Introduction of a Single Unit Transfusion Policy Patient Blood Management Pilot 2014

Introduction Patient Blood Management The Safety of Blood – SHOT data Single unit blood transfusion policy Causes of anaemia Alternatives to blood Case studies

Changing Transfusion Practice Patient Blood Management (PBM) is a National and International initiative in Blood Transfusion To give blood transfusions appropriately and effectively on an individual patient basis

Blood safety SHOT Report deaths –Avoidable, delayed or undertransfused (5) –Transfusion-related Acute Lung Injury (1) –Post Transfusion Purpura (1) –Haemolytic Transfusion Reaction (1) –Transfusion-associated circulatory overload (12) –Incorrect Blood Component Transfused (1) –Unclassified complication of transfusion (1) Annual SHOT Report 2013

Blood safety 143 Major Morbidity –Acute transfusion reactions (76) –Transfusion-associated circulatory overload (34) –Incorrect blood component transfused (6) –Haemolytic transfusion reactions (8) –Transfusion-related acute lung injury (9) –Anti-D errors (1) –Transfusion-transmitted infections (0) –Avoidable, delayed or undertransfusion (7) –Unclassifiable complications of transfusion (1) –Transfusion-associated dyspnoea (1) Annual SHOT Report 2013

TACO The International Society of Blood Transfusion (ISBT) definition states that TACO includes any 4 of the following that occur within 6 hours of transfusion –Acute respiratory distress –Tachycardia –Increased blood pressure –Acute or worsening pulmonary oedema –Evidence of positive fluid balance Annual SHOT Report 201

TACO - Case Study 78 year old female, weight 63.3kg Admitted to Emergency Department unwell and feeling faint Vial signs normal Hb 59g/L, microcytic blood picture – likely iron deficiency 2 units RBC ordered by ED doctor First unit commenced at 14:12 Patient transferred to acute medical unit

TACO - Case Study During ward round an additional 2 units RBC prescribed After 270ml of 4 th unit patient developed massive pulmonary oedema and left ventricular failure Baseline obs – pulse 98, BP 120/75mmHg Reaction obs – pulse 82, BP 152/111mmHg Admitted to ITU and received CPAP and furosemide Patient died Annual SHOT Report 2013

Calculating dose Transfusing a volume of 4ml/kg will typically give a Hb rise of 10g/L and should only be applied as an approximation for a 70-80kg non- bleeding patient Annual SHOT report British Committee for Standards in Haematology: Addendum to Administration of Blood Components

Calculating dose National Comparative Audit of Blood Transfusion Audit of the use of blood in adult medical patients, part 2 Correlation between body weight and Hb increment

Errors in Transfusion Annual SHOT Report 2013

Single Unit Transfusions For stable non-bleeding patients Investigate causes of anaemia – Iron, B12, folate investigations Only transfuse if the patient is symptomatic Transfuse a single unit and reassess the patient for symptoms of anaemia (Hb) Only transfuse second unit if patient symptomatic

National Audit National Comparative Audit for Blood Transfusion of Medical Use of Blood Red cells transfused; 65% were 2 units, 15% were 3 units and 6% were 4 units Transfusion in cases with possible reversible anaemia (20%) Transfusion above the Hb threshold defined by the audit algorithm (29%) Over-transfusion (33%) Transfusion to more than 20g/L above threshold

Date of download: 9/9/2013 Copyright © 2012 American Medical Association. All rights reserved. From: Outcomes Using Lower vs Higher Hemoglobin Thresholds for Red Blood Cell Transfusion JAMA. 2013;309(1): doi: /jama Day mortality was evaluated in 4975 patients included in 11 of 19 trials. Adapted from Analysis 3.2 in Carson JL, Carless PA, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2012;4:CD doi: / CD pub3 Figure Legend :

Evidence Multicentre randomised controlled trials demonstrate that a restrictive approach to RBC transfusion decreases transfusions without increasing mortality or adverse events (Herbert et al 1999, Carson et al 2011, Villanueva 2013) Single unit policy reduces the number of transfusions and therefore reduces the risk to the patient (Berger et al 2012)

Evidence WA PBM program introduced in a tertiary hospital in 2008; 26% reduction in RBC transfusions and 16% reduction in PLT transfusions over three years (Leahy 2013) ReferenceFindings implementing restrictive/single unit policy Yerrabothala et al (2014) The total number of red blood cells transfused/1000 patient days decreased from 60.8 to 44.2 and the proportion of 2-unit transfusions decreased from 47% to 15% Berger et al (2012) Reduced red cell usage by 25% with no evidence of more severe bleeding or reduction in survival in patients receiving intensive chemotherapy or stem cell transplantation. Royal Oldham Hospital, UK (HTC verbal report, 2014) Indicates a reduction in red cell usage of 10.4% last quarter (2.5% last year) and platelet usage by 16.8%

Causes of anaemia Why is your patient anaemic? –Iron Deficiency –B12 Deficiency –Folate Deficiency Test for these before transfusion

Blood results Royal College of Pathologists of Australia - Common sense pathology 2004

Alternatives to Blood Ferrous sulphate supplements IV Iron B12 injections Folate supplementation

Triggers Table from Handbook of Transfusion Medicine 4 th Edition

Indications for Transfusion National Blood Transfusion Committee - Indication codes for Transfusion Symptomatic Anaemia Fatigue Breathless at rest Chest pains/Palpitations Faint

Patient Assessment

Consent for Transfusion SaBTO Valid consent for blood transfusion should be obtained and documented in the patient's clinical record by the healthcare professional There should be a standardised information resource for clinicians indicating the key issues to be discussed by the healthcare professional when obtaining valid consent from a patient for a blood transfusion

Single Unit Project Audit Education Prospective collection of data Regular review Feedback Multidisciplinary team

Case Study 1 Female, 83 Admitted to Marjory Warren with new diagnosis of PE Background of LRTI Long smoking history Aiming for sats of 85-92% on room air

Case Study 1 Hb 05/06/14 – 86 g/L Medical notes - 9/6/14 12:28 states ‘Hb 8.6 – likely to be adding to hypoxia. Plan:- transfuse 2 units’ Sats – Hb 09/06/14 12:27 – 100 g/L

Case Study 1 Nursing notes 10/6/14 00:13 state ‘NIC contacted 888.’ ‘They came up to the ward and said they had checked Hb which was 10 and not for blood transfusion tonight’ 10/06/ – Sats 93% on RA. Patient feels well, comfortable at rest, no pain, denies SOB 10/6/14 Hb :35 am

Case Study 1 10/06/14 – Patient transfused 2 units of blood (Units collected 9:55 and 14:31) No Hb check or documented review between units Medical notes 11/06/14 09:40 - ‘Chronic iron deficiency anaemia – transfused 2 units 11/06’

Case study 1 Hb 11/06/14 – 132 g/L No evidence of haematinic tests performed – B12/Folate/Fe Patient macrocytic Discharged with daily dose of ferrous sulphate

Case Study 2 Female, 76, weight 59.2kg Admitted on 07/04/2014 to Oliver Ward with SOB, non-productive cough and chest tightness. History of COPD. RCA managed with stents. July Bilateral PE on warfarin

Case Study 2 12/07/14 - Patient lost blood from cannula following fall. No physical injury noted 13/07/14 17:22 - Hb 88g/L 13/07/14 19:37 - Hb trending 101 – 94 – 88, day team to investigate drop in Hb 14/07/14 07:54 - Hb 80 14/07/14 13:42 - (Physiotherapy) Current medical issues: SOB, ongoing chest pain, hypotensive last 2 days, dropping Hb

Case Study 2 14/07/14 – 2 units red cells authorised. No documented symptoms of anaemia. Unit 1 collected 21:49 Unit 2 collected 02:11 15/07/14 05:41 – unable to sleep due to transfusion monitoring

Case Study 2 15/07/14 07:45 – pyrexic this morning. Temp pre-transfusion 37.2 and post transfusion Advised to give paracetamol and monitor patient 15/07/14 12:45 - Hb 119g/L

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