“Appropriate Red Cell Use in Adults” Royal Derby Hospital
Learning objectives • What’s the project about? • Why are we doing it? • Who will be involved? • How? – What will we be doing? How will it work?
What and Why ? Implement a single unit/appropriate use protocol into Royal Derby Hospital Invest in staff: Increase overall knowledge, understanding around appropriate transfusion in both lab and clinical areas Encourage lab staff to look at the reasons for transfusion requests, check relevant patient results and increase their confidence to discuss an inappropriate request with the requester
What and Why? Improve patient outcomes and reduce the number of inappropriate red cell transfusions Reduce financial costs to the Trust Improve compliance to NICE Blood Transfusion Quality Standard QS138 : Standard 3 Improve compliance with Choosing Wisely campaigns in UK ‘Why give two when one will do?’
Why is it important to avoid unnecessary transfusion? • Patient safety – PBM initiatives – Risks /hazards – Transfusion reactions • Limited supply
What is Patient Blood Management? • An evidence-based, multidisciplinary team approach to optimising the care of patients who might need transfusion – puts the patient first • Focuses on measures for blood avoidance as well as correct use of blood components when they are needed • Improves patient care, optimises use of donor blood and reduces transfusion-associated risk • Reduces financial costs
Transfusion process is very complex - - - - - - - - - - - - Midwife Phlebotomist - - - - - - - - - Lab Admin Trainee - - - - - - - - - - - Scientist Med Lab Asst - - - - - - - - - - - - - Porter Doctor - - - - - - - - - - - - - Nurse
ABO-incompatible transfusions compared to near miss 2016 and 2018
Transfusion Reactions
Limited Supply: The falling donor base...
“Save one O D Neg” Campaign • 134 Trusts • Estimated O D Neg savings: “Save One O D neg” – 6968 units a year – 581 units a month It only takes one to make a difference For more information or to access resources from the “Toolkit” visit hospital.blood.co.uk or contact your local Transfusion Team
Decision to Transfuse
NBTC Indications for Red Cell Transfusion (2016)
Dose of Red Cells Single Unit Transfusions 'Transfuse one dose of blood component at a time - one unit of red cells in stable non- bleeding patients and reassess the patient clinically and with a further blood count to determine if further transfusion is needed.'
Single Unit Transfusions • The Patient Blood Management (PBM) recommendations endorsed by NHS England (2014): • The British Society for Haematology (BSH) - Component administration guidelines • NICE transfusion guidelines 2015
Change this to PBM poster??
Factors Affecting Blood Cell Production in relation to anaemia • Growth factors e.g. EPO, TPO, GCSF • Haematinics e.g. iron, B12, folate • Toxins, e.g. alcohol, lead • Inappropriate marrow production e.g. leukaemia • Increased loss e.g. bleeding, haemolysis • Immune system problems
Causes of Anaemia
Types of Anaemia low Hb MCV Low High Normal microcytic macrocytic anaemia anaemia • Iron deficiency • Anaemia of • B12 / folate • Thalassemia chronic disease deficiency • Hook worm – CKD • Alcohol excess infection • Red cells • Hypothyroid disorders – • Haemolysis sickle cell • Bone marrow disease disorders- MDS • Bone marrow + myeloma disorders
Anaemia • Patients may tolerate extremely low Hb levels if it has fallen slowly and they have had time to compensate • Conversely, rapidly falling Hb levels can make people feel ill even at moderately low levels • So history and examination / clinical picture is critical to making good decisions
Full blood count
One step at a time… • Are the values normal in Hb, WCC, Plts? • IF Hb is low, look at the MCV to determine if it is a microcytic or macrocytic anaemia • Are the platelets reduced or increased? • Are all cell lines affected ?
An unexpected result • Sampling error/ analyzer problem • Too old • Compare to previous results • Clinical history • Remember to relate any abnormalities in the results to the clinical context • Are these results expected? • If not suggest repeat FBC
Case 1 Clinical details: Miss Red 23yrs old Attended pre-op clinic - heavy periods Blood test results: Hb 70g/L MCV 65 MCH 25 Request: 3 unit red cell transfusion Appropriate? Not appropriate?
Possible management • Oral iron • IV iron • Management of blood loss – referral to gynecology for further management • Routine surgery can be deferred until Hb is optimized.
Case 2 Clinical details: A 24 year old woman is admitted to MAU after attending her GP with tiredness Blood test results: Hb 64g/L, MCV 62, WCC 7, Plts 500 • List the FBC abnormalties? • What are the possible causes of her anaemia? • What other blood tests should be done?
Case 2 Request: 4 unit red cell transfusion as she feels very tired, a bit breathless on climbing stairs, and has 3 young children to care for at home Appropriate? Not appropriate?
Possible management • 4 units = inappropriate • How many units would be appropriate? – 1 unit and re-assess • ? Oral iron • ? Gastro referral
Case 3 Clinical details: Doris frail 85 year old, admitted following a fall. CCF, CKD, AF, hypothyroid : Weight 45Kg Blood test results: Hb 75g/L, MCV 80 fl, MCH 28, creatinine 120 mmol/ml Request: 3 unit red cell transfusion Appropriate? Not appropriate?
Possible management 3 units = inappropriate • TACO awareness • What would happen if 3 units given? • 1 unit and re-assess • Use of diuretic • Slow transfusion rate
Empowerment to question inappropriate transfusion requests
What are the obstacles?
Myths to bust!
Myth 1 ‘We’re just here to provide a service – no questions asked’
Better Blood Transfusion 3 and PBM
Where do lab staff fit in to PBM? • Collective responsibility to ensure appropriate use of blood: – PATIENT SAFETY – Blood conservation – Falling blood stocks – £££ • Need to be a service which advises and questions • BUT be mindful of urgency and clinical situation and not delay blood provision….
Myth 1 ‘We’re just here to provide a service – no questions asked’
Myth 2 ‘Doctors know more than us about blood transfusion’
• Clinical transfusion education in medical school and as FY1/2s • Pick up practice on wards…good and bad – Non-haematology consultants & GPs can be ‘out of date’ – Trainee doctors reluctant to challenge consultant’s authority – this is where you can help...
• Laboratory staff complete lengthy training and education in blood transfusion science • Annual competencies, CPD programme, NEQAS • Knowledge extensive in certain areas but possibly lacking in clinical relevance – Can offer valuable support and education – Can direct to guidelines, haematology advice
Myth 2 ‘Doctors know more than us about blood transfusion’
Collaboration • Working together is the key • Stronger as a team with a common goal – best practice for best patient outcome
Myth 3 ‘I don’t have the authority to question’
Facts • Know your rights and responsibilities – BMS: • HCPC registration – must take responsibility for own actions – Medical staff: • GMC and medical liability insurance - as above, but with extra cover • Be aware of your place in the clinical pathway – does the buck stop with you? Any avoidable delay in provision may result in patient harm
So what does that mean? THIS IS IMPORTANT • You have the authority to discuss/question a request, but… • You do NOT have the authority to refuse it • It’s important they know you aren’t saying ‘No’ you are just seeking advice • So…if you get a request that doesn't ‘fit’ the guidelines…
Algorithm for Reviewing Red Cell Requests Red Cell Request Patient actively NO YES Look up FBC bleeding? / Theatre standby YES YES Is the patient Hb ≤ 70 g/L MCV < 80 fl symptomatic? AP: Refer to BMS N NO YES NO O AP: Refer to Discuss need for BMS transfusion with Symptomatic More than 1 unit requestor YES cardiovascular NO ISSUE Refer to TP requested? disease? Hb ≤ 80 g/l UNIT YES NO Suggest single unit followed by clinical review Issue and Refer to TP Refused for follow up Agreed Issue and refer to TP for follow up
Myth 3 ‘I don’t have the authority to question’
To achieve this? • Guidelines must be pragmatic and comprehensive, well evidenced – NICE, BSH, PBM Recommendations • Medical staff must know the lab staff will question requests – Medical induction/teaching – Governance meetings etc. • Good education for medical staff • Changes hospital perception of labs – Will start asking labs for advice – Supportive service
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