WA News Feature Articles Preventing Unnecessary Transfusions
Preventing Unnecessary Transfusions
Written by Jan Hallam
Tuesday, 29 August 2017


 

25082017-Leahy-Michael-Dr May14Dr Michael LeahyFor centuries the medical profession has be mesmerised by blood – particularly besotted with taking it out and putting it back in. What period drama would be complete without a fevered hero being ‘cupped’ or a hospital soapie not awash with doctors in theatre screaming for more blood?

In real-time and real-life, the WA Patient Blood Management (PBM) Program is changing those scenarios not just here in WA but nationally and internationally.

Haematologist Prof Michael Leahy is the lead author of the paper, Improved outcomes and reduced costs associated with a health-system-wide patient blood management program, which was published recently and is receiving significant international attention.

The retrospective observational study examined the health and economic outcomes of a six-year study of 605,046 patients admitted to four major adult tertiary-care hospitals between July 2008 and June 2014.

The study’s outcome measures included red blood cell (RBC), fresh-frozen plasma (FFP), and platelet units transfused; single-unit RBC transfusions; pre-transfusion haemoglobin levels; elective surgery patients anaemic at admission; product and activity-based costs of transfusion; in-hospital mortality; length of stay; 28-day all-cause emergency readmissions; and hospital-acquired complications.

Negatives of transfusions

Many studies had shown adverse outcomes from blood transfusions in various clinical situations, including increased infections, increased hospital length of stay, immunosuppression and increased mortality.

“Blood transfusion is a form of liquid organ transplant, which brings both short-term and long-term risks. In the short term, we could be looking at things including fever, allergic reactions, fluid overload, toxicity from components of the blood which has been treated to facilitate storage, and infections,” Michael said.

“However the long-term risks have not always been so obvious, and are thought to be related to immune reactions triggered by allogenic blood, even with careful cross-matching.”

“There is also a dose-related effect (that is the more units of blood transfused, the greater the risk) which can be measured more than 10 years after transfusion.”

PBM had its origins at the privately run Kaleeya Hospital in East Fremantle.

Interest in ‘bloodless surgery’

Clinicians had a growing interest in exploring the mounting overseas evidence around ‘bloodless surgery’ in part because some of the hospital’s patients belonged to the Jehovah’s Witness faith and refused blood transfusions on religious grounds.

Many patients admitted for elective orthopaedic surgery were found to be anaemic and requiring iron replacements.  Moving to pre-operative assessment to identify and manage all anaemic patients by increasing their iron levels before surgery was seen as a logical evolution. 

Michael, who was at Fremantle Hospital at the time, said some of those ideas flowed to the public system from those surgeons at Kaleeya, who had public lists at Fremantle.

With increasing local and overseas evidence showing the benefits of PBM, in 2008, WA Department of Health initiated a six-year project across four tertiary sites to implement the program with a larger population in multiple clinical settings.

“With the State’s increasing population and falling blood donor pool it was becoming clear that the usage rate of blood by the hospitals was going to outweigh the donation rate,”

“It just adds another dimension to the fact that we needed to change our practice,” Michael said.

Improvements being made

The study period showed major improvements in patient outcomes including:

  • 28% reduction in hospital mortality
  • 15% reduction in average hospital length of stay
  • 21% decrease in hospital-acquired infections
  • 31% decrease in the incidence of heart attack or stroke.

The study period also showed a 41% reduction in the use of RBC, FFP and platelet products, resulting in direct cost savings of $18.5 million.  Overall savings, which include the cost of processing blood donations by the Australian Red Cross Blood Service along with administering transfusions in hospital, is estimated to be between $80-100 million.

“An important feature of the success of the program is its focus on changing the culture around blood transfusion, making the focus around individual patient need, rather than a transfusion exercise based on haemoglobin levels,” Michael said

“Patients with anaemia need to have the cause established rather than just receive treatment with a blood transfusion.  If the patient is stable and not bleeding, there really is no point in giving blood if they are not symptomatic.”

“We also use a number of different strategies in the operating theatre to help minimise bleeding, including new technologies and pharmaceutical agents (such as TEMs, cell savers and tranexamic acid) to help conserve a patient’s own blood.”

“PBM is about educating clinicians and patients about blood conservation as well as thinking about the potential benefits and risks of a transfusion,” Michael said.

PBM across the board25082017-WA-Patient-Blood-Management-Infographic

Other jurisdictions and hospitals have focused on single speciality aspects of PBM such as in surgery or critical care. The WA study showed how to implement PBM across all aspects of hospital care, in both surgical and medical specialities.

“The WA program was unique in that it placed trained PBM clinical staff in key positions in each hospital so they could provide leadership, feedback and education to other medical staff on the use of blood conservation and the judicious use of blood products,” Michael said.

When health systems produce figures like that, other health systems sit up and take notice. Recently, the European Commission’s Director-General of Health and Food Safety announced it was adopting WA’s PBM model as a standard of care.

Closer to home, the Australian Commission on Safety and Quality in Health Care has now included PBM as a national priority.  Such is the acceptance of PBM in hospitals, that the UWA Professor of Surgery, Dr Jeffrey Hamdorf, is now introducing it in the medical school curriculum.

“The next step for us is to have PBM at the primary care level. We are working with GPs to see that blood screening is identified and managed before the patient comes to hospital. Those efforts are continuing in a number of Perth clinics and yielding good results,” Michael said.

Elements of the program are now used in all of the State’s public hospitals and many of the private hospitals are also on board, embedding PBM as a standard model of care.

It looks like the TV scriptwriters will need to change their tune.