“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 miss2016 and 2018

Transfusion Reactions

Limited Supply: The falling donor base...

“Save One O D neg”

“Save one O D Neg”

Campaign

• 134 Trusts

• Estimated O D Neg savings:

– 6968 units a year

– 581 units a month

It only takes one to make a difference

For more information or to access resourcesfrom 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 Productionin 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

low Hb

MCV

Lowmicrocytic anaemia

Highmacrocytic anaemia

Normal

• Iron deficiency • Thalassemia• Hook worm

infection

• Anaemia of chronic disease – CKD

• Red cells disorders –sickle cell disease

• Bone marrow disorders

• B12 / folate deficiency

• Alcohol excess• Hypothyroid • Haemolysis• Bone marrow

disorders- MDS + myeloma

Types of Anaemia

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 oldAttended pre-op clinic - heavy periods

Blood test results: Hb 70g/L MCV 65MCH 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 isadmitted to MAU after attending her GP withtiredness

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 3Clinical 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, creatinine120 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 bleeding? /

Theatre standby

Symptomatic cardiovascular

disease? Hb ≤ 80 g/l

Look up FBC

Hb ≤ 70 g/L

Issue and Refer to TP for follow up

Discuss need for transfusion with

requestor Refer to TP ISSUE

UNIT

MCV < 80 flIs the patient symptomatic?

More than 1 unit requested?

Suggest single unit followed by clinical review

Refused Agreed

Issue and refer to TP for follow up

NO

NO

NO YES

YESYES

YES

NO

YES

NO

YESNO

AP: Refer to BMS

AP: Refer to BMS

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

What if things get heated?• Empathise – you do not have the patient in front

of you• It takes two…try not to get sucked in • Always be polite and calm, constructive and

helpful • This is where robust guidelines help• Take their name and contact number• Document everything

PASS IT ON TO A TP

REMEMBER: • no-one has the right to be rude or abusive • there is a patient at the end of this • We’re all on the same side

In summary:What’s the Lab’s role in all this?

• You are entitled to ask the question if a request seems inappropriate, excessive or outside the framework of the trust transfusion guidelines but you cannot refuse

• You should approach the team in a friendly, helpful manner– Most likely way to get a meaningful discussion going– Use phrases like “Have you considered giving one unit and

reviewing in line with national advice?”

• Ultimately the decision is the medical/surgical team’s to make but your advice may be very helpful in making that decision!

Thanks!Any questions?