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Biologicals 40 (2012) 205e208

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Biologicals

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Barriers and enablers to introducing comprehensive patient blood managementin the hospital

Dora Mbanya*

Faculty of Medicine & Biomedical Sciences, Haematology and Transfusion, University of Yaoundé I, Melen, Centre Province, B.P.8046 Yaoundé, Cameroon

a r t i c l e i n f o

Article history:Received 2 November 2011Received in revised form16 January 2012Accepted 17 January 2012

Keywords:Patient blood managementBlood transfusionBarriersEnablers

* Tel./fax: þ237 22314039.E-mail address: dmbanya1@yahoo.co.uk.

1045-1056/$36.00 � 2012 The International Alliancedoi:10.1016/j.biologicals.2012.01.003

a b s t r a c t

Patient Blood Management (PBM) is a patient-focused multidisciplinary and comprehensive concept thatis designed to ensure the optimal, appropriate and safe use of blood and blood products, resulting inbetter outcome and safety for the recipients. The World Health Organization, in May 2010, adopteda resolution in favour of PBM, on the availability, safety and quality of blood products and their safe andrational use. However, several factors may enhance or hamper this process including health carepersonnel, available techniques and technologies, devices, standards, guidelines and documentation,quality systems as well as coordination, monitoring and evaluation. The implications in developingcountries may have other peculiarities.

� 2012 The International Alliance for Biological Standardization. Published by Elsevier Ltd. All rightsreserved.

1. Introduction

Blood safety continues to be an issue of concern worldwide,especially in the developing countries where all aspects of thetransfusion chain are inadequately addressed [1].

Patient Blood Management (PBM) is a patient-focused, multi-disciplinary and comprehensive process that ensures the optimal,appropriate, rational and safe use of blood and blood products. Theexpected outcome is improved safety for the recipients. Accordingto 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 beneficiaries (patients). Thus, PBM ought tobe 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.

for Biological Standardization. Pub

2. Barriers and enablers of patient blood management

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).

2.1. Standards and guidelines

Quality documents should be available which provide infor-mation on policies; organizational systems, specific methods andactivities to be accomplished. Such information documents includetechnical reports, regulatory texts, records, norms & recommen-dations; clerical procedures including standard operating proce-dures (SOPs) established for various activities. The different tasksare distinguished with theoretical descriptions and diagrammaticpresentations where applicable. An operational manual is drawnfor tasks requiring manipulations. With appropriate implementa-tion and surveillance, these contribute significantly to enablingPBM.

Guidelines for the appropriate clinical use of blood have alsobeen developed by theWHO and are available in various formats toall. These have been modified and adapted to various settings, and40 countries of the AFRO region have developed guidelines for theclinical use of blood [3].

lished by Elsevier Ltd. All rights reserved.

Table 1Indications for blood transfusion in various countries of sub-Saharan Africa.

Country Main indications Reference/Source

Cameroon Anaemia from malaria Mbanya et al. [8]Cameroon Anaemia from Malaria, Mbanya et al. [17]

Sickle cell diseaseCameroon Main indications Mbanya & 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]

HaemorrhageUNAIDS HIV infection UNAIDS/WHO, 2009 [18]

D. Mbanya / Biologicals 40 (2012) 205e208206

2.2. Professional leadership and commitment

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 identified; 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 findingsand 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].

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.

2.3. Staff

2.3.1. Transfusion service (providers)For effectiveness, sufficient numbers of qualified staff are

required who are knowledgeable in their field 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 institution’s 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].

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.

These will allow for continuing education and career develop-ment which favours staff retention, as well as staff competency.

2.3.2. Clinicians (blood prescribers/users)Blood users also need to understand the indications for blood

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].

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 specific knowledge adapted tospecific conditions. Some studies reported that the Paediatric and

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 identified 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 significantly to thrombocytopeniaalthough it usually does not require platelet transfusions [13e15].

According to the WHO in 2002, only 20% of the African coun-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.

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; thepatient’s name, sex and date of birth (DOB); the hospital identifi-cation (Hospital ID) number as well as the ward. Furthermore, theindication for blood transfusion should be specified; the type ofblood product and the number of units required as well as thepatient’s 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 alwaysaffix their name and signature on the blood request form. Inter-estingly, in many RLS, paramedics often prescribe and administerblood transfusions [5,19].

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 patient’s namefrom the blood collection register.

Blood products should be transported under appropriatelyrecommended conditions to the site of use.

Availability of blood products

Whole blood (70%)

Red Cell Concentrates (60%)

Fresh Frozen Plasma (50%)

Platelet Concentrates (20%)

Fig. 1. Availability of blood products in countries of sub-Saharan Africa (WHO Globaldatabase on Blood Safety, Report 2001e2002 [16]).

D. Mbanya / Biologicals 40 (2012) 205e208 207

2.3.2.3. Blood transfusion act. There is a need for appropriatebedside checks prior to transfusion. Firstly, the patient should bepositively identified by stating their names and DOB, comparedagainst their medical notes and wrist band. For unconscious,unidentified 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 patient’s 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.

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.

Once a transfusion is being administered, close monitoring ofthe recipients blood pressure, pulse and respiratory rate is indis-pensable during the first 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].

2.3.2.4. Use of alternatives. Clinicians are also encouraged to usealternatives to blood transfusion whenever possible. These includeintravenous replacement fluids such as macromolecules (normalsaline; Ringer’s) and albumins. However, fluid boluses have beenreported to significantly increase 48-h mortality in critically illchildren in RLS in Africa [21], thus caution is required.

Haemostatic drugs including coagulation factor concentratesand Desmopressin (indicated for selected cases of mild Haemo-philia A and von Willebrand’s 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

gain [22]. Ongoing studies are suggesting reduced bleeding too intrauma and women with postpartum haemorrhage [23].

Hormones and growth factors including erythropoietin andgranulocyte colony stimulating factors (G-CSF) are commerciallyavailable although they are very costly, hence requiring that theiruse be carefully assessed. In addition, the use of appropriate tech-niques in surgery and other disciplines of Medicine are alsoencouraged and haematinics may be used for correcting nutritionalanaemias.

2.4. Communication

Good communication between the clinical and Blood bank staffis an effective enhancer of PBM [24].

2.5. Programmes

Some programme must be implemented on a permanent basisfor PBM to be effective. These may include Quality systems; Hae-movigilance; Audits; Research and HTC (see Section 2.2).

2.5.1. Quality systemsStrong management support and the need for a designated

Quality Manager, sufficient staff, proper working conditions, facil-ities and training (summarised as financial support) are indis-pensable for the system to work. Even a 1% error in quality couldimpact tremendously on time, financial resources, personnel effortsand, more importantly, on patient outcome. For example, in ananalysis of the quality of red cell concentrates transfused ina hospital setting of Yaoundé, only 57% and 80% units conformed tothe ISO 9001:2000 norms regarding volumes and haemoglobin/haematocrit content respectively [25]. Yet by 2006, only 32 coun-tries of the African region had designated Quality Managers [3],a marked improvement though, from nothing in 1999. Further-more, 16 countries of the region had an External Quality AssuranceScheme for transfusion transmissible infections [3].

2.5.1.1. Haemovigilance. Haemovigilance is indispensable for PBMand the ultimate aim is to take preventive and/or correctivemeasures against recurrences and improving blood safety asa whole.

Haemovigilance is poorly developed in many countries of theAfrican regionwhere only about 50% of countries had some form ofa haemovigilance and quality control systems in 2002 [16]. Yetavailable data suggests its necessity. A report on transfusionoutcome over a five-year period in Cameroon noted unfavourableincidents in over 50% of transfusion recipients, indicating themagnitude of the problem in these settings [26]. The major barriersobserved in that study included the absence of a system in place formonitoring transfusion outcome; for reporting outcomes and thelack of trained staff to recognize the adverse effects of transfusionand the appreciate the relevance of monitoring [personalobservations].

2.5.1.2. Audits. This measures staff performance against set stan-dards using defined 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.

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 frozen plasma transfusions found to beunnecessary and 81% inappropriate platelet transfusions [27]. Theuse of uncrossmatched units has also been reported [28].

D. Mbanya / Biologicals 40 (2012) 205e208208

Audits lead to the revision and/or improvement of existingstandards and keep the system in line with changing practices.

2.5.1.3. Research. This is indispensable because it allows forevidence-based policies, decisions and guidelines.

3. Conclusions

Effective Patient BloodManagementmeans optimal use of bloodand blood products through appropriately set standards andguidelines that produce the right unit of blood for the right patientat the right time and under the right conditions. Sadly, low policyimplementation rates; inadequate financial resources; high prev-alence of TTIs in some regions and the lack of trained humanresources in many countries are barriers to appropriate PBM.

4. Recommendations

The following recommendations may be made on various armsof PBM including human resources, where there is a need forcapacity building and personnel development especially inresource-limited settings, so that the right people with the rightskills, competencies and motivations are available for PBM.Hospital Transfusion Committees should be encouraged in hospitalsettings for managing all the transfusion-related issues of theinstitution. Monitoring and Evaluation of the implementation andcompliance levels of staff are not commonly carried out in manysettings. Only such feedback could lead to the development ofperformance indicators and standards for hospitals, on variousaspects of the transfusion process. Furthermore, effective collabo-ration between the Blood Bank and the clinicians is indispensablein PBM and should be fostered.

Acknowledgement

I wish to acknowledge all who contributed material towards thewriting of this paper including Prof. Jean Pierre Allain; Dr. NeelamDhingra, Dr Jean Baptist Tapko and Dr. Brian McClelland.

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