Patient blood management knowledge and practice among clinicians from seven European university hospitals: a multicentre survey.

BACKGROUND AND OBJECTIVES: The aim of this survey was to evaluate the knowledge about Patient Blood Management (PBM) principles and practices amongst clinicians working in seven European hospitals participating in a European Blood Alliance (EBA) project. MATERIALS AND METHODS: A web-based questionnaire was sent to 4952 clinicians working in medical, surgery and anaesthesiology disciplines. The responses were analysed, and the overall results as well as a comparison between hospitals are presented. RESULTS: A total of 788 responses (16%) were obtained. About 24% of respondents were not aware of a correlation between preoperative anaemia (POA) and perioperative morbidity and mortality. For 22%, treatment of POA was unlikely to favourably influence morbidity and mortality even before surgery with expected blood loss. More than half of clinicians did not routinely treat POA. 29%, when asked which is the best way to treat deficiency anaemia preoperatively, answered that they did not have sufficient knowledge and 5% chose to 'do nothing'. Amongst those who treated POA, 38% proposed red cell transfusion prior to surgery as treatment. Restrictive haemoglobin triggers for red blood cell transfusion, single unit policy and reduction of number and volumes of blood samples for diagnostic purposes were only marginally implemented. CONCLUSION: Overall, the responses indicated poor knowledge about PBM. Processes to diagnose and treat POA were not generally and homogeneously implemented. This survey should provide further impetus to implement programmes to improve knowledge and practice of PBM.

Patient blood management: how is implementation going?: A report comparing the 2015 survey with the 2013 survey of PBM in England.

BACKGROUND: Patient blood management (PBM) is an evidence-based approach to optimising the care of patients who might need transfusion. In 2013, all NHS Trusts in England were surveyed about their readiness to implement PBM. National PBM recommendations were launched in 2014. AIMS: The aim of this study was to determine progress of PBM initiatives. METHODS/MATERIALS: A survey was constructed by staff in hospitals and NHS Blood and Transplant (NHSBT). An online questionnaire was sent to all NHS Trusts in England (N = 149) in November 2015. RESULTS: Improvements in 2015: Education/training in transfusion: 80-100% from 60-90% in 2013 Provision of information relating to consent for transfusion: 98% from 65% in 2013 (P = <0·001) The management of anaemia: elective general surgery management, 66% from 41% in 2013 (P = <0·001) Transfusion alternatives: Tranexamic use in surgery, 92% from 71% in 2013 (P = <0·001) Laboratory staff empowered to challenge transfusion requests, 95% from 65% in 2013 (P = 0·001) Further work required: Electronic systems to support requesting (e.g. mandatory recording of diagnosis: 47% from 48% in 2013 (P = 0·85), incorporation of standardised requesting codes: 27% from 33% in 2013 (P = 0·24) Appropriate use of components: in 2015, only 42% had a lower red cell transfusion thresholds policy in non-bleeding patients CONCLUSIONS: The results provided information to support the development of local and national work plans. It is hoped that the collaborative work across NHS Blood and Transplant (NHSBT), the National Blood Transfusion Committee (NBTC) and NHS Trusts will continue to drive the PBM agenda to support best practice in this field.

Improving transfusion education for junior doctors; exploring UK experiences.

OBJECTIVES: To provide evidence-based guidance on how transfusion education should be delivered to junior doctors by employing established qualitative research methodology. BACKGROUND: There is a global call for increased transfusion education for doctors to support the delivery of evidence-based practice. Education is reported as an effective measure to improve transfusion practice, although there is a paucity of research evaluating how this should be effectively delivered. METHODS: Serial focus groups with junior doctors and relevant healthcare professionals explored experiences of, and reactions to, education and competency assessments in transfusion, which were audio-recorded and transcribed. Temporal and final analysis, performed by two independent assessors, informed subsequent recruitment, analysis and challenging of emerging theories - until saturation was reached. RESULTS: Eight focus groups were held involving 53 personnel, 77% of whom were junior doctors. Current transfusion education for doctors in the UK is reliant on e-learning and 'cascade training' (on-the-job from senior clinicians/nursing staff). E-learning is viewed as a 'tick box exercise'. There is a call for relevant and practical continuing education delivered face to face by good educators in an environment away from clinical practice. Preferred methods include small group and simulation learning based on real-life cases. In contrast to practical competency, the assessment of clinical competency is deemed unfeasible. CONCLUSION: Current methods of transfusion education employed in the UK are unsatisfactory to ensure safe transfusion practice. Ongoing education is deemed necessary throughout career progression, and suggested improvements include increased emphasis on face-to-face teaching and simulation training. Employed educational methods and decision support tools require appropriate evaluation.

Patient Blood Management in Europe: surveys on top indications for red blood cell use and Patient Blood Management organization and activities in seven European university hospitals.

BACKGROUND AND OBJECTIVES: Patient Blood Management (PBM) in Europe is a working group of the European Blood Alliance with the initial objective to identify the starting position of the participating hospitals regarding PBM for benchmarking purposes, and to derive good practices in PBM from the experience and expertise in the participating teams with the further aim of implementing and strengthening these practices in the participating hospitals. METHODS: We conducted two surveys in seven university hospitals in Europe: Survey on top indications for red blood cell use regarding usage of red blood cells during 1 week and Survey on PBM organization and activities. RESULTS: A total of 3320 units of red blood cells were transfused in 1 week at the seven hospitals. Overall, 61% of red cell units were transfused to medical patients and 36% to surgical patients, although there was much variation between hospitals. The organization and activities of PBM in the seven hospitals were variable, but there was a common focus on optimizing the treatment of bleeding patients, monitoring the use of blood components and treatment of preoperative anaemia. CONCLUSION: Although the seven hospitals provide a similar range of clinical services, there was variation in transfusion rates between them. Further, there was variable implementation of PBM activities and monitoring of transfusion practice. These findings provide a baseline to develop joint action plans to further implement and strengthen PBM across a number of hospitals in Europe.

The use of big data in transfusion medicine.

'Big data' refers to the huge quantities of digital information now available that describe much of human activity. The science of data management and analysis is rapidly developing to enable organisations to convert data into useful information and knowledge. Electronic health records and new developments in Pathology Informatics now support the collection of 'big laboratory and clinical data', and these digital innovations are now being applied to transfusion medicine. To use big data effectively, we must address concerns about confidentiality and the need for a change in culture and practice, remove barriers to adopting common operating systems and data standards and ensure the safe and secure storage of sensitive personal information. In the UK, the aim is to formulate a single set of data and standards for communicating test results and so enable pathology data to contribute to national datasets. In transfusion, big data has been used for benchmarking, detection of transfusion-related complications, determining patterns of blood use and definition of blood order schedules for surgery. More generally, rapidly available information can monitor compliance with key performance indicators for patient blood management and inventory management leading to better patient care and reduced use of blood. The challenges of enabling reliable systems and analysis of big data and securing funding in the restrictive financial climate are formidable, but not insurmountable. The promise is that digital information will soon improve the implementation of best practice in transfusion medicine and patient blood management globally.

Fresh blood for transfusion in adults with beta thalassaemia.

BACKGROUND: Patients with beta-thalassaemia major require life-long blood transfusion with the aim of achieving normal growth and development whilst minimising iron overload. A pre-transfusion Hb between 9.5 and 10 g/dL is thought to achieve this balance. UK consensus is that fresh blood (less than 14 days) is better at maintaining this target pre-transfusion Hb but there is no firm stipulation in place and no robust evidence supporting this. METHODS: After introduction of a universal fresh blood policy for adult beta-thalassaemics in 2010, we reviewed locally transfused adult patients to determine if there was any significant difference in pre-transfusion Hb using fresh blood. Nine adult thalassaemic patients were analysed for two consecutive 6-month periods in 2009 and 2010 (periods 1 and 2). RESULTS: Mean pre-transfusion Hb was significantly higher by an average of 0.5 g/dL in period 2 than period 1 (P < 0.05). The average unit age was 18 vs 9.5 days for periods 1 and 2 respectively (P < 0.05). There were no significant differences in potential confounders such as transfusion volume (P = 0.06), number of units transfused, ferritin or transfusion interval. DISCUSSION: Use of fresh blood produced significantly higher pre-transfusion Hb, giving credence to UK consensus. Lesser volumes of fresh blood appeared to achieve the target pre-transfusion Hb, which may translate to reduced iron overload and chelation costs. Whether the assumption that the use of blood less than 7 days old in these patients would result in greater benefit requires further study.

Targeted screening for genetic haemochromatosis: a combined phenotype/genotype approach.

OBJECTIVE: To evaluate the clinical utility of a targeted screening approach for the detection of genetic haemochromatosis. METHODS: Screening by measuring fasting serum transferrin saturation (TS) and gene testing was carried out in patients in whom a raised serum alanine amino transferase (ALT) activity and raised random serum TS had been found on routine blood testing. RESULTS: During the 29 month study period, 32 patients homozygous for the C282Y genotype were detected from a catchment population of 330,000 by screening blood samples referred initially for routine laboratory liver function tests. By comparison, during the same period of time and within the same population, only seven patients were found by clinical suspicion alone. The patients in the study, after treatment by venesection, have shown both clinical and biochemical improvement. CONCLUSIONS: The study shows that from a population of patients in whom a routine liver function profile had been requested, it is possible to detect subjects homozygous for the C282Y HFE genotype who have clinical or biochemical markers of iron overload.

Early discharge of patients with pulmonary embolism: a two-phase observational study.

The aim of the present study was to assess whether patients with pulmonary embolism (PE) could be managed as outpatients after early discharge from hospital using low molecular weight heparin instead of remaining as in-patients until effective oral anticoagulation was achieved. Phase 1 of the study identified criteria for the safe discharge of selected patients; phase 2 treated a cohort of low-risk patients with PE as outpatients with tinzaparin using existing deep venous thrombosis services. In phase 1, 127 (56.4%) of 225 patients were considered unsuitable for outpatient management. Reasons included: admission for another medical reason; additional monitoring or requirement for oxygen; bleeding disorders; previous PE/further PE while on warfarin; co-existing major deep venous thrombosis; likelihood of poor compliance; significant immobility; and pregnancy. In phase 2, 157 patients with PE received outpatient anticoagulation therapy. There were no deaths, bleeding or recurrent thromboembolic events during acute treatment with low molecular weight heparin. The median (range) length of hospital stay was 1.0 (1-4) day, with a median saving of 5.0 (1-42) bed-days per patient. Patients were highly satisfied with outpatient management; 144 (96.6%) indicated that they would prefer treatment as outpatients for a subsequent pulmonary embolism. Early discharge and outpatient management of pulmonary embolism appears safe and acceptable in selected low-risk patients, and can be implemented using existing outpatient deep venous thrombosis services.

Analysis of pre- and post-donation haematological values in plateletpheresis donors.

Pre- and post-donation haematological values were measured in 112 donors undergoing plateletpheresis using Haemonetics PCS machines. We found significant differences between pre- and post-donation means for males (M) and females (F) for haemoglobin (M: pre 14.73 g/dl, post 15.25 g/dl; F: pre 13.57 g/dl, post 13.94 g/dl), haematocrit (M: pre 0.418, post 0.431; F: pre 0.389, post 0.4), total protein (M: pre 73.1 g/l, post 66 g/l; F: pre 72.2 g/l, post 63.7 g/l) and albumin (M: pre 42.2 g/l, post 38.5 g/l; F: 41.4 g/l, post 37 g/l). Significant differences were also seen for platelet count (pre 258.6 x 10(9)/l, post 229.2 x 10(9)/l), total white cells (pre 5.3 x 10(9)/l, post 5.55 x 10(9)/l) and neutrophils (pre 3.15 x 10(9)/l, post 3.33 x 10(9)/l), but there were no differences between males and females. This information was of value in establishing post-donation reference ranges which could be utilised when reviewing the suitability of donors for subsequent donations.

Factors influencing haematological recovery in 53 patients with acute myeloid leukaemia in first remission after autologous bone marrow transplantation.

The kinetics of haematological recovery were retrospectively analysed in 53 patients with acute myeloid leukaemia in first remission after myeloablative chemoradiotherapy followed by autologous bone marrow transplantation. The median time to achieve a neutrophil count of 1 x 10(9)/l was 46 d (22-196 d) and median time to achieve unsupported platelet counts of 20 x 10(9)/l and 50 x 10(9)/l was 70 d (24-310 d) and 126 d (29-497 d) respectively. Multivariate analysis revealed two factors that were significantly associated with delayed neutrophil and platelet recovery: (1) use of high dose fractionated TBI and mononuclear cell cryopreservation, and (2) low platelet count at the time of bone marrow harvest. There was no correlation with: number of courses of chemotherapy, remission to ABMT interval, CMV status, indices of autograft quality or the development of elevated platelet associated immunoglobulin. Delayed haematological recovery did not predict for relapse or death. Delayed platelet recovery did, however, present significant problems with increased blood and platelet requirements and lengthening of hospital stay.

Polymerase chain reaction amplification of two polymorphic simple repeat sequences within the von Willebrand factor gene: application to family studies in von Willebrand disease.

We have used the polymerase chain reaction to amplify two variable number of tandem repeats (VNTRs) within a region of repetitive DNA located in intron 40 of the von Willebrand factor (vWf) gene. Heterozygosity for VNTR I was observed in 30 out of 39 normal unrelated individuals tested (77%), and for VNTR II in 29 out of 44 (66%) similar individuals. Family studies were carried out on 11 kindreds with von Willebrand disease (vWD). Ten of these families were found to be informative for one or other of the VNTRs or for a combination of data from both VNTRs. This method can be used for antenatal diagnosis and for carrier diagnosis in recessive forms of vWD. It is also useful for tracking the gene associated with vWD in type I families where there may be one or more individuals with a phenotypically uncertain diagnosis.