Background Mounting evidence exists for more restrictive blood transfusion practices in patients undergoing cardiac surgery. Few studies, however, have recognized or agree upon a method by which this ...decrease in allogeneic red blood cell transfusion can be achieved. We will review our methods and experience in a blood conservation initiative from 2003 to 2007. Methods A data driven, multidisciplinary effort to decrease allogeneic red blood cell transfusion was instituted in a community hospital. Numerous innovations in treatment protocols were implemented and evaluated. Clinical data from 2003 to 2007 will be presented. Yearly review of outcomes led to an evolving clinical practice and lowered transfusion rates. Results A total of 2,531 consecutive cardiac surgical procedures were performed during a five-year period. Using a multidisciplinary approach to quality improvement, and with the goal of using fewer blood products, our incidence of allogeneic red blood cell transfusion was decreased, from 43% in 2003 to 18% in 2007. Patient outcomes were not significantly changed. Conclusions Cardiac surgery in a community hospital can be performed safely with low utilization of allogeneic red blood cell transfusions. A multidisciplinary approach to blood conservation can result in lower transfusion rates and equivalent patient outcomes.
Summary
Patient Blood Management is the timely application of evidence‐based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss ...to improve patient outcomes. Conceptually similar to a “bundle” strategy, it is designed to improve clinical care using comprehensive evidence‐based treatment strategies to manage patients with potential or ongoing critical bleeding, bleeding diathesis, critical anemia, and/ or a coagulopathy. Patient Blood Management includes multimodal strategies to screen, diagnose and properly treat anemia, coagulopathies and minimize bleeding, using goal‐directed therapy and leverages a patient's physiologic ability to adapt to anemia while definitive treatment is undertaken. Allogeneic blood component transfusion is one traditional therapeutic modality out of many for managing blood loss and anemia and, while it may be the best choice in certain situations, other effective and more appropriate options are available and should be used in conjunction or alone. Therefore, comprehensive Patient Blood Management is the new standard of care to prevent and manage anemia and optimize hemostasis and has been recommended by the World Health Organization, the American Society of Anesthesiologists, the European Society of Anaesthesiology and the Australian National Blood Authority. While there is a plethora of expert consensus and good practice guidelines published for blood component transfusion from multiple professional organizations and societies, there remains a need for more comprehensive and broader standards of patient medical management to proactively reduce the risk of exposure to allogeneic transfusions. In 2010, the Society for Advancement of Blood Management published the first comprehensive standards to address the administrative and clinical components of an effective, patient‐centered Patient Blood Management program. Recognizing the need to reduce inappropriate transfusions, some professional organizations have placed their emphasis on transfusion guidelines. In contrast, the focus of the Society for Advancement of Blood Management Standard is on the centrality of the patient and the full spectrum of therapeutic strategies needed to improve clinical outcomes in patients at risk for blood loss or anemia, thereby reducing avoidable transfusions as well. The Standards are meant not to replace, but to complement transfusion guidelines by more completely addressing the need for a multi‐modal clinical approach with the goal to improve patient outcomes. Compared to adult programs, Pediatric Patient Blood Management programs are currently not commonly accepted as standard of care for pediatric patients. This is partly due to the fact that, until recently, there was a paucity of robust evidence‐based literature and expert consensus guidelines on pediatric PBM. Managing pediatric bleeding and blood product transfusion presents a unique set of challenges. The main goal of transfusion is to correct or avoid imminent inadequate oxygen carrying capacity caused by inadequate red blood cell mass. Determining when, what, and how much to transfuse can be difficult. Neonates, infants, children, and adolescents each have specific considerations based on age, weight, physiology, and pharmacology. In this edition of Pediatric Anaesthesia we provide, in abbreviated format, the 4th edition of the Administrative and Clinical Standards for Patient Blood Management; Pediatric Version, first published in 2010 with the addition of a new Pediatric section in 2016. These Standards provide guidance for implementing a comprehensive Pediatric Patient Blood Management program at both pediatric and adult medical institutions. While every hospital may not be equipped to have a dedicated Pediatric Patient Blood Management program, this document highlights important universal clinical strategies that can be implemented to optimize pediatric bleeding management and minimize allogeneic blood product exposure through the use of multi‐modal therapeutic strategies that have their central emphasis on the patient rather than the transfusion. Important strategies include: treatment of preoperative anemia, standardized transfusion algorithms, the use of restrictive transfusion thresholds, goal‐directed therapy based on point of care and viscoelastic testing, antifibrinolytics, and avoidance of hemodilution and hypothermia as supported by evidence. For the full version, please go to https://www.sabm.org/publications.
BACKGROUND
Patient blood management (PBM) programs are associated with improved patient outcomes, reduced transfusions and costs. In 2008, the Western Australia Department of Health initiated a ...comprehensive health‐system–wide PBM program. This study assesses program outcomes.
STUDY DESIGN AND METHODS
This was a retrospective study of 605,046 patients admitted to four major adult tertiary‐care hospitals between July 2008 and June 2014. Outcome measures were red blood cell (RBC), fresh‐frozen plasma (FFP), and platelet units transfused; single‐unit RBC transfusions; pretransfusion hemoglobin levels; elective surgery patients anemic at admission; product and activity‐based costs of transfusion; in‐hospital mortality; length of stay; 28‐day all‐cause emergency readmissions; and hospital‐acquired complications.
RESULTS
Comparing final year with baseline, units of RBCs, FFP, and platelets transfused per admission decreased 41% (p < 0.001), representing a saving of AU$18,507,092 (US$18,078,258) and between AU$80 million and AU$100 million (US$78 million and US$97 million) estimated activity‐based savings. Mean pretransfusion hemoglobin levels decreased 7.9 g/dL to 7.3 g/dL (p < 0.001), and anemic elective surgery admissions decreased 20.8% to 14.4% (p = 0.001). Single‐unit RBC transfusions increased from 33.3% to 63.7% (p < 0.001). There were risk‐adjusted reductions in hospital mortality (odds ratio OR, 0.72; 95% confidence interval CI, 0.67‐0.77; p < 0.001), length of stay (incidence rate ratio, 0.85; 95% CI, 0.84‐0.87; p < 0.001), hospital‐acquired infections (OR, 0.79; 95% CI, 0.73‐0.86; p < 0.001), and acute myocardial infarction‐stroke (OR, 0.69; 95% CI, 0.58‐0.82; p < 0.001). All‐cause emergency readmissions increased (OR, 1.06; 95% CI, 1.02‐1.10; p = 0.001).
CONCLUSION
Implementation of a unique, jurisdiction‐wide PBM program was associated with improved patient outcomes, reduced blood product utilization, and product‐related cost savings.
Background
We describe the implementation and impact of a patient blood management program (PBMP) in an Australian teaching hospital.
Study Design and Methods
A PBMP was introduced at a single ...tertiary care hospital in 2009 as a pilot for the Western Australian Health Department statewide PBMP. The first 3 years of interventions aimed to make effective use of preoperative clinics, manage perioperative anemia, improve perioperative hemostasis, reduce blood sample volumes, and implement restrictive transfusion triggers and a single‐unit transfusion policy.
Results
Between 2008 and 2011, admissions to Fremantle Hospital and Health Services increased by 22%. Using 2008 as a reference year, the mean number of red blood cell (RBC) units per admission declined 26% by 2011. Use of fresh‐frozen plasma and platelets showed 38 and 16% declines, respectively. Cryoprecipitate increased 7% over the 4‐year period. For elective admissions between 2008 and 2011, the leading decline in RBC transfusion rate was seen in cardiothoracic surgery (27.5% to 12.8%). The proportion of single RBC unit use increased from 13% to 28% (p < 0.001), and the proportion of double units decreased from 48% to 37% (p < 0.001).
Conclusion
This is the first tertiary hospital in Australia to establish a multidisciplinary multimodal PBMP. Interventions across disciplines resulted in decreased use of RBC units especially in orthopedic and cardiothoracic surgery. Continuing education and feedback to specialties will maintain the program, improve patient outcomes, and decrease the transfusion rate.
Patient Blood Management is the timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis and minimize blood loss to ...improve patient outcomes. Conceptually similar to a "bundle" strategy, it is designed to improve clinical care by using comprehensive evidence-based treatment strategies to manage patients with potential or ongoing critical bleeding, bleeding diathesis, critical anemia and/ or a coagulopathy. Patient Blood Management includes multimodal strategies to screen, diagnose and properly treat anemia, coagulopathies and minimize bleeding, using goal-directed therapy and leverages a patient's physiologic ability to adapt to anemia while definitive treatment is undertaken. Allogeneic blood component transfusion is one traditional therapeutic modality out of many for managing blood loss and anemia and, while it may be the best choice in certain situations, other effective and more appropriate options are available and should be used in conjunction or alone. Therefore, comprehensive Patient Blood Management is the new standard of care to prevent and manage anemia and optimize hemostasis and has been recommended by the World Health Organization, the American Society of Anesthesiologists, the European Society of Anaesthesiology and the Australian National Blood Authority. While there is a plethora of expert consensus and good practice guidelines published for blood component transfusion from multiple professional organizations and societies, there remains a need for more comprehensive and broader standards of patient medical management to proactively reduce the risk of exposure to allogeneic transfusions. In 2010, the Society for Advancement of Blood Management published the first comprehensive standards to address the administrative and clinical components of an effective, patient-centered Patient Blood Management program. Recognizing the need to reduce inappropriate transfusions, some professional organizations have placed their emphasis on transfusion guidelines. In contrast, the focus of the Society for Advancement of Blood Management Standard is on the centrality of the patient and the full spectrum of therapeutic strategies needed to improve clinical outcomes in patients at risk for blood loss or anemia, thereby reducing avoidable transfusions as well. The Standards are meant not to replace, but to complement transfusion guidelines by more completely addressing the need for a multi-modal clinical approach with the goal to improve patient outcomes. Compared to adult programs, Pediatric Patient Blood Management programs are currently not commonly accepted as standard of care for pediatric patients. This is partly due the fact that, until recently, there was a paucity of robust evidence based literature and expert consensus guidelines on pediatric patient blood management. Managing pediatric bleeding and blood product transfusion presents a unique set of challenges. The main goal of transfusion is to correct or avoid imminent inadequate oxygen carrying capacity caused by inadequate red blood cell mass. Determining when, what and how much to transfuse can be difficult. Neonates, infants, children and adolescents each have specific considerations based on age, weight, physiology and pharmacology. In this edition of Pediatric Anaesthesia we provide, in abbreviated format, the 4
edition of the Administrative and Clinical Standards for Patient Blood Management; Pediatric Version, first published in 2010 with the addition of a new Pediatric section in 2016. These Standards provide guidance for implementing a comprehensive Pediatric Patient Blood Management program at both pediatric and adult medical institutions. While every hospital may not be equipped to have a dedicated Pediatric Patient Blood Management program, this document highlights important universal clinical strategies that can be implemented to optimize pediatric bleeding management and minimize allogeneic blood product exposure through the use of multi-modal therapeutic strategies that have their central emphasis on the patient rather than the transfusion. Important strategies include: treatment of preoperative anemia, standardized transfusion algorithms, the use of restrictive transfusion thresholds, goal-directed therapy based on point of care and viscoelastic testing, antifibrinolytics, and avoidance of hemodilution and hypothermia as supported by evidence. For the full version, please go to https://www.sabm.org/publications. This article is protected by copyright. All rights reserved.
For many years, nurses have performed the tasks related to blood transfusion monitoring and the associated quality-control documentation. There have been multiple job titles given to healthcare ...providers in this field: haemovigilance officer, transfusion practitioner, transfusion nurse, patient blood management (PBM) nurse, blood conservation nurse and blood management nurse. These titles share some overlap in tasks. In this article, the authors discuss Australian and US experiences of the historical transfusion nurse role, and the newer title of PBM nurse. The article will attempt to answer the question: is it time these two job titles and roles were merged into one, creating the evolved role of PBM nurse? It will define the unique nature of these roles and attempt to explore any differences between them. PBM is becoming a standard of care and embedded in institutions around the world. The transition and adoption of a joint role is timely, and the article also addresses the issue of appropriate staffing levels. PBM has become the overarching phrase that addresses the prevention of transfusion as well as the quality and safety needs of transfusion medicine. The authors propose it is time to merge the roles of the PBM nurse and the transfusion nurse, which would ultimately benefit patients, as well as more thoroughly address the needs of hospitals.
Introduction
Predictive testing for
BRCA1 or BRCA2
allows at-risk individuals to engage with appropriate screening and treatment services if a pathogenic mutation is identified. Previous studies have ...shown uptake of predictive testing to most commonly range between 20% and 40% (Table
2
). This represents a missed cancer prevention opportunity. Possible explanations for this low uptake include lack of disclosure of at-risk status to relatives, lack of awareness of cancer genetics services, or patient preference. The goal of the current study was to investigate the uptake of
BRCA1 or BRCA2
predictive testing in an Irish population.
Methods
We performed a multicentre, retrospective analysis of 63 pedigrees from two Irish tertiary referral hospitals over a five-year period (2012-2017). Family pedigrees were reviewed to identify at-risk family members eligible for predictive
BRCA1 or BRCA2
mutation testing as per international guidelines, and testing rates were determined.
Results
A total of 1048 eligible individuals were identified, 318 (30.4%) proceeded to
BRCA1 or BRCA2
germline testing including 215 (37.5%) females and 99 males (21.5%). Women were significantly more likely to test than men (
T
= 3.7,
p
< .0002). Uptake of testing was significant higher amongst first-degree relatives 45% (150/323) compared to 20% (50/258) amongst second degree relatives, and 10 % (33/317) amongst more distant relatives (
F
= 25.32,
p
< 0.00001).
Conclusions
Uptake of
BRCA1 OR BRCA2
mutation testing in Ireland is suboptimal, particularly amongst Irish males and distant relatives. Further research is needed to identify strategies which may improve uptake within current legal and ethical frameworks.
Abstract only
613
Background: Approximately 1-8% of renal cell carcinomas (RCCs) are associated with inherited predisposition. No consensus referral guideline exists for genetic assessment for RCC. ...Early age of onset, the presence of a family history and type II papillary RCC should trigger clinical genetics referral. We investigated the pattern of cancer genetics referral for early-onset RCC in Ireland. Methods: The number of patients with RCC diagnosed under the age of 50 between 2005 and 2013, was obtained from the National Cancer Registry of Ireland. RCC was defined by the WHO/IARC Classification. The number of patients referred for genetic work-up with RCC < 50 years of age was ascertained from The National Centre for Medical Genetics. Individuals unaffected by RCC but with a family history of RCC were excluded. The database was searched using the following search terms: Von Hippel-Lindau (VHL), Birt-Hogg-Dube (BHD) and RCC; and the clinical reason for referral recorded. Results: 580 patients were diagnosed with RCC below the age of 50. 71 percent were between 40 and 49 years of age (n=410). 52 patients were referred to The National Centre for Medical Genetics. Indications for referral are listed in Table 1. 7 patients were referred for a diagnosis of RCC < 50 years of age. The average age of these patients was 37.8 years. Three of the referrals were for early age of onset of RCC; two referrals were made for early age of onset with a family history of RCC; and two with early onset RCC and bilateral RCCs. This represents a referral rate of approximately 0.01% for early onset RCC in Ireland. Conclusions: Most early onset RCC is not referred for clinical cancer genetics assessment. The heritability of RCC is incompletely understood. Improved referral patterns, increased clinical genetics assessment and a better understanding of the genetic aetiology of RCC may have preventive and therapeutic implications for this disease. Table: see text
Highlights • We present a national cohort study of carriers of large genomic rearrangements in BRCA1 and BRCA2. • As expected, LGRs were more commonly identified in BRCA1 (49 families) than BRCA2 (7 ...families). • A number of recurrent LGRs were identified in BRCA1: deletions of Exons 1–23; Exon 3; and Exons 19–20. • One LGR in BRCA2, deletion of Exons 19–20 was identified in five unrelated families. • There was regional variation in distribution of LGRs, with most recurrent LGRs detected in the West.
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