Blood transfusion: rethinking
who, what and when
Dr Rebecca Howman
Consultant Haematologist
Blood transfusion practice
• Blood is unique treatment
– It’s a gift: voluntary donors
– It’s complex:
Australian Red Cross Blood Service
TGA
hospitals
laboratories
clinicians
patients
Evolution of transfusion
Transfusion practice in 21st century
Transfusion guidelines from
NHMRC
• >100 g/L transfusion prob
not good
• <70 g/L transfusion prob
good
• 70-100 g/L …you decide
Normal Hb male 130g/L, female 120g/L
1 unit of blood can increase Hb by 10g/L
“If you have decided the patient needs one unit, then you might as well give two”
“You need a blood transfusion.”….”Do I?”
Transfusion for anaemia in nonbleeding patient
• We have assumed for too long that
transfusion is safe, beneficial and free
• In anaemic patients
– ?does an increase in Hb equate to improved patient
symptoms, improved patient outcomes
– ?at what threshold is the clinical benefit
– ?is there any harm
Recognition of risks of blood
transfusion
• Risks of blood transfusion go beyond transmission of
infection, fever, incomptability reactions etc
• Blood transfusion is associated with worse patient
outcomes
–
–
–
–
–
Increased post-operative infection (immune modulation)
Increased length of stay
Increased thrombosis rate
Increased cancer recurrence
Increased mortality in short term
Blood Budget
• Blood is freely given but it is not free!
• $350 per unit red cells from ARBCS
• $650-1000 per unit = administration,
transport, hospital costs
• Future (2016)– blood budget is to be devolved
to hospitals
Patient Blood Management (PBM)
The timely application of evidence-based medical and
surgical concepts designed to maintain hemoglobin
concentration, optimize hemostasis and minimize blood
loss in an effort to improve patient outcome.
PBM in WA
• 3.9% hospital separations in 2012-2013 were associated with a
transfusion
• DoH in WA has been implemented Patient Blood Management
– FH 2008
– SCGH mid-2012
– RPH, KEMH 2013
• PBM staff provide
– education regarding risks and benefits of transfusion
– advocate alternatives to transfusion e.g. IV iron
– initiate and advocate for hospital policies that support the appropriate
use of blood and blood products
– develop innovations such as paediatric tubes, Rotem, etc
Single unit transfusion policy at SCGH
Why give 2,
when 1 will do?
•In many instances a
transfusion of one unit of
red cells will be sufficient to
improve symptoms
• A second unit should only
be prescribed following
review of the patient
Comparison of pre- and post-single unit policy
4967
3923
3165
2863
Reduction of
1044 units
(21%)
transfused
Comparison of pre- and post-single unit policy
2065
1707
1227
646
231
172
Comparison of pre- and post-single unit policy
43%
reduction
956
24%
reduction
360
233
547
Overall “value”
• Cost savings: significant
– $361,570 saved (RBC price)
– $2-3.6 million (total transfusion price)
• Patient outcomes….???
– Length of stay
– Infection rate
– Readmission rates
What enabled change to transfusion
practice?
• Education of clinicians regarding better clinical
practice for patients
• NOT educating clinicians on
– Cost savings
– Waste prevention
– Standardising care
The future?
• PBM is attempting to change hospital culture
– we have achieved a lot in 18 months
– still much work to be done to make the change
permanent
• Currently funded by DoH, longer term plan for
hospitals to fund directly
– ?will it continue for 2014-15
– ?what will become of program if (when) hospitals
decide that they are not funding extra positions