1 1 Adapted from the National Blood Authority, Patient Blood Management Guidelines: Module 2 Perioperative and Module 3 Medical. (2012) www.nba.gov.au 2 Refer to Warfarin Reversal Guidelines in Transfusion Policy Manual Is the patient actively bleeding? Is Hb <70g/L Is Hb 70-100g/L • Transfuse 1 unit then reassess • For haemorrhagic shock, activate MTP Transfuse to relieve clinical signs and symptoms of anaemia. Transfusion may not be required in well compensated patients Is the patient symptomatic? eg angina In pts with Acute Coronary Syndrome and Hb <80g/L, transfusion is likely to be appropriate. Transfuse 1 unit and reassess Medical Patients: Hb 70-100g/L RBC transfusion is not associated with reduced mortality. Transfuse to relieve sign and symptoms of anaemia. There is no evidence to warrant a different approach for patients who are elderly or who have respiratory or cerebrovascular disease Hb >100g/L: Transfusion is likely to be unnecessary and inappropriate unless the patient is actively bleeding Component Clinical code Indication for Transfusion RBC 1 Active bleeding 2 Symptomatic anaemia 3 Bone Marrow Suppression Platelets 4 Bone Marrow Failure Plt count <10x10 9 /L in absence of risk factors 5 Bone Marrow Failure Plt count <20x10 9 /L in presence of risk factors: fever, sepsis 6 Plt count < 50x10 9 /L with invasive procedure planned 7 Surgical/invasive procedure: maintain Plt count >50x10 9 /L 8 Platelet dysfunction: medical or drug related 9 Massive Haemorrhage/Transfusion FFP 10 Liver Disease in the presence of bleeding or at risk of serious bleeding 11 Multiple coagulation deficiencies: use specific coagulation factors when available 12 Plasma exchange procedure 13 Massive Haemorrhage/Transfusion 14 2 Warfarin reversal in clinically significant bleeding: in addition to Prothrombinex Cryoprecipitate 15 Disseminated Intravascular Coagulopathy (DIC) 16 Fibrinogen Deficiency 17 Coagulation factor deficiencies Other 18 Albumex / IVIg / other plasma derived products Consider consultation with Transfusion Haematologist via Switch, Transfusion Medicine Unit ext 834018 or page 4467. Transfusion CNC page 4815, Patient Blood Management CNC page 4179 North Metropolitan Health Service Surgical Patients: Hb 70-100g/L Post op patients with acute MI or cerebrovascular ischaemia: transfuse 1 unit RBC and reassess YES YES YES YES YES NO NO North Metropolitan Health Service SIR CHARLES GAIRDNER HOSPITAL USE PATIENT LABEL WHEN AVAILABLE Surname: Forename: Gender: URN: DOB: M042 06/13 BLOOD PRODUCT TRANSFUSION FORM 826 BLOOD PRODUCT TRANSFUSION FORM Hb ALONE SHOULD NOT BE USED AS TRIGGER FOR TRANSFUSION In non-bleeding patients: order one unit and review the patient following transfusion Specific instructions for transfusion: e.g. ‘transfuse 1 unit platelets if platelet count <10 x 10 9 /L or if clinically significant bleeding’; ‘transfuse 1 unit red blood cells if Hb <85 g/L in the first 12 hours post-op, or subsequently if Hb <65g/L’; ‘in a stable medical patient, transfuse 1 unit of packed cells if patient has symptomatic anaemia (shortness of breath after walking 100m) Check Hb at date/time Result g/L Valid consent sighted? Yes c Unable c SIGN declaration below This patient was unable to consent to transfusion of blood products because the transfusion was urgent/emergency AND the patient’s conscious state was impaired due to c illness/injury c sedation in ICU c anaesthesia. There is no evidence that the patient objects or would have objected to receiving a blood product transfusion e.g. refusal of treatment form, advanced health directive. Signature of Doctor Designation Date Date Blood Product Clinical Code Dose Rate RMO Signature Date of Admin Time of Admin Signature of 2 staff checking and hanging blood Start Finish Start Finish Start Finish Start Finish Start Finish Start Finish Start Finish Start Finish Start Finish Start Finish Why give 2 when 1 will do? A second unit should only be prescribed following review of the patient North Metropolitan Health Service Transition from Transfusion: The Implementation of a Patient Blood Management Program References 1 National Blood Authority. Patient Blood Management Guidelines ( Accessed 20th August 2013, at http://www. blood.gov.au/pbm-guidelines ) 2 Western Australia Department of Health. Patient Blood Management (Accessed 6th August 2013, at http://www. health.wa.gov.au/bloodmanagement/professionals/dev. cfm ) 3 Ma M, Eckert K, Ralley F, Chin-Yee I. A retrospective study evaluating single-unit red blood cell transfusions in reducing allogeneic blood exposure. Transfusion Med 2005; 15:307-312 4 Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards.Sydney.ACSQHC 2011 Background Evidence regarding transfusion efficacy, safety and costs has exploded over recent years culminating in the National Blood Authority’s publication of the Patient Blood Management (PBM) Transfusion Guidelines 1 . Even with a growing body of evidence, changes to transfusion practice are slow to be adopted. The aim of a PBM program is to improve patient outcomes by optimising and conserving the patient’s own blood, reducing transfusion and conserving the blood supply 2 . In this role, PBM has become the new champion of transfusion by implementing practices to minimise or avoid unnecessary transfusions. Objective To demonstrate how the Transfusion and PBM Clinical Nurse Consultants (CNC) led the collaboration between the Transfusion and PBM committees to implement transfusion practice changes. To identify resources that were developed and strategies that were undertaken to guide this process. Method Changes to transfusion culture and practice were identified as PBM priorities and potentially the greatest challenges. Engagement of a wide range of clinical experts was required to successfully implement transfusion practice change. The multi- disciplinary PBM team provided leadership and representation across a number of areas where blood use was regularly used in clinical practice. Collaboration on changes to transfusion policy and protocols was achieved by ensuring that a clear consultation process occurred between the Transfusion Services and PBM committees, with the CNCs acting as conduits to both committees. The CNCs used evidence based models in the development of policies, protocols, posters and algorithms to legitimise and reinforce the change message. Transfusion education focused on the positive aspects of reducing transfusion by pre- operative anaemia screening and optimisation to improve the patient’s own red cell resources and implementation of a single unit transfusion policy to reduce the risks of transfusion. Staff were encouraged to consider the consequences of inappropriate transfusion, not only from a theoretical evidence based perspective but also as a potential health consumer. Transfusion policy updates were communicated to Transfusion Champions at monthly education forums; in turn these staff were able to disseminate information and engage with clinical staff at the local ward level. Results Single unit policy and poster The literature indicates that a single unit policy initiative can be a safe and effective strategy in reducing the patient’s exposure to transfusion related risks 3 . Single unit transfusions are used for non-bleeding patients with low haemoglobin who are haemodynamically stable. In many instances one unit of red blood cells will be sufficient to relieve symptoms of anaemia. A second unit should only be considered after assessing the patient for ongoing clinical signs and symptoms of anaemia. The CNCs worked together to provide medical and nursing education utilising a variety of communication formats and media to facilitate the implementation of the policy. Regular articles were submitted to medical and nursing newsletters and were complemented by a widely advertised Transfusion and PBM road show. The road show was set up in a busy thoroughfare over lunch time and provided an opportunity for hospital staff and consumers to ask questions. Posters promoting the new single unit policy were distributed to clinical areas and placed in lifts hospital-wide. Blood Management Champions The Transfusion Link nurse team was formed in 2009 to promote safe clinical practice around blood and blood products and act as a positive role model and clinical resource person for colleagues in clinical areas. The team agreed to expand their current role to encompass both transfusion safety and PBM in June 2013 and the name was changed to Blood Management Champions.The new name was used to reflect their expanded role as an integral part of the PBM team. The Blood Management Champions are utilised to deliver information and help in the dissemination of Transfusion/PBM policy changes and practices to colleagues in the clinical areas. The monthly meetings include education session relating to Transfusion/PBM with an opportunity to discuss practice issues. The Champions are proving to be an effective resource for facilitating change at a local level. Decision to Transfuse Algorithm Using the National Blood Authority (NBA) PBM transfusion guidelines, the CNCs created a decision to transfuse algorithm which was reviewed and endorsed by the Transfusion and PBM committees. The intent was to facilitate the decision making process by providing succinct overarching information for medical staff to prescribe transfusion in accordance with the NBA PBM guidelines 1 . The algorithm has been incorporated into the Blood Product Transfusion form and is widely available in clinical areas. Revision of the Blood Product Transfusion form In accordance with PBM recommendations and National Standards Blood and Blood products 4 , the transfusion prescription form was revised to address 4 key areas relating to transfusion practice: ▉ Visual prompt to facilitate consent compliance ▉ Ability to provide patient focused prescribing ▉ Coding of clinical indications to identify rationale for transfusion. This assists clinical coders when reviewing patient notes ▉ Algorithm adapted from NBA’s PBM guidelines 1 for decision to transfuse Audit Results A recent snapshot audit of transfusion rates at Sir Charles Gairdner Hospital of 100 elective joint replacement patients showed ▉ a decline in transfusion rate by number of units ▉ a reduction in the number of transfusion episodes Although the sample size was small, this audit has suggested a trend toward declining transfusion rates and a change in transfusion practice culture. Conclusion Single unit transfusion orders are becoming more apparent and staff are beginning to reject traditional transfusion thresholds in line with PBM recommendations. Ongoing data collection and clinical audits will evaluate the effectiveness of these transfusion guidelines and demonstrate the application of PBM in clinical practice. The implementation of a new program requires a collaborative team approach with clear and realistic expectations of what is to be achieved. The two CNCs share a vision in providing evidence based patient focused care, by promoting the principles of PBM which encompasses appropriate transfusion practices. As change champions, they have been integral in developing clinical tools and have provided significant leadership to guide this new transfusion paradigm. Authors: Linda Campbell RN, BSc Grad Cert Transfusion Practice, Patient Blood Management Clinical Nurse Consultant, Sue Field RN, Grad Cert Transfusion Practice, Grad Cert HPEd,Transfusion Clinical Nurse Consultant, Sir Charles Gairdner Hospital, Nedlands, Western Australia AVPU SCGH Ref: 3514-13
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M042 BOB BLACK
SIR CHARLES GAIRDNER HOSPITAL
USE PATIENT LABEL WHEN AVAILABLE
Surname:
Forename:
Gender:
URN:
DOB:
BlOOd prOduct
transFusiOn FOrM(continued)
scGH patient Blood Management transfusion Guidelines 1
• Red blood cell transfusion should not be dictated by Haemoglobin alone but based on assessment
of the patient’s clinical status.
• In patients with iron deficiency or depleted iron stores, replacement iron therapy is indicated.
is the patient actively bleeding?
• Transfuse 1 unit then reassess
• For haemorrhagic shock, activate MTP
Hb >100g/l: Transfusion is likely to be unnecessary and inappropriate unless the patient is
actively bleeding
Transfuse to relieve clinical signs and symptoms
of anaemia. transfusion may not be required
in well compensated patients
is Hb <70g/l
is Hb 70-100g/l
surgical patients: Hb 70-100g/l
Post op patients with acute MI or
cerebrovascular ischaemia:
transfuse 1 unit RBC and reassess.
is the patient symptomatic? e.g. angina in pts
with Acute Coronary Syndrome and Hb <80g/L,
transfusion is likely to be appropriate.
Transfuse 1 unit and reassess.Medical patients: Hb 70-100g/l
RBC transfusion is not associated with reduced
mortality. Transfuse to relieve sign and symptoms
of anaemia. There is no evidence to warrant a
different approach for patients who are elderly or
who have respiratory or cerebrovascular disease.
component clinical code
indication for transfusion
rBc
1Active bleeding
2Symptomatic anaemia
3Bone Marrow Suppression
platelets
4Bone Marrow Failure Plt count < 10x10 9/L in absence of risk factors
5Bone Marrow Failure Plt count < 20x10 9/L in presence of risk factors: fever, sepsis
6Plt count < 50x10 9/L with invasive procedure planned
7Surgical/invasive procedure: maintain Plt count > 50x10 9/L
8Platelet dysfunction: medical or drug related
9Massive Haemorrhage/Transfusion
FFp
10Liver Disease in the presence of bleeding or at risk of serious bleeding
11Multiple coagulation deficiencies: use specific coagulation factors when available
12Plasma exchange procedure
13Massive Haemorrhage/Transfusion
142 Warfarin reversal in clinically significant bleeding: in addition to Prothrombinex
cryoprecipitate15
Disseminated Intravascular Coagulopathy (DIC)
16Fibrinogen Deficiency
17Coagulation factor deficiencies
Other
18Albumex / IVIg / other plasma derived products
Consider consultation with Transfusion Haematologist via Switch, PathWest Transfusion Medicine Unit, Transfusion CNC page 4815, Patient Blood Management CNC page 4179.
1 Adapted from National Blood Authority, Patient Blood Management Guidelines: Module 2 Perioperative and Module 3 Medical. (2012) www.nba.gov.au
2 Refer to Warfarin Reversal Guidelines in Transfusion Policy Manual
YesNo
No
Yes
Yes
Yes
Yes
transfused Blood products1
2
Patient / Product I.D
Witness Witness
Initial Initial
Pt name/DOB/URMN check:
Blood product:
Date: Time:
Patient / Product I.D
Witness Witness
Initial Initial
Pt name/DOB/URMN check:
Blood product:
Date: Time:
3
4
Patient / Product I.D
Witness Witness
Initial Initial
Pt name/DOB/URMN check:
Blood product:
Date: Time:
Patient / Product I.D
Witness Witness
Initial Initial
Pt name/DOB/URMN check:
Blood product:
Date: Time:
Vital signs Monitoring for Blood products
A nurse must stay with the patient for the first 5 minutes of the blood product transfusion. The patient must be visually
monitored for signs of transfusion reaction such as fever, chills, rash, shortness of breath, chest pain and back pain.
please refer to transfusion policy Manual for management of a transfusion reaction
red Blood cells: Temperature, pulse, blood pressure and respiration rate (T, P, BP and RR) must be monitored and
recorded immediately prior to commencement, then 15 minutes following commencement, hourly and at completion of
transfusion.Fresh Frozen plasma: T, P, BP and RR must be monitored and recorded immediately prior to commencement, then
15 minutes following commencement, and at completion of transfusion
platelets: T, P, BP and RR must be monitored and recorded immediately prior to commencement, then 5 minutes
following commencement, and / or at completion of transfusion.
cryoprecipitate: T, P, BP and RR must be monitored and recorded immediately prior to commencement, then
15 minutes following commencement, and / or at completion of transfusion.
More frequent vital signs monitoring may be required if patient is clinically unstable during the blood product
transfusion episode.
• RBC transfusion should not be dictated by Haemoglobin alone but based on assessment of the patient’s clinical status.
• In patients with iron deficiency or depleted iron stores, replacement iron therapy is indicated
SCGH Patient Blood Management Transfusion Guidelines1
1 Adapted from the National Blood Authority, Patient Blood Management Guidelines: Module 2 Perioperative and Module 3 Medical. (2012) www.nba.gov.au2 Refer to Warfarin Reversal Guidelines in Transfusion Policy Manual
Is the patient actively bleeding?
Is Hb <70g/L
Is Hb 70-100g/L
• Transfuse 1 unit then reassess • For haemorrhagic shock, activate MTP
Transfuse to relieve clinical signs and symptoms of anaemia. Transfusion may not be required in well compensated patients
Is the patient symptomatic? eg anginaIn pts with Acute Coronary Syndrome and Hb <80g/L, transfusion is likely to be appropriate. Transfuse 1 unit and reassess
Medical Patients: Hb 70-100g/LRBC transfusion is not associated with reduced mortality. Transfuse to relieve sign and symptoms of anaemia. There is no evidence to warrant a different approach for patients who are elderly or who have respiratory or cerebrovascular disease
Hb >100g/L: Transfusion is likely to be unnecessary and inappropriate unless the patient is actively bleeding
Component Clinical code Indication for Transfusion
RBC1 Active bleeding2 Symptomatic anaemia3 Bone Marrow Suppression
Platelets
4 Bone Marrow Failure Plt count <10x109/L in absence of risk factors5 Bone Marrow Failure Plt count <20x109/L in presence of risk factors: fever, sepsis6 Plt count < 50x109/L with invasive procedure planned7 Surgical/invasive procedure: maintain Plt count >50x109/L8 Platelet dysfunction: medical or drug related9 Massive Haemorrhage/Transfusion
FFP
10 Liver Disease in the presence of bleeding or at risk of serious bleeding11 Multiple coagulation deficiencies: use specific coagulation factors when available12 Plasma exchange procedure13 Massive Haemorrhage/Transfusion14 2Warfarin reversal in clinically significant bleeding: in addition to Prothrombinex
Cryoprecipitate15 Disseminated Intravascular Coagulopathy (DIC)16 Fibrinogen Deficiency 17 Coagulation factor deficiencies
Other 18 Albumex / IVIg / other plasma derived products
Consider consultation with Transfusion Haematologist via Switch, Transfusion Medicine Unit ext 834018 or page 4467. Transfusion CNC page 4815, Patient Blood Management CNC page 4179
North Metropolitan Health Service
Surgical Patients: Hb 70-100g/LPost op patients with acute MI or cerebrovascular ischaemia: transfuse 1 unit RBC and reassess
YESYES
YES
YES
YES
NO
NO
North Metropolitan Health Service
SIR CHARLES GAIRDNER HOSPITAL
USE PATIENT LABEL WHEN AVAILABLE
Surname:
Forename:
Gender:
URN:
DOB:
SIR CHARLES GAIRDNER HOSPITAL
USE PATIENT LABEL WHEN AVAILABLE
Surname:
Forename:
Gender:
URN:
DOB:
M042 FOB BLACK, PMS 366 GREEN
M04206/13
BlOOd prOduct transFusiOn FOrM
826
Bl
OO
d p
rO
du
ct
tr
an
sF
us
iOn
FO
rM
BlOOd prOduct transFusiOn FOrM
(continued)
Hb alOnE sHOuld nOt BE usEd as triGGEr FOr transFusiOnin non-bleeding patients: order one unit and review the patient following transfusion
specific instructions for transfusion: e.g. ‘transfuse 1 unit platelets if platelet count <10 x 109/L or if clinically significant bleeding’;‘transfuse 1 unit red blood cells if Hb <85 g/L in the first 12 hours post-op, or subsequently if Hb <65g/L’; ‘in a stable medical patient, transfuse
1 unit of packed cells if patient has symptomatic anaemia (shortness of breath after walking 100m)
check Hb at date/time
result g/l
Valid consent sighted? Yes c Unable c SIGN declaration below
This patient was unable to consent to transfusion of blood products because the transfusion was urgent/emergency and the patient’s conscious state was impaired due to c illness/injury c sedation in ICU c anaesthesia.There is no evidence that the patient objects or would have objected to receiving a blood product transfusion e.g. refusal of treatment form, advanced health directive.
Signature of Doctor Designation Date
DateBlood Product
Clinical Code
Dose Rate RMO SignatureDate of Admin
Time of Admin
Signature of 2 staff checking and hanging blood
Start
Finish
Start
Finish
Start
Finish
Start
Finish
Start
Finish
Start
Finish
Start
Finish
Start
Finish
Start
Finish
Start
Finish
transfused Blood products
5 6
Patient / Product I.D Witness Witness Initial Initial
Pt name/DOB/URMN check:
Blood product:
Date: Time:
Patient / Product I.D Witness Witness Initial Initial
Pt name/DOB/URMN check:
Blood product:
Date: Time:
7 8
Patient / Product I.D Witness Witness Initial Initial
Pt name/DOB/URMN check:
Blood product:
Date: Time:
Patient / Product I.D Witness Witness Initial Initial
Pt name/DOB/URMN check:
Blood product:
Date: Time:
9 10
Patient / Product I.D Witness Witness Initial Initial
Pt name/DOB/URMN check:
Blood product:
Date: Time:
Patient / Product I.D Witness Witness Initial Initial
Pt name/DOB/URMN check:
Blood product:
Date: Time:
Why give 2
when 1 will do?
A second unit should only
be prescribed following
review of the patient
North Metropolitan Health Service
Transition from Transfusion: The Implementation of a Patient Blood Management Program
References1 National Blood Authority. Patient Blood Management
Guidelines ( Accessed 20th August 2013, at http://www.blood.gov.au/pbm-guidelines )
2 Western Australia Department of Health. Patient Blood Management (Accessed 6th August 2013, at http://www.health.wa.gov.au/bloodmanagement/professionals/dev.cfm )
3 Ma M, Eckert K, Ralley F, Chin-Yee I. A retrospective study evaluating single-unit red blood cell transfusions in reducing allogeneic blood exposure. Transfusion Med 2005; 15:307-312
4 Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards.Sydney.ACSQHC 2011
Background
Evidence regarding transfusion efficacy, safety and costs has exploded over recent years culminating in the National Blood Authority’s publication of the Patient Blood Management (PBM) Transfusion Guidelines1. Even with a growing body of evidence, changes to transfusion practice are slow to be adopted. The aim of a PBM program is to improve patient outcomes by optimising and conserving the patient’s own blood, reducing transfusion and conserving the blood supply2. In this role, PBM has become the new champion of transfusion by implementing practices to minimise or avoid unnecessary transfusions.
Objective
To demonstrate how the Transfusion and PBM Clinical Nurse Consultants (CNC) led the collaboration between the Transfusion and PBM committees to implement transfusion practice changes.
To identify resources that were developed and strategies that were undertaken to guide this process.
Method
Changes to transfusion culture and practice were identified as PBM priorities and potentially the greatest challenges. Engagement of a wide range of clinical experts was required to successfully implement transfusion practice change. The multi-disciplinary PBM team provided leadership and representation across a number of areas where blood use was regularly used in clinical practice. Collaboration on changes to transfusion policy and protocols was achieved by ensuring that a clear consultation process occurred between the Transfusion Services and PBM committees, with the CNCs acting as conduits to both committees.
The CNCs used evidence based models in the development of policies, protocols, posters and algorithms to legitimise and reinforce the change message. Transfusion education focused on the positive aspects of reducing transfusion by pre-operative anaemia screening and optimisation to improve the patient’s own red cell resources and implementation of a single unit transfusion policy to reduce the risks of transfusion. Staff were encouraged to consider the consequences of inappropriate transfusion, not only from a theoretical evidence based perspective but also as a potential health consumer. Transfusion policy updates were communicated to Transfusion Champions at monthly education forums; in turn these staff were able to disseminate information and engage with clinical staff at the local ward level.
Results
Single unit policy and poster
The literature indicates that a single unit policy initiative can be a safe and effective strategy in reducing the patient’s exposure to transfusion related risks3 . Single unit transfusions are used for non-bleeding patients with low haemoglobin who are haemodynamically stable. In many instances one unit of red blood cells will be sufficient to relieve symptoms of anaemia. A second unit should only be considered after assessing the patient for ongoing clinical signs and symptoms of anaemia.
The CNCs worked together to provide medical and nursing education utilising a variety of communication formats and media to facilitate the implementation of the policy. Regular articles were submitted to medical and nursing newsletters and were complemented by a widely advertised Transfusion and PBM road show. The road show was set up in a busy thoroughfare over lunch time and provided an opportunity for hospital staff and consumers to ask questions. Posters promoting the new single unit policy were distributed to clinical areas and placed in lifts hospital-wide.
Blood Management Champions
The Transfusion Link nurse team was formed in 2009 to promote safe clinical practice around blood and blood products and act as a positive role model and clinical resource person for colleagues in clinical areas. The team agreed to expand their current role to encompass both transfusion safety and PBM in June 2013 and the name was changed to Blood Management Champions.The new name was used to reflect their expanded role as an integral part of the PBM team. The Blood Management Champions are utilised to deliver information and help in the dissemination of Transfusion/PBM policy changes and practices to colleagues in the clinical areas. The monthly meetings include education session relating to Transfusion/PBM with an opportunity to discuss practice issues. The Champions are proving to be an effective resource for facilitating change at a local level.
Decision to Transfuse Algorithm
Using the National Blood Authority (NBA) PBM transfusion guidelines, the CNCs created a decision to transfuse algorithm which was reviewed and endorsed by the Transfusion and PBM committees. The intent was to facilitate the decision making process by providing succinct overarching information for medical staff to prescribe transfusion in accordance with the NBA PBM guidelines1. The algorithm has been incorporated into the Blood Product Transfusion form and is widely available in clinical areas.
Revision of the Blood Product Transfusion form
In accordance with PBM recommendations and National Standards Blood and Blood products4, the transfusion prescription form was revised to address 4 key areas relating to transfusion practice:
▉ Visual prompt to facilitate consent compliance
▉ Ability to provide patient focused prescribing
▉ Coding of clinical indications to identify rationale for transfusion. This assists clinical coders when reviewing patient notes
▉ Algorithm adapted from NBA’s PBM guidelines1 for decision to transfuse
Audit Results
A recent snapshot audit of transfusion rates at Sir Charles Gairdner Hospital of 100 elective joint replacement patients showed
▉ a decline in transfusion rate by number of units
▉ a reduction in the number of transfusion episodes
Although the sample size was small, this audit has suggested a trend toward declining transfusion rates and a change in transfusion practice culture.
Conclusion
Single unit transfusion orders are becoming more apparent and staff are beginning to reject traditional transfusion thresholds in line with PBM recommendations. Ongoing data collection and clinical audits will evaluate the effectiveness of these transfusion guidelines and demonstrate the application of PBM in clinical practice.
The implementation of a new program requires a collaborative team approach with clear and realistic expectations of what is to be achieved. The two CNCs share a vision in providing evidence based patient focused care, by promoting the principles of PBM which encompasses appropriate transfusion practices. As change champions, they have been integral in developing clinical tools and have provided significant leadership to guide this new transfusion paradigm.
Authors:
Linda Campbell RN, BSc Grad Cert Transfusion Practice, Patient Blood Management Clinical Nurse Consultant,
Sue Field RN, Grad Cert Transfusion Practice, Grad Cert HPEd,Transfusion Clinical Nurse Consultant,
Sir Charles Gairdner Hospital, Nedlands, Western Australia
AVPU SCGH Ref: 3514-13
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