Action 7.04

Ensure that all clinicians apply PBM as the standard of care for patients facing a medical or  surgical intervention who are at high risk of significant blood loss. Put processes and procedures in place for the various practices that can be initiated before, during and after surgery or other treatments. Provide orientation and training on PBM for all clinicians involved in the clinical pre-, intra- and post-administration or prescription of blood or blood products.

Develop a PBM implementation plan

Develop a plan for implementing PBM that includes:

• Understanding and raising awareness of PBM practices and concepts
• Using an existing governance structure or implementing a new structure, including identifying and supporting one or more PBM champions
• Selecting the PBM initiatives to implement and set benchmarks to evaluate implementation
• Collecting patient-level data to set pre-, intraand post-implementation benchmarks for the
• PBM initiative
• Educating and training the workforce
• Communicating about the PBM Guidelines, including target audiences, strategies and tools for effective implementation, communication channels, and key messages
• Maintaining an effective PBM program through monitoring, ongoing evaluation and reporting
• against benchmarks for each initiative.
• The National Patient Blood Management Implementation Strategy may help health service organisations develop a plan. Online courses within the BloodSafe eLearning Australia program are useful for training.

Consider PBM initiatives

The NBA has guidance on how to implement a PBM program and initiatives for organisations in the PBM Guidelines, PBM Guidelines companions and National Patient Blood Management Implementation Strategy.

Consider developing local protocols for PBM, including establishing a PBM governance process and group. This could be part of the blood management governance group set up in Action 7.01.

Key initiatives for implementation in all organisations are:

• Optimising patients’ own RBC mass, haemoglobin and iron stores
• Identifying and managing patients with, or at risk of, bleeding
• Determining the clinical need for blood and blood products, and related risks.

Optimise patients’ own RBC mass, haemoglobin and iron stores

Preoperative anaemia is independently associated with an increased risk of morbidity and mortality¹, and increases the likelihood of RBC transfusion.² Managing anaemia before elective surgery can improve a patient’s pre-surgery clinical status, and reduce post-surgery morbidity, mortality and length of stay.¹

Establish a definitive diagnosis of anaemia, including whether it is related to the patient’s current condition and if it is correctable. Some forms of anaemia cannot be prevented (if caused by a failure in the cell production process), but others (for example, anaemia caused by blood loss or dietary deficiency) can be prevented and managed.

Before the treatment or surgery:

• Identify, evaluate and manage anaemia as the key strategy for optimising RBC mass, haemoglobin and iron stores in all patient groups
• Communicate with the patient’s general practitioner to identify, evaluate and manage anaemia as the key strategy for optimising RBC mass, haemoglobin and iron stores in all patient groups
• Implement preoperative anaemia assessments within the health service organisation
• Develop communication systems between the hospital and the primary care sector to reduce presurgical risks of transfusion
• Ensure that assessment and management of iron stores are considered when managing anaemia and optimising RBC mass
• Use evidence-based therapies for boosting the production of RBCs and optimising RBC mass in specific groups of patients
• Consider using perioperative or day clinics to identify, evaluate and manage anaemia

To assess impact and success, identify practice changes that increase the number of preoperative patients with optimised haemoglobin and iron stores. Examples of performance indicators include:

• Postoperative infections and adverse reactions from blood products
• Transfusion-related inflammatory events
• Rates at which patients are screened for anaemia and iron deficiency
• Volumes of blood products used
• Rates or proportions of patients transfused
• Hospital length of stay
• Readmissions as a result of infectious complications of transfusion
• Elective surgery cancellations due to non-optimised haemoglobin and iron stores.

Identify and manage patients with, or at risk of, bleeding

Assessment of bleeding risk is a key component of PBM strategies to minimise blood loss. Patients may be at increased risk of bleeding as a result of:

• Advanced age³
• Decreased preoperative RBC volume (small body size or preoperative anaemia)³
• Medicines affecting haemostasis, including complementary medicines
• Medical conditions causing haemostatic defect, including hereditary bleeding disorders and acquired medical conditions such as chronic kidney or liver disease
• The type of surgery.

Identify patients at high risk of bleeding or excessive blood loss, including history of bleeding diathesis. Use a structured patient interview or questionnaire before surgery or invasive procedures to assess bleeding risk. This should include:

• Personal or family bleeding history
• Previous excessive post-traumatic or post-surgical bleeding
• Detailed information on the patient’s medicines, including complementary medicines.

Numerous medicines and complementary therapies affect haemostasis. In the case of anticoagulant or antiplatelet agents, cessation or bridging therapy may be required to minimise blood loss.

To assess bleeding risk before and during treatment, use a multidisciplinary approach to bleeding management and excessive blood loss, including:

• Appropriate diagnostic testing to measure haemostatic capacity for at-risk patients
• For patients at risk of suffering from adverse outcomes from ongoing blood loss over time
  • minimising phlebotomy
  • use of small-volume blood collection tubes
  • use of closed blood sampling systems to minimise loss of blood
• Identifying medicines that affect haemostasis
• Optimising physiological conditions conducive to haemostasis
• Applying appropriate pharmacological suppor
• Appropriate use of cell salvage
• Appropriate use of factor concentrate.

Determine the clinical need for blood and blood products, and related risks

Allogeneic blood is a valuable adjunct to health care, but it is a limited resource, and transfusion can be a risk for patients. Therefore, diagnosing patient-specific haemostatic dysfunction to support patient-specific treatment will improve patient outcomes, and reduce unnecessary and inappropriate transfusion. The goal of effective management of critical bleeding is rapid and targeted treatment with ongoing assessment of treatment effect.

Evidence-based blood management strategies should be applied for all patients to ensure optimisation of the patient’s own blood, but also to reduce the patient’s exposure to allogeneic transfusion and many of the associated risks of transfusion.

Human and systems risks associated with transfusions may be preventable, but other risks relate to the nature of blood products and can only be avoided by avoiding transfusions.² Risks associated with allogeneic blood transfusion include:

• Wrong blood incidents
• Transmission of bloodborne infections
• Haemolytic transfusion reaction
• Immunosuppression.⁴,⁵

Review patients’ healthcare records and discuss with them their previous and current transfusion risks before transfusion, to identify at-risk patients. This may involve:

• Prescribing and ordering special products to suit the patient’s transfusion needs
• Amending administration practices, such as infusion rate
• Increased monitoring of the patient during a transfusion
• Undertaking bedside checks before transfusion
• Matching patient and intended treatment.

Where there is, or may be, a need to treat the patient with blood and blood products:

• Identify the cause of bleeding quickly
• Implement algorithms to manage bleeding (for example, massive transfusion protocol, bleeding management algorithms)
• Develop procedures and work unit guidelines to support appropriate, timely and effective access to providing and transfusing prohaemostatic, anticoagulant, antifibrinolytic and antithrombotic therapies
• Support the use of cell saver to salvage and replace the patient’s own blood when appropriate
• Develop and maintain good lines of communication between the clinical environment and blood banks
• Provide ongoing education to support evidence-based bleeding management and sustainability of
• practice for all patients
• Understand the risks of using and administering blood and blood products
• Ensure that safe transfusion practices are followed when blood products are administered
• Ensure assessment and reporting of adverse reactions or outcomes.

Consider implementing the following initiatives to support these activities:

• Maintain meticulous surgical techniques as the cornerstone of intraoperative blood conservation
• Implement strategies and techniques to minimise iatrogenic anaemia
• Consider cell salvage in the surgical setting
• Consider all treatment options
• Consider using point-of-care testing devices to provide rapid bedside monitoring to help the clinician direct appropriate targeted therapy
• Implement single-unit RBC transfusion practice for haemodynamically stable patients (prescribing only one unit at a time), with clinical reassessment of the patient before prescribing a subsequent unit; although restrictive transfusion thresholds (triggers) are an effective method of reducing and conserving RBC use, RBC transfusion should not be dictated by a haemoglobin ‘trigger’ alone, but take account of clinical signs and symptoms, and patient tolerance of anaemia.

The NBA has further information on implementing strategies and initiatives.

Applicability of actions

The actions in the Blood Management Standard will not be applicable for day procedure services that do not use blood or blood products. These services should provide evidence that they do not use, receive, store, collect or transport the blood or blood products governed under this standard.

Services using blood or blood products should refer to the information provided for hospitals for blood management.

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established processes for PBM.

Small hospitals that are not part of a local health network or private hospital group should:

• Identify, develop and implement policies, procedures and protocols for PBM to optimise and conserve the patient’s own blood, and manage the need for blood and blood products
• Develop effective PBM strategies
• Develop and implement education activities for PBM to optimise and conserve the patient’s own blood, and manage the need for blood and blood products
• Establish perioperative standard practice for assessment and management of anaemia
• Implement processes to communicate elective surgical time frames to patients’ primary carers to enable effective anaemia management in the primary care sector, if possible.

The NBA has further information on implementing strategies and initiatives.