Barriers and enablers to introducing comprehensive patient blood management in the hospital

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<ul><li><p>pf Yao</p><p>Barriers</p><p>t (PBopty foM,veriqus copec</p><p> 2012 The International Alliance for Biological Standardization. Published by Elsevier Ltd. All rights</p><p>issueies whddress) is acess thblood ay for th</p><p>be patient-focused, taking into account various phases of trans-fusion including the pre-transfusion phase that focuses on thepatients evaluation and clinical management, the decision totransfuse, the transfusion act proper as well as post-transfusionsurveillance.</p><p>presentations where applicable. An operational manual is drawnfor tasks requiring manipulations. With appropriate implementa-tion and surveillance, these contribute signicantly to enablingPBM.</p><p>Guidelines for the appropriate clinical use of blood have alsobeen developed by theWHO and are available in various formats toall. These have been modied and adapted to various settings, and40 countries of the AFRO region have developed guidelines for theclinical use of blood [3].</p><p>* Tel./fax: 237 22314039.</p><p>Contents lists available at</p><p>Biolog</p><p>se</p><p>Biologicals 40 (2012) 205e208E-mail address: dmbanya1@yahoo.co.uk.to a statement from the American Association of Blood Banks(AABB), a comprehensive PBM programme should include: appro-priate indications; minimization of blood loss; maximization ofpatient red cell mass as well as being evidence-based [2]. Thiswould involve equilibrated interactions between various stake-holders and factors including transfusion services; associatedlaboratory services; clinicians (surgeons, anaesthetists, paediatri-cians, obstetricians-gynaecologists, internists and nurses amongstothers) as well as the beneciaries (patients). Thus, PBM ought to</p><p>2.1. Standards and guidelines</p><p>Quality documents should be available which provide infor-mation on policies; organizational systems, specic methods andactivities to be accomplished. Such information documents includetechnical reports, regulatory texts, records, norms &amp; recommen-dations; clerical procedures including standard operating proce-dures (SOPs) established for various activities. The different tasksare distinguished with theoretical descriptions and diagrammatic1. Introduction</p><p>Blood safety continues to be anespecially in the developing countrtransfusion chain are inadequately a</p><p>Patient Blood Management (PBMdisciplinary and comprehensive proappropriate, rational and safe use ofexpected outcome is improved safet1045-1056/$36.00 2012 The International Alliancedoi:10.1016/j.biologicals.2012.01.003of concern worldwide,ere all aspects of theed [1].patient-focused, multi-at ensures the optimal,nd blood products. Thee recipients. According</p><p>2. Barriers and enablers of patient blood management</p><p>Within the hospital setting, several factors may intervene atvarious levels as barriers or enablers of PBM such as standards/guidelines; professional leadership and commitment; humanresources (quality and quantity); clinicians as well as relevantprogrammes put in place to accompany these (see Section 2.5below).Enablers reserved.Barriers and enablers to introducing comin the hospital</p><p>Dora Mbanya*</p><p>Faculty of Medicine &amp; Biomedical Sciences, Haematology and Transfusion, University o</p><p>a r t i c l e i n f o</p><p>Article history:Received 2 November 2011Received in revised form16 January 2012Accepted 17 January 2012</p><p>Keywords:Patient blood managementBlood transfusion</p><p>a b s t r a c t</p><p>Patient Blood Managemenis designed to ensure thebetter outcome and safeta resolution in favour of PBrational use. However, sepersonnel, available technquality systems as well acountries may have other</p><p>journal homepage: www.elfor Biological Standardization. PubM) is a patient-focused multidisciplinary and comprehensive concept thatimal, appropriate and safe use of blood and blood products, resulting inr the recipients. The World Health Organization, in May 2010, adoptedon the availability, safety and quality of blood products and their safe andal factors may enhance or hamper this process including health carees and technologies, devices, standards, guidelines and documentation,ordination, monitoring and evaluation. The implications in developinguliarities.rehensive patient blood management</p><p>und I, Melen, Centre Province, B.P.8046 Yaound, Cameroon</p><p>SciVerse ScienceDirect</p><p>icals</p><p>vier .com/locate/bio logicalslished by Elsevier Ltd. All rights reserved.</p></li><li><p>Obstetrics/Gynaecology services were the greatest users of blood ina hospital setting of Cameroon [5,6] whichwould not be the patternin the developed countries. Some issues identied includedavoidable blood prescriptions from misdiagnosis; indispensableones due to late diagnosis and in some cases inappropriate quan-tities were prescribed. Paramedical staff represented the mainprescribers in some instances and whole blood was prescribed inmore than 90% cases [5]. Another study in East Africa reportedmalaria and bleeding disorders as the main indications for trans-fusion with 58% transfusions consisting of whole blood [7]. Indeedmalaria is a major cause of morbidity and anaemia requiringtransfusions, especially in young children [8,9]. Table 1 shows somemajor indications of blood transfusions in SSA [7,9e12]. Malaria hasalso been shown to contribute signicantly to thrombocytopenia</p><p>als 40 (2012) 205e2082.2. Professional leadership and commitment</p><p>Hospital Transfusion Committees (HTC) could play a leadershiprole providing effective hospital governance that would cater for alltransfusion-related issues within the institution. The HTC isa multidisciplinary body involving all hospital departments thatdeal with blood prescription and blood provision. They oversee theimplementation of national policies on blood transfusion andguidelines on the clinical use of blood and blood products as well asinvestigate and provide feedback following critical incidents(examples: malpractice, fatal outcomes). It should have authoritywithin the hospital to determine hospital policies in relation totransfusion and resolve any problems identied; to develop bloodordering schedules and monitor blood usage in the hospital, in linewith changing practices. Thus, the HTC ensures the availability ofSOPs. It is responsible for organizing audits, providing the ndingsand effecting improvement on existing standards based on theaudits conclusions. However, in the African region, very low levelof HTC exists coupled with the lack of communication betweenclinicians and blood bank staff [3].</p><p>Furthermore, a respected senior clinician with an activeprofessional interest in improving transfusion practice could alsoplay a leadership role. The interest of such Clinical Champions maybe captured by involving them in organizing audits or clinicalresearch on transfusion.</p><p>2.3. Staff</p><p>2.3.1. Transfusion service (providers)For effectiveness, sufcient numbers of qualied staff are</p><p>required who are knowledgeable in their eld of expertise andcompetent in their output. This is maintained and enhanced overtime through in-house and external training programmes. Distantlearning can also be used for staff improvement. However, this idealsituation is not always applicable in many resource-limited settings(RLS). For example, in an Ugandan study, it was observed thatclinicians lacked adequate knowledge even on the products avail-able in their institutions blood bank as well as on their uses [4].Such situations can be salvaged by informal in-house educationalprogrammes. Yet only in 27 of 46 country Blood TransfusionServices in the African region have educational programmes [3].</p><p>Interestingly, several training and educational materials areavailable from theWorld Health Organization (for Distant Learning;Quality Management; costing Blood Transfusion Services; theClinical use of blood and donor recruitment among others). TheInternational Federation of the Red Cross and Red Crescent; theEuropean Union, the AABB also provide educational and trainingmaterials.</p><p>These will allow for continuing education and career develop-ment which favours staff retention, as well as staff competency.</p><p>2.3.2. Clinicians (blood prescribers/users)Blood users also need to understand the indications for blood</p><p>products and prescribe them appropriately. Such knowledge couldbe acquired formally or informally through refresher courses andbedside discussions. For example, in Kumasi, Ghana, informaltraining on the use of blood and blood components is carried outfor each new batch of residents received in the service [Allain JP,personal communication].</p><p>Nevertheless, the major indications of blood transfusion mayvary from place to place, hence the need to emphasis on someaspects in different settings. For example, the uses of blood in Africawould differ from those in Europe, and the availability of bloodproducts may also vary, requiring specic knowledge adapted to</p><p>D. Mbanya / Biologic206specic conditions. Some studies reported that the Paediatric andalthough it usually does not require platelet transfusions [13e15].According to the WHO in 2002, only 20% of the African coun-</p><p>tries produced platelet concentrates, less than 60% red cellconcentrates; less than 50% fresh frozen plasma and about 70% ofall transfusions comprised of whole blood [16] e see Fig. 1. Inmany RLS, especially of sub-Saharan Africa, whole blood ispredominantly used, mainly because of the lack of facilities andlogistics for component preparations. Nevertheless, anaemiaremains the main indication for transfusion in these settingswhere parasitic infections (malaria, hookworm); haemoglobinop-athy and HIV are prevalent [8,17,18], hence other components arenot indispensable in those instances.</p><p>2.3.2.1. Ordering blood. All blood should be ordered on bloodrequest forms and these should carry the name of the institution,the date of the request, date and time the blood is required; thepatients name, sex and date of birth (DOB); the hospital identi-cation (Hospital ID) number as well as the ward. Furthermore, theindication for blood transfusion should be specied; the type ofblood product and the number of units required as well as thepatients blood group if known. Any history of previous trans-fusions and/or reactions should be mentioned, and an obstetricalhistory is needed for women. The blood prescriber should alwaysafx their name and signature on the blood request form. Inter-estingly, in many RLS, paramedics often prescribe and administerblood transfusions [5,19].</p><p>2.3.2.2. Blood collection from the blood bank. A written document(and not verbal only) should always be used to identify the patient,whose name, Hospital ID number, ward and ABO and RhD groupsshould exactly match the details corresponding to the blood bag.The blood products should be signed out against the patients namefrom the blood collection register.</p><p>Blood products should be transported under appropriatelyrecommended conditions to the site of use.</p><p>Table 1Indications for blood transfusion in various countries of sub-Saharan Africa.</p><p>Country Main indications Reference/Source</p><p>Cameroon Anaemia from malaria Mbanya et al. [8]Cameroon Anaemia from Malaria, Mbanya et al. [17]</p><p>Sickle cell diseaseCameroon Main indications Mbanya &amp; Kaptue, 1995 [5]Kenya Malaria Pedro R et al., 2010 [11]Kenya Malaria Akech SO et al., 2008 [9]Tanzania Sickle cell anaemia Makani J et al., 2011 [12]Tanzania Malaria Mosha D et al., 2009 [10]Uganda Malaria, Natukunda et al., 2010 [7]</p><p>Haemorrhage</p><p>UNAIDS HIV infection UNAIDS/WHO, 2009 [18]</p></li><li><p>cals2.3.2.3. Blood transfusion act. There is a need for appropriatebedside checks prior to transfusion. Firstly, the patient should bepositively identied by stating their names and DOB, comparedagainst their medical notes and wrist band. For unconscious,unidentied or paediatric patients, a relative and/or anothermember of staff or responsible person must verify their identity.The blood group (ABO and Rhesus) on the unit must match that onthe request form and the patients blood groups with previousrecords. A last check is recommended just prior to setting up thetransfusion unit. However, several unpublished observationssuggest that these recommendations are not often implemented.</p><p>For example, one report of the Serious Hazards of Transfusion,United Kingdom, indicated that of 87 cases of errors reported, 50were clinical with 23 (46%) of blood to wrong patients, 23 (46%) ofwrong blood sent to clinical areas and 4 (8%) were errors in patientsampling [20]. This is even worse in RLS where blood safety isfurther compromised by so much including the lack of haemovi-gilance systems. However, bedside checks would curb these.</p><p>Once a transfusion is being administered, close monitoring ofthe recipients blood pressure, pulse and respiratory rate is indis-pensable during the rst 15 min of transfusion because severeincompatibility reactions could be intercepted and fatal outcomesreversed, especially in ABO incompatibility. Following this criticalperiod, monitoring throughout the rest of procedure is alsoimportant. All incidents should be recorded and reported, some-thing not often done [7].</p><p>Availability of blood products </p><p>Whole blood (70%)Red Cell Concentrates (60%)Fresh Frozen Plasma (50%)Platelet Concentrates (20%)</p><p>Fig. 1. Availability of blood products in countries of sub-Saharan Africa (WHO Globaldatabase on Blood Safety, Report 2001e2002 [16]).</p><p>D. Mbanya / Biologi2.3.2.4. Use of alternatives. Clinicians are also encouraged to usealternatives to blood transfusion whenever possible. These includeintravenous replacement uids such as macromolecules (normalsaline; Ringers) and albumins. However, uid boluses have beenreported to signicantly increase 48-h mortality in critically illchildren in RLS in Africa [21], thus caution is required.</p><p>Haemostatic drugs including coagulation factor concentratesand Desmopressin (indicated for selected cases of mild Haemo-philia A and von Willebrands Disease) may also be used. InCameroon, in collaboration with the University of Geneva and theWorld Federation of Haemophilia, the provision of small amounts ofFactor VIII, Factor IX and Novoseven have considerably reducedtransfusion needs in people living with bleeding disorders inCameroon [unpublished observations]. Vitamin K1, Somatostatin aswell as Tranexamic acid are other haemostatic drugs used in varioussettings. In Cameroon, Tranexamic acid is used indiscriminately inmany cases of bleeding, with positive outcome in some [unpub-lished observations], and there are reports of its effectiveness inreducing bleeding in surgery hence minimizing the need for bloodwhere blood shortage is commonplace and providing economic</p><p>incidents in over 50% of transfusion recipients, indicating the</p><p>observations].2.5.1.2. Audits. This measures staff performance against set stan-dards using dened indicators on their ability to correctly assessvarious situations, take appropriate actions and with prioritisation,appropriate timing of interventions and the correct use of the rightskill and techniques.</p><p>A few reports on audits in Nigeria suggest their great need in theAfrican region. The one reported 29% of transfusions for moderateanaemia and 36% of fresh froz...</p></li></ul>