Transfusion Medicine: Time for a Change: Patient Blood Management and the Ontario ONTraC Program

Abstract

Despite increasing recognition of the potential adverse effects of blood transfusion there is evidence that the procedure is over-utilized and often inappropriately and unnecessarily administered. Patient Blood Management (PBM) is a recent world-wide initiative to optimize transfusion therapy by employing preoperative and perioperative maneuvers and alternatives to avoid unnecessary blood transfusion. These approaches are, however, not restricted to the surgical setting, but may be applied whenever transfusion is contemplated. A key component of PBM is the appropriate management of anemia, a prime determinant of transfusion. Another is tolerance of anemia through the use of restrictive transfusion thresholds for transfusion and of a single unit at a time policy. Among a number of options at surgery, antifibrinolytics have proven effective at reducing blood loss and transfusion. Burgeoning literature demonstrates that PBM (also known as Blood Conservation or as 'Bloodless Medicine/Surgery') is costeffective while improving patient outcomes and conserving the blood supply. Data from the ONTraC program in Ontario are described herein to illustrate the effectiveness of PBM approaches.

Patient blood management and the importance of the Transfusion Practitioner role to embed this into practice

“…Where TP roles are established, they are widely acknowledged as a critical part of the transfusion/PBM process in the healthcare setting. Literature is slowly emerging that supports the value of the role and the benefit it brings (Bielby et al, ; Miller et al, ; Freedman, ).…”

“…As PBM is becoming more established, there is an increasing number of peer‐reviewed literature becoming available about the TP and their role in PBM (Puca & Johnson, , Miller et al, , Freedman, , Moss, , Gallagher et al .·). As Freedman also acknowledged, it is important for those in the role to document and share their experiences, challenges and successes to allow others to learn from these.…”

“…One characteristic critical to all PBM programmes is the ‘buy in’ from all involved across the clinical spectrum. Freedman () outlines the TP as an important member of the multidisciplinary team – as an enabler, engaging all involved, including the patients. They are seen as the conduit for information, able to pull together resources, provide education, undertake reviews, collect data and evaluate outcomes.…”

“…Freedman () describes blood transfusion as one of the five most overused procedures, with much of it being inappropriate use and very variable in and between organisations.…”

The role of the transfusion practitioner in the multidisciplinary team

“…Freedman outlines the critical role the TP plays in developing a PBM culture and their significant contribution to improving transfusion practice. Freedman goes on to describe how the TP role has been able to implement tolerance of anaemia ‘restrictive transfusion thresholds’ in knee arthroplasty (when appropriate) showing the mean nadir Hb reduced from 84 to 72 g/L significantly reducing the percentage of patients requiring transfusion .…”