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]. / Gestion du sang du patient et pour le patient.

OBJECTIVES: In a context of regular review of transfusion practice, the aim of this review is to present an update of the scientific basis of the so-called "patient blood management" (PBM), the state of its development in Europe, and possible ways to progress its development further in France. METHODS: Analysis and synthesis of the data from scientific literature on the scientific basis of PBM (methods, indications, efficacy, risks, efficiency). RESULTS: PBM appears as an evidence-based, patient centred, multidisciplinary approach, aiming to optimise the care of patients who might need transfusion and, consequently, the use of blood products. PBM is based on three pillars: optimise the patient's own blood supplies, minimise blood loss, optimise patient's tolerance of anaemia. Available scientific evidence can be considered as sufficient to consider PBM guidelines and practices as an indispensable complement to the transfusion medicine guidelines and practices. Several countries have launched PBM programmes (alternatives to allogeneic transfusion and optimisation of the use of blood components). Although current French national transfusion guidelines contain some PBM measures, PBM programmes should be further developed in France, primarily for medical reasons. CONCLUSIONS: Possible ways, using the existing basis having proved to be effective, are proposed to further develop PBM in France, as a complement to transfusion medicine, with the participation of involved stakeholders, including experts from relevant medical specialties, both at local and national levels.

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 revision of the European blood directives: A major challenge for transfusion medicine.

AIM: Using both patient-focused and donor-focused perspectives, to review the current EU blood directives, in order to derive proposals, in principle, for what should evolve during the revision process of these directives. METHODS: Review of the EU blood directives in the light of scientific literature, related reports from the Directorate General Health and Consumers (DG SANTÉ), and from the Council of Europe (CoE). RESULTS: The analyses led us to present the main following proposals: developing voluntary unpaid donations: the directives should consider taking into consideration ethically acceptable forms of compensation consistent with altruistic donation (including plasma donations for fractionation); current expertise: more extensive utilization of the expertise of blood establishments and their consultants should be considered; donor selection: an evidence-based approach for basing donor deferral criteria on sound scientific evidence should be promoted; donor reactions: measures to prevent donor reactions and to make donations safer for the donors should also be included; quality control: The quality control requirements should relate to the Council of Europe Blood Guide specifications: these should become minimum standards (as is the case with monographs of the European Pharmacopeia), facilitating regular update of blood component lists and related specifications and compliance with the specifications; haemovigilance: because of reporting difficulties (e.g. lack of number of blood products transfused), the effectiveness of haemovigilance has so far been limited. This should lead appropriate bodies to investigate alternative or complementary ways to help improve patient safety, taking into consideration, in principle, patient blood management and the appropriate use of blood products. Furthermore, donor vigilance, which is still absent from the current directive should be included in a revised directive. CONCLUSIONS: These proposals for revising the current EU blood directives (if taken into account and given appropriate regulatory formulation) should help to optimize patient safety and donor care, progress the compliance with the ethical principles for donors and improve the efficiency of the healthcare systems dedicated to transfusion medicine.

[Roundtables of SFTS Congress 2013: Needs, indications and safety of blood products; self-sufficiency in blood products]. / Besoins, prescriptions et sécurité des produits sanguins labiles ; autosuffisance en produits sanguins labiles.

The current issues debate brings together experts around the themes of self-sufficiency (in its national and European aspects) and of needs in cellular blood products. The point of view of the manufacturer and prescribers of blood products are confronted.

[Self-sufficiency, needs, prescription and safety of blood products]. / Autosuffisance, besoins, prescription et sécurité des produits sanguins labiles.

The current issues debate will bring together experts around the themes of self-sufficiency (in its national and European aspects) and of needs in cellular blood products. The point of view of the manufacturer and prescribers of blood products will be confronted.

Donor cycle and donor segmentation: new tools for improving blood donor management.

BACKGROUND AND OBJECTIVES: An adequate donor population is of key importance for the entire blood transfusion chain. For good donor management, a detailed overview of the donor database is therefore imperative. This study offers a new description of the donor cycle related to the donor management process. It also presents the outcomes of a European Project, Donor Management IN Europe (DOMAINE), regarding the segmentation of the donor population into donor types. MATERIALS AND METHODS: Blood establishments (BEs) from 18 European countries, the Thalassaemia International Federation and a representative from the South-Eastern Europe Health Network joined forces in DOMAINE. A questionnaire assessed blood donor management practices and the composition of the donor population using the newly proposed DOMAINE donor segmentation. 48 BEs in 34 European countries were invited to participate. RESULTS: The response rate was high (88%). However, only 14 BEs could deliver data on the composition of their donor population. The data showed large variations and major imbalances in the donor population. In 79% of the countries, inactive donors formed the dominant donor type. Only in 21%, regular donors were the largest subgroup, and in 29%, the proportion of first-time donors was higher than the proportion of regular donors. CONCLUSION: Good donor management depends on a thorough insight into the flow of donors through their donor career. Segmentation of the donor database is an essential tool to understand the influx and efflux of donors. The DOMAINE donor segmentation helps BEs in understanding their donor database and to adapt their donor recruitment and retention practices accordingly. Ways to use this new tool are proposed.

[European Blood Alliance (EBA) and EuroNet TMS: what challenges for the transfusion of tomorrow?]. / European Blood Alliance (EBA) et EuroNet TMS: quels enjeux pour la transfusion de demain?

The primary mission of the European Blood Alliance (EBA) is to contribute to the safety and efficiency of the supply of blood products, cells and tissues, in developing an active network of blood establishments in Europe (25 countries). Its strategic objectives are to improve performance (through working groups and projects funded by the European Union), to engage in regulatory affairs (particularly at the European Commission level) to promote best practices and to facilitate a network to collect and share knowledge and experiences. The main objective of EuroNet TMS, combining the blood scientific societies from more than 30 countries in Europe, is to update and publish regularly, intended for policymakers, a White Book on the transfusion chain from donor to patient and probable or possible changes in the coming 5 years. Since 2008, EBA and EuroNet TMS actively collaborate on the drafting of the 2nd edition to be published in 2011. The two presidents jointly drafted the final chapter outlining the major issues of transfusion for tomorrow, summarized thereafter. Transfusion will still be useful for a long time and for reasons of safety and ethics the voluntary and unpaid donations, with non-profit blood establishments, will remain, the cornerstone of the supply of blood products. This renders crucial the continuous improvement of donor management and optimal blood use. On the regulatory side, after 5 years of implementation, EU directives must be independently evaluated and the Blood Guide of the Council of Europe should gradually become a regulatory standard. Finally, if a competition should be introduced for the blood products, it should be strictly regulated to prevent any threat to the security of their supply and quality for patients.

[Work organisation improvement methods applied to activities of Blood Transfusion Establishments (BTE): Lean Manufacturing, VSM, 5S]. / Méthodes d'amélioration organisationnelle appliquées aux activités des établissements de transfusion sanguine (ETS): Lean manufacturing, VSM, 5S.

BACKGROUND: Continuous improvement of efficiency as well as new expectations from customers (quality and safety of blood products) and employees (working conditions) imply constant efforts in Blood Transfusion Establishments (BTE) to improve work organisations. METHODS: The Lean method (from "Lean" meaning "thin") aims at identifying wastages in the process (overproduction, waiting, over-processing, inventory, transport, motion) and then reducing them in establishing a mapping of value chain (Value Stream Mapping). It consists in determining the added value of each step of the process from a customer perspective. Lean also consists in standardizing operations while implicating and responsabilizing all collaborators. The name 5S comes from the first letter of five operations of a Japanese management technique: to clear, rank, keep clean, standardize, make durable. The 5S method leads to develop the team working inducing an evolution of the way in the management is performed. RESULTS: The Lean VSM method has been applied to blood processing (component laboratory) in the Pays de la Loire BTE. The Lean 5S method has been applied to blood processing, quality control, purchasing, warehouse, human resources and quality assurance in the Rhône-Alpes BTE. The experience returns from both BTE shows that these methods allowed improving: (1) the processes and working conditions from a quality perspective, (2) the staff satisfaction, (3) the efficiency. CONCLUSIONS: These experiences, implemented in two BTE for different processes, confirm the applicability and usefulness of these methods to improve working organisations in BTE.

Satisfaction survey in general hospital personnel involved in blood transfusion: implementation of the ISO 9001: 2000 standard.

As part of its policy of constant quality improvement, Etablissement francais du sang (EFS) des pays de la Loire (Pays de la Loire Regional Blood Transfusion Centre) carried out a satisfaction survey among the hospital personnel involved in prescribing and using immunohaematological tests and labile blood products (LBP). The polling tool selected by agreement between the Saint Nazaire's hospital management and Quality Assurance (QA) Department was a questionnaire that permitted item rating and free commentary. It addressed the personnel's perception of the quality of erythrocyte immunohaematological (EIH) testing and of the products administered, as well as their perception of the quality of communications with the local EFS. The questionnaire was sent to 26 physicians and 32 senior nurses in 15 hospital departments. The reply rate was 60% and expressed an 85% overall satisfaction level. Dissatisfaction causes were more specifically analysed, the main one involving LBP distribution in emergency situations. A joint undertaking by the EFS and the hospital led to the implementation of corrective measures, including the writing and implementation of a common standard operating procedure for emergency transfusion management. The results obtained demonstrated the feasibility of this type of survey and the interest, to a blood transfusion centre and the hospital personnel involved in transfusion, of assessing their very own perception of service quality.

[Satisfaction survey in general hospital personnel involved in blood transfusion: implementation of the ISO 9001: 2000 standard]. / Enquête de satisfaction des acteurs impliqués dans la transfusion dans un centre hospitalier général: une application de la norme ISO 9001: 2000.

As part of its policy of constant quality improvement, Etablissement Français du Sang (EFS) des Pays de la Loire (Pays de la Loire Regional blood transfusion institution) carried out a satisfaction survey among the hospital personnel involved in prescribing and using immuno-hematological tests and labile blood products. The polling tool selected by agreement between the hospital management and quality assurance department was a questionnaire that permitted item rating and free commentary. It addressed the personnel's perception of the quality of erythrocyte immuno-hematological (EIH) testing and of the products administered, as well as their perception of the quality of communications with the local EFS. The questionnaire was sent to 26 physicians and 32 senior nurses in 15 hospital departments. The reply rate was 60% and expressed a 85% overall satisfaction level. Dissatisfaction causes were more specifically analysed, the main one involving labile blood product distribution in emergency situations. A joint undertaking by the EFS and the hospital led to the implementation of corrective measures, including the writing and implementation of a common standard operating procedure for emergency transfusion management. The results obtained demonstrated the feasibility of this type of survey and the interest, to a blood transfusion centre and the hospital personnel involved in transfusion, of assessing their very own perception of service quality.

[Luminex technology for HLA typing by PCR-SSO and identification of HLA antibody specificities]. / Technologie Luminex: application aux typages HLA par biologie moléculaire (PCR-SSO) et à l'identification des anticorps anti-HLA.

Luminex technology is a new flow cytometry technology enabling us to analyse numerous reactions in a unique tube or well. It is a multiplexed data acquisition and analysis platform of microsphere-based assays that performs simultaneous measurements of up to 100 different analytes. In the histo- compatibility field, individual sets of microspheres are modified with reactive components such as antigens in order to perform HLA antibodies identification, or with oligonucleotides in order to perform HLA typing after reverse PCR-SSO. Thus microspheres are the equivalent of a panel of HLA typed lymphocytes (for PRA determination and antibody identification) or equivalent to a large set of probes selected to assign HLA typing. This new tool can be very useful in HLA laboratories since it is very easy to use and the results are concordant with those obtained with reference technics.

Identification of a new HLA-DRB1 allele, DRB1*0321.

This communication reports the identification of a new HLA-DRB1*03 allele identified in three members of a Caucasian French family. This new allele has been officially named HLA-DRB1*0321 by the World Health Organization Nomenclature Committee. The complete exon 2 sequence of DRB1*0321 is identical to that of DRB1*0307 except for the first and second nucleotides of codon 37 (TT replacing AA), which lead to the substitution of a tyrosine for a phenylalanine (AAC-->TTC at position 37). The family study showed that this new allele was transmitted into the HLA-A*0101/09, -B*0801/14, -Cw*0701, -DRB1*0321, -DRB3*0101, -DQB1*0503 and -DPB1*0401 haplotype. The complete exon 2 sequence of this new allele has been previously deposited in the EMBL Sequence Database under accession number AF297266.

[The role of yaws in the serologic screening of treponematoses in blood donors in Martinique]. / La place du pian dans le dépistage sérologique des tréponématoses chez les donneurs de sang de la Martinique.

Using TPHA instead of VDRL for syphilis blood-screening since 1995 showed an important increase of positive blood donors in Martinique. Yaws, another treponema disease, has been present on the island until 1975-1980. Usual tests are unable to identify which type--venereal or non venereal--of treponema is involved. Our study, carried out from January 1995 to May 1999, compares actual serological and epidemiological characteristics of TPHA reactive donors to former studies. In our results, the frequency of reactive TPHA is about 1.04% in blood donations. Donors are carrying serological tracks of a past treponema disease with very low rate of antibodies, sometimes linked to yaws. Among donors aged 18 to 30, prevalence is low and is going to become similar to the rate observed in Continental France. This means that this problem will disappear in new donor generations. We suggest the possibility for them to continue blood donation, if their personal preliminary enquiry fits the admission criteria for blood giving.

[Labile blood products and their preparation]. / Produits sanguins labiles et leur préparation.

Licensed labile blood components are put down on a regulatory list by the French Health Authority. They are prepared by the French National Blood Service and controlled according to regulatory and validated procedures. Depending on the origin of the blood, labile blood components are either homologous (donors) or autologous (from patients). Blood components (red cell concentrates, platelet concentrates and fresh frozen plasma) are processed within sterile closed disposable systems using either post-donation processing of whole blood or apheresis technology. All homologous blood components are leuco-reduced. Depending on specific settings, blood components could be washed, gamma irradiated or cryopreserved. Fresh frozen plasma is either "donor retested" after quarantine or viro-attenuated by solvent detergent treatment. Release is only allowed after a full conformity control of each blood component unit.