Dr. Richard Gammon OneBlood, Inc. Patient Blood Management

Patient Blood ManagementWhat you Need to Know!

Speaker Name

Dr. Richard Gammon

OneBlood, Inc.

At the end of the session, the participant will be able to:

Discuss current transfusion thresholds

Possess a basic knowledge of patient blood management

Be knowledgeable of alternatives to blood transfusion

HEADER / PRESENTATION TITLE

Current Transfusion Thresholds

Recommendation 1

• Transfusion is not indicated until the hemoglobin level is 7g/dL

• Hospitalized adult patients who are hemodynamically stable

• Including critically ill patients

• Strong recommendation, moderate quality evidence

JAMA 2016; 316: 2025-35

Recommendation 1

• Orthopedic surgery or cardiac surgery and those with preexisting cardiovascular disease

• Restrictive RBC transfusion threshold hemoglobin level of 8g/dL

• Strong recommendation, moderate quality evidence

5

JAMA 2016; 316: 2025-35

Recommendation 1 Does Not Apply

• Acute coronary syndrome

• Severe thrombocytopenia (patients treated for hematological or oncological disorders who are at risk of bleeding)

• Chronic transfusion–dependent anemia

• Evidence is insufficient for any recommendation

6

JAMA 2016; 316: 2025-35

Recommendation 2

• Patients, including neonates, should receive RBC units selected at any point within their licensed dating period (standard issue)

• Rather than limiting patients to transfusion of only fresh (storage length: <10 days) RBC units

• Strong recommendation, moderate quality evidence

7

JAMA 2016; 316: 2025-35

RBC Dosing

• Hematocrit increased 3%

• Hemoglobin increased 1 g/dL• In non-bleeding, non hemolysing

patients administered as single unit dose

• A posttransfusion H/H • Obtained within 15 minutes -

determines if additional transfusions are indicated

8

Transfusion 1997; 37: 573-76

Recommendation 1

• Prophylactically at a count 10,000/uL or less

• Reduce the risk for spontaneous bleeding

• Hospitalized adult patients

• Hypoproliferative thrombocytopenia

• Grade: strong recommendation; moderate-quality evidence

9

Ann Intern Med. 2015;162:205-213

Recommendation 2

• Prophylactic platelet transfusion for elective central venous catheter placement with platelet count less than 20,000/uL

• Grade: weak recommendation; low-quality evidence

10

www.medical-dictionary.thefreedictionary.com 09/20Ann Intern Med. 2015;162:205-213

Recommendation 3

• Prophylactic platelet transfusion for patients having elective diagnostic lumbar puncture with platelet count less than 50,000/uL

• Grade: weak recommendation; very low-quality evidence

11

www.enwikepedia.org 09/20Ann Intern Med. 2015;162:205-213

Recommendation 4

• Prophylactic platelet transfusion for patients having major elective nonneuraxial surgery with a platelet count less than 50,000/uL

• Grade: weak recommendation; very low-quality evidence

12

Ann Intern Med. 2015;162:205-213

Recommendation 5

• Cardiopulmonary bypass (CPB)

• Perioperative bleeding with thrombocytopenia and/or evidence of platelet dysfunction

• Grade: weak recommendation; very low-quality evidence

13

Ann Intern Med. 2015;162:205-213

Recommendation 6

• The AABB cannot recommend for or against platelet transfusion for patients receiving antiplatelet therapy who have intracranial hemorrhage (traumatic or spontaneous)

• Grade: uncertain recommendation; very low-quality evidence

14

Ann Intern Med. 2015;162:205-213

Active BleedingNo High-Quality Evidence for Guidance

Criteria Platelet Count (/uL)

Thrombocytopenic Bleeding Patients Often recommended maintain count above 50,000/uL

15

AABB Technical Manual 20th ed. 2020

Some facilities use 100,000/UL for ophthalmologic, neurologic and pulmonary hemorrhage

Thrombocytopathy

• Causes• Congenital (e.g., Glanzmann thrombasthenia)

• Acquired as the result of disease (e.g., myelodysplasia)

• Drug treatment (e.g., with aspirin or glycoprotein IIb/IIIa antagonists)

• Transfusion Decisions• Acceptable even at normal counts

• Based upon patient’s clinical status

• Test platelet function

AABB Technical Manual 20th ed. 2020

• Platelet count should be obtained • Before

• 10 to 60 minutes after transfusion

• Platelet count should increase by 30,000 to 60,000/uL

• Assess the adequacy of response to transfusion

Platelets-Pre and Post Counts

AABB Technical Manual 20th ed. 2020Transfusion 1988:28:66-67

AABB Clinical Practice GuidelinesPlasma Thresholds• Current evidence-based guidelines for plasma transfusion are weak

• Systematic review of the available data found it to be sparse and of low quality

• Multidisciplinary panel of 17 experts developed evidenced-based guidelines

18

Murad MH, et al. Transfusion 2010; 50:1370-83Roback JD, et al. Transfusion 2010; 50: 1227-39

Plasma - Primary Supportable Indications

•Use for massive transfusion

•Reversal of warfarin anticoagulation in patients with intracranial hemorrhage

•Another therapeutic use is with plasma exchange for treatment of thrombotic thrombocytopenic purpura (TTP)*

19

*Common use not included with indicationsMurad MH, et al. Transfusion 2010; 50:1370-83Roback JD, et al. Transfusion 2010; 50: 1227-39

Not Recommended

• Situations that have typically resulted in prophylactic plasma infusion

• Coagulopathy or bleeding was absent, the risk of lung injury and possible increased mortality outweighed benefit

20

Transfusion-Related Acute Lung Injury (TRALI)

https://groupbpart5meltech.wordpress.com/case-study-transfusion-relate-acute-lung-injury/ 09/20

Murad MH, et al. Transfusion 2010; 50:1370-83Roback JD, et al. Transfusion 2010; 50: 1227-39

Additional Plasma Indications

• Before Invasive Procedures• INR>2.0

• Congenital factor deficiencies no coagulation concentrate available

21

Blood transfusion therapy. A physician’s handbook. 12th ed. 2017 Transfusion 2006; 46:1279-85

INR 1.1-1.5 1.5-1.85

Timing and Dose of Administration

• Correction -INR, PT or PTT is required• Plasma should be given immediately before surgery

• Dose• Based upon the patient’s size

• 10 to 20 mL/kg – multiple units are acceptable

• Measurement of coagulation parameters • Before and within 5 hours after transfusion

• Factor VII has a biologic half-life of 5 hours

22

AABB Technical Manual 20th ed. 2020

Choosing Wiselyand Alternatives to Blood Transfusion

• Overuse of blood transfusion has also been listed as Choosing Wisely statement • American Society of Hematology• Society of Hospital Medicine • Critical Care Societies

Collaborative

• AABB developed set of five recommendations with input committees and Board of Directors

Choosing Wisely Program

Transfusion 2014; 54: 2344-2352

#1 Don’t transfuse more units of blood than absolutely necessary

•Restrictive threshold (7.0-8.0g/dL) should be used for vast majority of hospitalized, stable patients without evidence of inadequate tissue oxygenation

• Evidence supports threshold of 8.0g/dL in patients with existing cardiovascular disease

25

#1 Don’t transfuse more units of blood than absolutely necessary

• Transfusion decisions should be influenced by symptoms and hemoglobin (Hb) concentration

• Single unit red blood cell transfusions should be standard for nonbleeding hospitalized patients

•Additional units should only be prescribed after reassessment of patient and Hb value

26

#2 Don’t transfuse RBCs for iron deficiency without hemodynamic instability

•Blood transfusion has become routine medical response despite cheaper and safer alternatives in some settings

•Preoperative patients with iron deficiency and patients with chronic iron deficiency without hemodynamic instability (even with low Hb levels) • Oral and/or intravenous (IV) iron

27

Anemia Management

28

Benitez-Sanchez – Blood Management Workshop 11/11

Myths About Vitamin K

Intravenous vitamin K is safe

• Some clinicians (and nurses) refuse to administer vitamin K intravenously due to the risk of anaphylaxis

•Historically, product had castor oil…

•Risk:• 0.04-11/10,000 doses

Fiore et al. J Thromb Thrombolysis 2001; 11:175-83

Slow to Reverse Warfarin

• Observation of effect of vitamin K on the international normalized ratio (INR) when administered subcutaneously

• Fat-soluble compound, subcutaneous injection slows absorption due to its solubility in subcutaneous fat

• Route of administration is least effective

• Effectively reverses the INR when given intravenously (IV) or orally

31

Overuse of plasma transfusion. ASCP Webinar 05/08/13Transfusion 2012;52:45S-55S

Arch Intern Med 1999;159:2721-4.Ann Intern Med 2002;137:251-4

Arch Intern Med 2003;163:2469-73

When should you consider reversing with a blood product?

• Limb or life-threatening bleeding• Intracranial hemorrhage

• Pericardial bleed

• Emergency surgical procedure in the next 6 hours• Traumatic rupture of a spleen, perforated viscous, ruptured

aneurysm

• Not just because the surgeon has operating room time in one hour

Transfusion 2012;52:45S-55S

#4 Don’t perform serial blood counts on clinically stable patients• Blood counts

• Reason to believe that new clinically significant abnormality will be detected

• Stable patients• Serial blood counts are

unlikely to detect clinically significant abnormalities

• Contribute to iatrogenic anemia

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Study 1- Cardiac Surgery PatientsSingle Center Study

• January 1, 2012 to June 30, 2012

• 1,894 patients underwent cardiac surgery • 1,867 - 1 hospitalization

• 27 – 2 hospitalizations

• Phlebotomy volume was estimated separately • Intensive care unit (ICU)

• Hospital floors

• Cumulatively

34

Ann Thorac Surg 2015; 99: 779-85

Increasing length of stay was associated with increasing overall phlebotomy volume and red blood cell transfusion

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Study Conclusions

• During the length of stay

• Patient’s total phlebotomy volumes approached amounts equivalent to 1 to 2 red blood cell units

Study 2 – Hospital Blood Loss

• All patients discharged 2012-2014

• Cumulative daily blood volume and draw frequency were reported by service and days since admission

• Changes in Hb and red blood cell transfusion rates were reported for nontransfused and transfused patients

Transfusion 2019;59;2849–2856

Results

• 59,715 subjects

• Mean daily estimated blood loss varied from 8.5-27.2 mL/day (ICU; p < 0.001)

• Phlebotomy volumes highest on first day of admission and declined thereafter (p < 0.001)

Results

• First week of admission, Hb levels decreased by highest percentage in ICU

• Rate of RBC transfusion highest in ICU

• 232.4 units/1000 patient-days

• p < 0.0001 compared with all other locations

Conclusions

•Considerable variation observed in estimated blood loss due to diagnostic phlebotomy across different services within one teaching hospital

• Foundation for planning interventions to minimize estimated blood loss from phlebotomy

#5. Don’t transfuse O– blood

•Recommended group O Rh(D)-negative RBCs should be reserved for group O Rh(D)-negative patients and in emergencies to females of childbearing potential

•Recent study estimated 44.5% of group O Rh(D)-negative RBC units used could have been replaced by group O Rh(D)-positive RBC units if age and gender factors were considered

Transfusion 2014, 54: 2344-2352Transfusion 2018;58: 1348-55

AABB Association Bulletin 19-02

Patient Blood ManagementThe Basics

Which Best Describes the Patient Blood Management Program At Your Hospital?

43

Jadwin D, et al. AABB 10/17

Patient Blood Management Covers Vein to Vein

44ABC Webinar 02/26/2014

Program Evolution

S. Benitez- Santana. Blood Management Summit 11/10

Cost of Allogeneic Blood

Transfusion 2010; 50: 753-65Transfusion 2018;58;846–853

What is Patient Blood Management??

• AABB- Patient Blood Management is the evidence-based multidisciplinary approach to optimizing the care of patients who may need transfusion

• SABM - Timely application of evidenced-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss in an effort to improve patient outcomes

Transfusion Medicine’s Emerging Positions- AABB Press 2013

Getting StartedEstablish Working Group

•Medical director

•Blood Bank Supervisor

• Lab Director

• Transfusion Safety Officer

•Administration

•Quality Assurance

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Establish Patient Blood Management StructureQuality

Council/Medical Executive Committee

Chief Medical Officer

Transfusion Safety Officer

Patient Blood Management

Committee

PBM Working Group

Massive Transfusion Review Committee

Medical Director

Review Polices and Procedures and Computer Order Entry (CPOE) Systems

50

≠

Enforce the Policies

• Alert physician letters are coming

• Informational for 6 months

• Medical Executive/Quality Council Committee decide how many nonconformities to elevate to additional action

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Fillable fields, email responsessend monthly

What To Measure

• Transfusion documentation

• Site audits

• Discharge instructions

• Task responses-follow-up

• Transfusion thresholds

• Wastage

• RBC per 1000 patient days

• Massive Transfusion Protocol

• Single unit Red Blood Cells

• Single unit Plasma

• Discharge Hemoglobin

• Failure to transfuse when indicated

• Product trends

• Transfusion reactions

• Clinical decision support data-cancelled orders

Transfusion Documentation

• Informed consent – fully completed -signed, witnessed, time/date

• Start/stop date/time

• Transfusionist/verifier

• Rate of infusion

• Volume transfused

• Vital signs at start, 15 min, end

• Pre-transfusion documentation

• Transfusion time (greater than 4 hours)

The Numbers – Transfusion Documentation

Discharge Instructions

Nursing Task Responses

Transfusion Thresholds

Wastage

0

5

10

15

20

25

30

35

40

Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun

Un

its

Wasted Products 2019

Red Blood Cells

Plasma

Platelets

Cryo

Martin North Martin South Martin Tradition

January 38.19 43.95 31.71

February 37.69 63.44 39.22

March 37.19 45.08 36.87

April 39.59 62.10 44.34

May 33.09 52.56 35.97

June 33.73 48.46 32.81

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

2020 CMI-weight Red Blood Cells 1K Acute Patient Days

January

February

March

April

May

June

Single Unit Red Blood Cells

• Percentage based off orders with hgb greater than 6• Screensaver month long launches: Oct 2017, Jan, Mar, Sept 2018, May, June, July 2019, Feb 2020 – blue arrows

• Goal is 60%- green line

2018- 55.41%2019- 62.25%2020-63.7%

Single Unit Plasma

• May and June 2020 COVID-19 Convalescent Plasma

• Includes single unit plasma for angioedema

Product Trends

Clinical Decision Support

• Displayed last three applicable labs

• First bullet of applicable transfusion threshold SOPs and link to full SOP

• Ask clinician if wanted to continue with order and gave option to cancel

63

Site Audits

• Issued from lab per policy

• Matched with order

• Completed Consent

• IV NaCl/blood tubing

• Two nurses compare/match and readback all identifiers

• Initiated within 30 min

• Form attached to component

• Vital signs at pre, 15 min, end

• Verification with two signatures

• Infused within 4 hours

• Lab values meet criteria

Site Audits/Floor Visits

Tracer Audits are Important

• The Joint Commission Resources (tracer software)

• Deficiency noted – email sent and request required by specified date

• Monthly meetings with Nursing Leadership• Follow-up on responses

where questions are not complete

• Provide PBM update

Nursing Response Rate - Percent

Patient Blood Management CommitteeOnly as Good as Its Members• Chair – Sets direction of PBM at

Medical Center• Transfusion Safety Officer• Blood Bank Supervisor• Laboratory Director• Administrator• Quality Assurance• Laboratory Transfusion Service

Pathologist • Hematology/Oncology • Risk Management

• Surgery • Anesthesia • Obstetrics/Gynecology • Hospitalist • Nephrology • Emergency Department• Neonatology• Marketing• Inpatient Care• Information Technology

68

Reduction in Blood - PBM approach

•Number of transfusions given per number of patient admissions

• Since initiation of PBM program in August 2014

•Reduction of 41% in rate of transfusions

PBM CertificationEstablish a Timeline

Year Goals Other items

One Establish PBM Program

Two Prepare for TJC/AABB PBM Certification

Budget for certification for year three

Three Obtain TJC/AABB PBM Certification

Partner with Quality Gap Analysis

PBM Timeline

2014 Patient Blood

Management program kick-

off

Developed auditing process

Updated CPOE to

match SOPs

Implemented CDS system (last 3 labs and link

to SOPs)

2015 Massive Transfusion

Protocol

Discharge instructions

automatically printed at

time consent generated

July 2016 Patient Blood Management Educational

Video

Bloodless Medicine Program

August 2017 Single Unit Transfusion Campaign

2018 Preparing for TJC PBM Certification

survey

PBM Metrics Summer

2018

Outcome

Few hospital systems

achieve this prestigious

Award!

73

What Worked

• Prepared for day of survey

• Provided opening presentation

• Followed agenda

• Surveyors/Assessors knowledgeable and professional

74

Know the Lingo

75

Assessment SurveyNonconformance Requirement for Improvement

Assessor Surveyor

What Did Not Work

• No documented evidence that staff attended educational opportunities that had been provided by Patient Blood Management

• Inconsistent understanding of goals and objectives of program

76

Facility Awareness is Important

• Ensure staff is aware of program

• Incorporated into annual physician and nursing education

Current Status

•Re-certification survey originally scheduled for 3Q20

•Date of survey to be determined

•May be virtual

•Happy 6th birthday!78

The Last Pandemic -1918

79

America’s Pastime Outdoor Court

The Last Pandemic -1918

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First Responders

SESSION NUMBER

4805