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Patient Blood Management: An International Perspective

Eichbaum, Quentin MD, PhD, MPH, MFA, MMHC, FCAP, FASCP*; Murphy, Michael MD, FRCP, FRCPath, FFPath; Liu, Yu MD, PhD; Kajja, Isaac MD, PhD, FCS(ECSA)§; Hajjar, Ludhmila Abrahao MD, PhD; Smit Sibinga, Cees Th. MD, PhD, FRCP Edin, FRCPath; Shan, Hua MD, PhD#

doi: 10.1213/ANE.0000000000001597
Blood Management
Free

This article describes practices in patient blood management (PBM) in 4 countries on different continents that may provide insights for anesthesiologists and other physicians working in global settings. The article has its foundation in the proceedings of a session at the 2014 AABB annual meeting during which international experts from England, Uganda, China, and Brazil presented the programs and implementation strategies in PBM developed in their respective countries. To systematize the review and enhance the comparability between these countries on different continents, authors were requested to respond to the same set of 6 key questions with respect to their country’s PBM program(s). Considerable variation exists between these country regions that is driven both by differences in health contexts and by disparities in resources. Comparing PBM strategies from low-, middle-, and high-income countries, as described in this article, allows them to learn bidirectionally from one another and to work toward implementing innovative and preferably evidence-based strategies for improvement. Sharing and distributing knowledge from such programs will ultimately also improve transfusion outcomes and patient safety.

From the *Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Transfusion Medicine, NHS Blood and Transplant and Oxford University Hospitals, Oxford, United Kingdom; Institute of Blood Transfusion, Chinese Academy of Medical Sciences, Chengdu, Sichuan, China; Department of Cardiology, University of São Paulo, São Paulo, Brazil; §Department of Orthopedics, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda; IQM Consulting, Zuidhorn, Netherlands; and #Department of Pathology, Stanford University, Stanford, California.

Accepted for publication July 28, 2016.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Quentin Eichbaum, MD, PhD, MPH, MFA, MMHC, FCAP, FASCP, Vanderbilt University Medical Center, Nashville, TN 37212. Address e-mail to Quentin.eichbaum@vanderbilt.edu.

The objective of patient blood management (PBM) is to provide an evidence-based, multidisciplinary approach to optimize the care of patients who might need a blood transfusion. Optimal transfusion support is characterized by giving the right blood products in the right amount to the right patient at the right time. An effective PBM program should result in the following outcomes: (1) reduced unnecessary blood transfusion and transfusion-associated adverse effects (infectious and noninfectious); (2) an assurance that blood products are available for patients who need them; (3) improvement in patient outcomes through overall better management of transfused patients (including patients with anemia and/or disorders of hemostasis); (4) a decrease in health care costs.

For a PBM program to be successful in achieving these goals, it needs to encompass all aspects of patient evaluation and clinical management across the entire transfusion decision-making process. Effective PBM programs may include the following components: (1) a strong hospital administrative support system; (2) appropriate education and training for clinical staff; (3) sound infrastructure and staff support; (4) transparent and accessible transfusion guidelines; (5) feedback mechanisms for evaluating the effectiveness and appropriateness of transfusions; (6) strategies to optimize transfusion support for surgical patients during the preoperative, intraoperative, and postoperative periods; (7) the use of technological tools to enhance the adherence to transfusion policies (such as including transfusion guidelines in the computerized physician order entry [CPOE] system).

Implementation of a comprehensive PBM program may encounter many obstacles. In an AABB survey of US hospitals in 2013 (The 2013 AABB Blood Collection, Utilization, and Patient Blood Management Survey Report; AABB), 37.8% had a PBM program; 41.9% participated in transfusion benchmarking programs; 42.0% of hospitals with PBM programs provided formal PBM training to physicians, 39.6% to nurses; 78.2% had transfusion guidelines but, of these, only 45.9% had CPOE decision systems to alert about blood products ordered outside the guidelines.

The dissimilarities in health care systems/environments internationally can present different challenges, as well as opportunities to the implementation of PBM programs. At the AABB annual meeting in October 2014, experts from England, Uganda, China, and Brazil were invited to present on PBM programs in their countries in an education session on implementing PBM programs in international settings. This article presents the perspectives of the country experts from that education session. To systematize this review and facilitate comparisons, we requested authors to answer the same set of 6 key questions about their country’s implementation of PBM:

  1. What are the greatest needs for developing PBM in your specific context?
  2. What specific elements of PBM have you implemented and why did you select these?
  3. What PBM strategies were too challenging to implement or considered unlikely to produce significant benefit in your context?
  4. What data do you have to demonstrate benefits of implementing PBM?
  5. What lessons have you learned from developing PBM in your context?
  6. What collaborations between countries and regions would be helpful to advance PBM practices?

We believe that sharing of experiences of PBM strategies in different international settings will help to promote collaboration between transfusion medicine and associated health professionals across borders and hopefully enhance the success of PBM internationally.

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PATIENT BLOOD MANAGEMENT IN ENGLAND

What Are the Greatest Needs for Developing PBM in Your Specific Context?

Table.

Table.

Reviews of blood transfusion utilization in the National Health Service (NHS) in England indicate that there is substantial inappropriate use of transfusions of all types of blood components (Table). A survey (unpublished) of English hospitals about their PBM practices was conducted in 2013 and showed limited implementation of PBM. The main findings indicated that (1) 40% of Hospital Transfusion Committees (HTCs) do not include PBM in their remit; (2) only 53% of hospitals undertake blood utilization reviews and <50% report data on blood utilization to their clinical teams; (3) only 78% of hospitals provide arrangements for the identification and management of anemia before elective surgery; (4) only 25% of hospitals use near-patient (point of care) hemostasis testing for the management of patients with major bleeding; (5) only 25% of hospitals have a policy to minimize the volume and frequency of blood samples for the avoidance of iatrogenic anemia; (6) there was limited use of antifibrinolytic agents to minimize blood loss during surgery; (7) only about 50% of hospitals use intraoperative cell salvage for orthopedic surgery; (8) only 29% of hospitals have a policy for transfusing 1 unit of red blood cells at a time in nonbleeding patients followed by reassessment of the further need for transfusion.

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What Specific Elements of PBM Have You Implemented and Why Did You Select These?

The focus at a national level is to encourage the implementation of all the elements of PBM. In June 2012, a conference on PBM was jointly hosted by the National Blood Transfusion Committee (NBTC), NHS Blood and Transplant (NHSBT), and NHS England. Its main aim was to share views on how blood transfusion practice could be improved and develop PBM recommendations to build on the success of previous Better Blood Transfusion initiatives,1 which achieved a reduction of over 20% in red blood cell usage in England in the 2000s (Figure), and to further promote appropriate use of blood components. Specific new initiatives were to improve the use of routinely collected data to influence transfusion practice and provide practical examples of high-quality transfusion practice and measures for the avoidance of transfusion.

Figure.

Figure.

Initial recommendations from the NBTC about how the NHS should start implementing PBM have been published.2 The NBTC will be working with NHS England and NHSBT to draw the recommendations to the attention of clinicians throughout the NHS. In addition, further impetus will be provided by the recent publication of guidelines for blood transfusion by the National Institute for Health and Clinical Excellence (NICE).2,3

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What PBM Strategies Were Too Challenging to Implement or Considered Unlikely to Produce Significant Benefit in Your Context?

As the results of the 2013 PBM survey indicate, many hospitals are struggling to implement the full range of PBM activities, including preoperative anemia management, intraoperative cell salvage, and near-patient hemostasis testing. Hospitals are being encouraged to conduct blood utilization reviews and to share the data with clinical teams, and NHSBT and the NBTC have a role in developing the tools to facilitate this.

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What Data Do You Have to Demonstrate Benefits of Implementing PBM?

National data indicate that there has been an acceleration in the decline in red blood cell usage in England since the 2012 Seminar on PBM (Figure). However, it is possible that other factors were responsible for this further decline. Furthermore, hospitals were already using some PBM measures before the term PBM was coined and the promotion of the initiative. Many PBM measures are directed at surgical patients, and indeed, the main reduction in red blood cell usage in England has been in patients with surgical rather than medical conditions.4,5 There are no robust data to indicate that the reduction in red blood cell usage has been associated with improved clinical outcomes.

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What Lessons Have You Learned From Developing PBM in Your Context?

As with previous national recommendations promoting appropriate blood use, it is clearly a major task to disseminate them to the many medical staff prescribing blood and implement them effectively. How else can the evidence supporting PBM be accelerated into routine transfusion practice? Prospective monitoring of blood orders provides the opportunity for intervention to avoid unnecessary transfusion in addition to collecting data for audit of transfusion practice. However, it is labor intensive and risks delaying patient care. Retrospective review is easier to do, but the possibility of intervention to prevent inappropriate transfusion is missed. Both methods for review are hugely facilitated by the use of information technology, and particularly so through blood ordering using a CPOE process.6,7 In addition, warning screen “alerts” can be triggered if the prescriber attempts to order a transfusion where the most recent laboratory tests are outside those recommended as triggers for transfusion, and the prescriber given the option of cancelling the order. The current introduction of electronic patient record systems into many hospitals in the United Kingdom provides the opportunity to implement CPOE for blood ordering to reduce inappropriate transfusion with the dual benefit of improved patient outcomes and reduced hospital costs.

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What Collaborations Between Countries and Regions Would Be Helpful to Advance PBM Practices?

There is much that the PBM initiative in England can learn from other countries. For example, the integration of PBM into more general initiatives for reducing variation in clinical practice and overuse of medical interventions, as with the American Board of Internal Medicine “Choosing Wisely” campaign,8 may increase the likelihood of success, and efforts are being made to integrate transfusion medicine into “Choosing Wisely” in the United States,9 the United Kingdom,2 and other countries. We can also learn from the experience of others in developing effective tools for blood utilization review10 and performance measures for PBM.11 Collaborations with other countries to share experience of implementing PBM are likely to be of considerable value; the European Blood Alliance has initiated an initiative to this effect, “Patient Blood Management in Europe.”

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PATIENT BLOOD MANAGEMENT IN UGANDA

What Are the Greatest Needs for Developing PBM in Your Specific Context?

PBM is a multidisciplinary approach that strives to safely and optimally utilize blood and blood products for patient care.12 The challenges of PBM vary from setting to setting particularly in the low-resource settings of Africa. Examples of such challenges include intrinsic human factors such as inadequately skilled workers at the clinical interface and extrinsic factors such as poor financing and inadequate organizational and hospital quality systems to ensure safe transfusion practices.13 Uganda has a fairly well-developed national Ugandan Blood Transfusion Service (UBTS) with 4 regional, and some smaller subregional, centers to supply outlying hospitals. However, a weak link lies in the poor clinical interface and communication between the prescribing clinicians and the UBTS.

Other key elements of PBM that need urgent attention include (a) establishment of policies that support in-hospital transfusion processes10—blood ordering, blood selection and compatibility testing, bedside transfusion; (b) development of nationally standardized administrative and operational structures to oversee transfusion practices; (c) establishment of preoperative anemia treatment protocols and perioperative blood-sparing strategies.

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What Specific Elements of PBM Have You Implemented in Uganda and Why Did You Select These?

To ensure standardization and accountability, Uganda has a National Transfusion Committee (NTC) composed of senior blood bank staff, as well as senior clinicians from all blood-prescribing specialties. The NTC works under the mandate of the UBTS and is regulated by the Ministry of Health.

The NTC has updated the National Guidelines for Clinical Use of Blood14 to ensure standardized practices in all health facilities, including national and regional referral hospitals and level IV health centers (facilities with at least 1 doctor). HTCs have been formed in referral hospitals with the following goals:

  • a. Capacity building for planning, implementation, monitoring, and evaluation, as well as timely feedback to clinicians about transfusion-related events;
  • b. Creation of national and regional training teams to facilitate dissemination of the HTC concept to all blood prescribing and administering health institutions;
  • c. Creation of a forum for mutual understanding and respect at the blood bank (supplier)–hospital (consumer) interface.

Individual hospitals have also written their standard operating procedures (SOPs) based on the 3 key in-hospital transfusion processes—ordering, selection and compatibility testing, and bedside administration. We are currently training physicians (across 4 manageable country regions) on the appropriate application of these SOPs and familiarizing them with the updated National Clinical Guidelines on Use of Blood.

A National Blood Order form is now available to standardize blood ordering, selection, and compatibility testing. This form also serves the purpose of documenting, archiving, and tracing blood in the hospital setting and, as such, also serves as a basic hemovigilance program. Because an electronic-based system is not yet available in all regions of Uganda, this paper-based information system remains in use nationally.

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What PBM Strategies Were too Challenging to Implement or Considered Unlikely to Produce Significant Benefit in Your Context?

Most sub-Sahara African countries, including Uganda, are in the early stages of developing PBM and have thus far implemented only a few management strategies. Competing priorities for health financing coupled with a poor and incoherent health insurance system pose major challenges.15

Additional challenges include (1) an inadequate clinical interface coupled with a limited clinical awareness of the benefits and risks associated with transfusion practice; (2) inadequate implementation of safe intraoperative blood salvage protocols and unavailability of antifibrinolytic agents; (3) poor Internet connectivity that makes access to e-learning materials unreliable—for example, from AABB, the World Health Organization (WHO), and the African Society for Blood Transfusion (AfSBT).

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What Data Do You Have to Demonstrate Benefits of Implementing PBM?

So far, there are no data available because we are still constructing the necessary infrastructure at the national level. However, the establishment of an NTC and the development of clinical guidelines and training resources for clinicians have increased clinical awareness of the need for appropriate and safe blood prescription practices.

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What Lessons Have You Learned From Developing PBM in Your Context?

Overcoming the weaknesses in PBM in Uganda will require sustained clinical, managerial, and political leadership and vision.16 The Ugandan Ministry of Healthy and the UBTS have improved the financing of transfusion services, including PBM activities—this is evidenced in the 2010–2015 UBTS Strategic Plan, and in the budgetary allocations of the Health Sector Strategic and Investment Plan 2010–2015.17 Hospital leadership is endorsing the concept of HTCs and 2 national referral hospitals (Mulago and Butabika), as well as 13 regional referral hospitals have now operationalized HTCs.

Although there has been progress, much work remains to be done to achieve sustainable PBM in Uganda and other African countries. Understanding local health, cultural, and sociopolitical contexts will be essential for achieving sustainable improvement in PBM programs. This will also require comprehensive teaching and training programs.

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What Collaborations Between Countries and Regions Would Be Helpful to Advance PBM Practices?

The AfSBT has developed a Stepwise Accreditation program to stimulate member countries and their blood transfusion services to more systematically work on the development of a sustainable vein-to-vein blood system.18 e-Learning and continuous education programs for clinicians and transfusion staff are being implemented for the purpose of improving awareness and understanding of transfusion and PBM practices. (Such programs have already been developed by like organizations WHO, AABB, AfSBT, European Union, and the Council of Europe). Close collaboration with these organizations will help increase clinical awareness and improve the quality and efficacy of blood usage, consonant with effective PBM programs. Such learning programs may ultimately also influence governmental policies leading to improved transfusion practices within the National Health System.

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PATIENT BLOOD MANAGEMENT IN CHINA

What Are the Greatest Needs for Developing PBM in Your Specific Context?

China has been experiencing a chronic shortage of blood supply for the past few decades. This shortage is caused primarily by a rapid increase in the number of patients seeking medical care because of a broadening coverage of government-provided health insurance and an increase in the number of complex medical and surgical procedures, such as marrow and solid organ transplants, now offered in the hospitals. Although national blood donation volume has been increasing every year for the past 20 years, this increase has not kept apace with the increasing demand for blood products. There are over 15,500 hospitals in China at 3 different levels (levels 1–3). The highest level is designated as “3A” level hospitals—these are mostly academic medical centers providing advanced comprehensive care. The amount of voluntarily donated blood has over recent years increased by 26%: from 3224 tons in 2008 to 4070 tons in 2013. (The metric ton, 1000 mL, is the unit used in China when reporting blood collection volume.)

Whole blood donation is done in 3 different volumes—400 mL, 300 mL, or 200 mL. Annual hospital visits have also increased from 4.90 billion in 2008 to 7.55 billion in 2013, representing a growth rate of 54%.19 The blood shortage is compounded by the inappropriate use of blood products, which is widespread. Traditionally, the overuse of blood products had been prevalent in many Chinese hospitals in part because of the influence of a traditional Chinese medicine belief that blood is a vital source of health and therefore has a general health-promoting benefit for all kinds of medical conditions. In recent years, blood shortage and the public’s increased awareness of the risks associated with transfusion have motivated hospitals to start implementing some PBM strategies.

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What Specific Elements of PBM Have You Implemented and Why Did You Select These?

In 2012, the National Health and Family Planning Commission (NHFPC, the former Chinese Ministry of Health, MOH) published the Regulation of Blood Management for Clinical Institutions (85th NHFPC), requiring hospitals to implement PBM protocols. Implementation of PBM is now even being incorporated into the assessment standards of the hospital grading system.20

To supervise effective blood utilization, a Quality Control Center of Clinical Transfusion (QCCCT) was established in every province and city. HTCs have been formed at some hospitals (mostly level 3 hospitals) to promote the oversight and coordination of blood utilization. Quality management systems have been established especially in level 2 and level 3 hospitals. SOPs for transfusion processes have been developed, and training of clinicians is being provided. Many hospitals are also making an effort to establish their own transfusion guidelines, and some local health bureaus have developed standards for evaluating the appropriateness of blood utilization for local hospitals.

The Chinese Society of Blood Transfusion, QCCCT, public health bureaus, and academic teaching hospitals have provided PBM education programs. Many hospitals have started to adopt some measures to reduce allogeneic blood usage. These measures include autologous transfusions, minimizing tissue injury during surgical operations, promoting endoscopic surgeries, and stricter adherence to transfusion guidelines. In addition, policies have been established to encourage intraoperative autologous blood transfusion (eg, including such autologous blood transfusion programs in accreditation criteria for 3A hospitals).

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What PBM Strategies Were Too Challenging to Implement or Considered Unlikely to Produce Significant Benefit in Your Context?

Although many hospitals have begun to implement some elements of PBM, the concept of PBM is still not widely appreciated among some level 2 and 3 hospitals. Almost all the actions so far have been aimed at reducing blood usage. More education is needed to promote the concept of PBM as a comprehensive program to enhance safety and effectiveness of blood transfusion. There are several other challenges that impede Chinese hospitals’ effort to implement comprehensive PBM programs, a major one being the shortage of trained transfusion medicine physicians. Only a small number of level 3 hospitals have physicians trained in transfusion medicine, but many of these physicians also have nontransfusion medicine clinical responsibilities. There is thus a need to increase the number of transfusion training programs. The current lower compensation and prestige of transfusion medicine as a medical subspecialty also need consideration.

Another major challenge is the lack of evidence-based guidelines for blood utilization and standards for evaluation of transfusion practice. The present technical recommendations for blood transfusion were issued in 2000, and there has not been another edition in the past 14 years. Although some hospitals have established their own transfusion guidelines and local health authorities have created standards for evaluating the appropriateness of transfusion practice for local hospitals, they were formulated according to a set of regulations from 2000 by the MOH based on WHO and AABB. Furthermore, data on blood utilization in China are very limited, and the guidelines and standards were not developed based on evidence obtained from Chinese hospital settings.

Lack of necessary equipment and technique is also a challenge for conducting PBM strategies. According to China’s present technical specification of clinical blood transfusion, hemoglobin concentration is an important indicator for prescribing transfusion. However, a multicenter survey on the status of clinical blood transfusion in Chinese 3A hospitals from 2006 to 2009 suggested that only 20% of patients had their hemoglobin or hematocrit concentrations tested before transfusion. The decision for intraoperative blood transfusion was mostly based on the anesthesiologist’s or surgeon’s opinion. Of the 43 hospitals, only 13 (30%) had the equipment for instant intraoperative hemoglobin and hematocrit measurement.19

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What Data Do You Have to Demonstrate Benefits of Implementing PBM?

An early emphasis of PBM programs in China was on promoting the use of component therapy over whole blood. The use of whole blood products has decreased significantly in the past 15 years. Whole blood transfusion now accounts for <10% of total transfusions compared with over 50%, from 15 years ago. In level 3 hospitals, component transfusion accounts >99% of total transfusions. Data on the benefit of other aspects of PBM have been limited although some data suggest a decrease in inappropriate blood usage. A study in Sichuan province showed that inpatient use of red blood cells (RBCs) has decreased considerably since 2009.21 A nationwide survey conducted by NHFPC showed that from 2011 to 2013, surgical operations increased year by year but both the number of allogeneic transfusions per 100 operations and the number of red blood cell transfusions decreased. More level 3 and level 2 hospitals have started to implement measures especially for surgical patients during the intraoperative period to reduce the need for allogeneic blood transfusion.19,22,23 The survey conducted by NHFPC showed that 25 (58%) of 43 hospitals had equipment for intraoperative autologous blood transfusion, although 8 to 10 operating rooms may share single items of equipment. The proportion of autologous blood transfusion in all transfusion cases has increased from 4% in 2011 to 7% in 2013.19

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What Lessons Have You Learned From Developing PBM in Your Context?

Developing transfusion medicine clinical departments, while gaining support from hospital administration, and training more transfusion medicine physicians will help to build the infrastructure for advancing PBM in China. More training about PBM needs to be provided for ordering physicians to combat outdated concepts and practices. Greater investment and focus on PBM should be placed on lower-level hospitals because these hospitals have more difficulties adopting a PBM program because of the lack of transfusion expertise, informatics systems, and quality management systems.21 In addition, a national data system of blood utilization in China is needed for monitoring and improving the effectiveness, efficiency, quality, and safety of blood transfusion practices.

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What Collaborations Between Countries and Regions Would Be Helpful to Advance PBM Practices?

Collaborations with other countries toward providing more training and education opportunities in PBM will be helpful. Sharing of successful experiences and lessons on how to overcome obstacles will also be valuable. Another area of fruitful collaboration should be in clinical research on how to define optimal transfusion outcomes and how to maximize the benefit of blood transfusion therapy for patients in different settings and with different diagnoses.

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PATIENT BLOOD MANAGEMENT IN BRAZIL

What Are the Greatest Needs for Developing PBM in Your Specific Context?

In Brazil, data from the Ministry of Health reveal that from 2000 to 2013, about 50% of critically ill patients received transfusion; 35% of surgical patients received at least 1 blood unit.24 More recently, however, transfusion practices in Brazil have begun to be questioned. Education in blood transfusion has until recently been largely ineffective, and millions of patients have been exposed to the risks of allogeneic transfusions.

A number of well-designed randomized clinical trials have been published that have had an impact in Brazil toward a restrictive approach for red blood transfusions.25 Brazil is entering a new period in PBM that entails focusing more intently on individual patient needs and weighing the balance between risks and benefits of each transfusion in trying to avoid anemia versus overtransfusion.26,27 The Brazilian Society of Intensive Care together with the Brazilian Society of Anesthesiology and the University of Sao Paulo conducted a survey in 2015 and endorsed a new approach for evaluation of transfusion practice with the goal of implementing a more effective and strategic PBM program.7

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What Specific Elements of PBM Have You Implemented and Why Did You Select These?

The strategic plan that started in 2014 aims to advance the following fields of transfusion medicine, through the following broad goals7,11:

  • Achieve self-sufficiency in the blood supply through 100% voluntary nonremunerated blood donation;
  • Strengthen quality management and define transfusion protocols for specific settings;
  • Implement hemovigilance, risk management, and monitoring/evaluation programs;
  • Ensure adequate resources in the surgical operating room (including adequate diagnostic capacity such as thromboelastometry and adequate availability of coagulation factor concentrates and other hemostatic products);
  • Implement continuing medical education.

Currently, a major focus of Brazil’s PBM program is education in transfusion medicine. This involves lectures, meetings, Web tools, audits, surveys, and ongoing analysis of data and benchmarking. Through appropriate education, the PBM program in Brazil strives to achieve the broader goals of PBM to improve patients’ outcomes.

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What PBM Strategies Were too Challenging to Implement or Considered Unlikely to Produce Significant Benefit in Your Context?

The survey of 2015 suggested that the most challenging PBM strategy to implement in Brazil was the decreased availability of transfusion resources in operating rooms (cell-savage, thromboelastometry, platelet function tests, and coagulation factor concentrates) (data not published). A second challenge has been the implementation of more comprehensive preoperative evaluation of anemia and predisposition to bleeding. To get more resources to the operating room, Brazil is establishing multiple partnerships between government and industry. Brazil’s plan for 2016 includes more education and development of appropriate guidelines for transfusion during the preoperative period.

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What Data Do You Have to Demonstrate Benefits of Implementing PBM?

Since the introduction of a national PBM program, the rates of RBC transfusion decreased by 27% in the 342 audited hospitals; rates of fresh frozen plasma transfusion decreased by 31%; and platelet transfusions decreased by 17%. In addition, 21% of the hospitals acquired point-of-care equipment to evaluate coagulation. Most Brazilian medical institutions are now adhering to the preoperative guidelines for the detection of anemia. We predict that in the coming years, we will see a significant reduction in the overuse of blood transfusion and a higher adherence to standards of clinical practice that will lead to enhanced outcomes in medical and surgical patients.

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What Lessons Have You Learned From Developing PBM in Your Context?

The development of PBM in Brazil has been possible largely because of its multidisciplinary team approach that includes intensivists, anesthesiologists, surgeons, blood banking specialists, and nurses—as well as enlisting the cooperation of industries, medical societies, and universities. Data acquisition remains weak point and may entail developing appropriate informatics tools within educational institutions. Ultimately, an effective PBM program will only be possible with adequate allocation of resources and with intense focus on cost-effectiveness analysis and patient-centered outcomes.

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What Collaborations Between Countries and Regions Would Be Helpful to Advance PBM Practices?

Sharing experiences in PBM will also be essential for the success of the program. Learning from the experiences of other countries may improve results and avert mistakes. Collaborations between countries will be helpful in acquiring technology and expanding knowledge, as well as in allowing adequate comparisons and benchmarking.

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CONCLUSIONS

Information shared by PBM experts from countries with diverse economic development levels serves to highlight several important lessons: (1) Coordination at the national level is important to ensure valuable administrative support for transfusion professionals in developing and implementing PBM programs. (2) For PBM programs to be effective, their objectives and design need to be evidence-based. A national (or regional) survey is an effective tool for collecting blood utilization and safety data. Clinical studies including randomized controlled studies will create the opportunity to evaluate the effectiveness, as well as safety of various PBM strategies (such as determining the hemoglobin trigger for red blood cell transfusion in specific clinical settings). Data-driven strategies tend to be more readily embraced by clinicians and hospital administrations and have a better chance of being successful. (3) Collaboration between countries and regions can enhance global adoption of PBM even though different countries and regions often encounter different challenges. Experiences from developed countries can be helpful to less developed countries in avoiding mistakes as their health care systems advance. Improvements in PBM can clearly also be bidirectional, and scientific innovations and clinical practices from developing countries may lead to global improvements in PBM.

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DISCLOSURES

Name: Quentin Eichbaum, MD, PhD, MPH, MFA, MMHC, FCAP, FASCP.

Contribution: This author conceived the idea for the article, and coordinated the writing of draft sections into the edited and rewritten final version.

Name: Michael Murphy, MD, FRCP, FRCPath, FFPath.

Contribution: This author helped write the article.

Name: Yu Liu, MD, PhD.

Contribution: This author helped write the article.

Name: Isaac Kajja, MD, PhD, FCS(ECSA).

Contribution: This author helped write the article.

Name: Ludhmila Abrahao Hajjar, MD, PhD.

Contribution: This author helped write the article.

Name: Cees Th. Smit Sibinga, MD, PhD, FRCP Edin, FRCPath.

Contribution: This author helped write the article.

Name: Hua Shan, MD, PhD.

Contribution: This author helped write the article.

This manuscript was handled by: Marisa B. Marques, MD.

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