The PBM is a three-pillar strategy to cure preoperative anemia and iron deficiency (intravenous [IV] iron + erythropoietin [EPO] + vitamin B12 + folic acid), reduce preoperative red blood cell (RBC) loss by an improved surgical technique, cell salvage, and re-transfusion, acute normovolemic hemodilution, coagulopathy management (anti-fibrinolytics, fibrinogen, Factor XIII, prothrombin complex concentrate [PCC], low central venous pressure, no hypertension, normothermia), and optimize anemia management (tolerate low hemoglobin values, IV iron + EPO postoperatively, increased fraction of inspired oxygen [FiO2]).[8-13]
In this review, we aimed to share previous experiences and indicate current problems with solutions which would ensure the implementation of a PBM protocol in our hospital that can be also a guide for similar large-volume tertiary hospitals.
SUCCESSFUL IMPLEMENTATION
STORIES: INTERNATIONAL
University Hospital of Zurich PBM Program
The University Hospital of Zurich (USZ) aimed
to achieve the best possible surgical patient outcome
(lowest mortality, no organ dysfunction, no lung injury,
no renal impairment, no stroke, no myocardial infarction,
minimal infection rate, minimal thromboembolic
adverse events, minimal length of hospital stay, least
amount of blood product transfusions, minimal costs)
and adopted the strategies of PBM to attain this target.
Key steps in the implementation of PBM included the development of hospital-wide guidelines, creating a commission for the responsible use of blood products, achieving general ownership at all disciplines, monitoring guideline adherence, and collecting data to evaluate the success rate. Firstly, the anesthesiology department, in collaboration with the hematology department, developed evidencebased transfusion and anemia management guidelines (Tables 1 and 2). Eight specialties were defined to use these guidelines: cardiac surgery, trauma, transplantation, obstetrics, neurosurgery, burn unit, intensive care unit (ICU), and plastic surgery. Patients with an RBC transfusion rate of >10% and an expected blood loss of >500 mL were included as the focus group identified by the workgroup of USZ. The PBM program organization is listed in Table 3.
The PBM was put into practice in USZ about 10 years ago, and its success was demonstrated in many studies.[14,15]
SUCCESSFUL IMPLEMENTATION
STORIES: NATIONAL
Numune Training and Research Hospital
The cardiovascular surgery clinic of Ankara
Numune Training and Research Hospital in 2016 was
one of the pioneers in launching the first applications
of PBM in Turkey (Table 4). Thus, a two-step project
was implemented: firstly, initiating a PBM program
in the cardiovascular surgery clinic and subsequently,
spreading out the program to the entire hospital after
accomplishing successful outcomes.
Table 1: University Hospital of Zurich Guideline-Hemoglobin thresholds for transfusion
Table 2: University Hospital of Zurich Guideline-Preoperative treatment of anemia
Table 3: University Hospital of Zurich-Patient blood management program organization
Table 4: 2016 data of Ankara Numune Training and Research Hospital
Staff training, transfusion monitoring, IV fluid restriction, preoperative anemia treatment (IV iron carboxymaltose), revision and adaptation of international guidelines, and cooperation with cardiology were the parts of the preoperative phase.[16] The preoperative phase included goal-directed coagulation (impaired platelet function, surgical bleeding, etc.), goal-directed perfusion (low blood pressure or anemia may not be indicative of blood transfusion every time, what is important is the oxygen that penetrates the tissues), minimally invasive surgery, routine tranexamic acid administration, cerebral/somatic oximetry, minimally invasive extracorporeal circulation circuits, microplegia, retrograde autologous priming, vacuum-assisted venous drainage, ultrafiltration, cytokine adsorption, and recirculation of waste blood. The postoperative phase comprised of transfusion monitoring, IV fluid restriction, fibrinogen concentrate administration, and goal-directed coagulation tests.
remarkable reduction in the use of blood and blood products after this PBM program was evident in the cardiovascular surgery clinic (Figure 1). A significant cost reduction was also achieved by implementing the PBM program. To accurately determine the cost of blood in this population, the activity-based costing (ABC) model was used as described by Shander et al.[17] The cost of approximately 42 triple coronary artery bypass surgeries was saved. Hospital records documented early extubation of patients accompanied by reduction of bleeding rates, shortening of the length of stay in hospital and ICU, and reduced mortality rate. Therefore, PBM was also successful in improving clinical outcomes. In the light of these data, Numune Hospital was entitled to 2018: JCI Patient Blood Management Certification.
Successful consequences obtained in the first step motivated the dissemination of the project in all surgical clinics. Objectives of the program included determining the current situation, determining the problems in blood use, constituting a team of surgical branches, and holding meetings to form a strategic plan with the purpose of reducing blood use in the hospital by 50% in the 2018 to 2021 period. Approximately 35,000 units of total blood and blood products were utilized for about 55,000 operations at Numune Hospital in 2017. Figure 2 illustrates the distribution in some prominent branches.
The in-depth investigation highlighted the wastage of many of the unused blood products, which incurred a high cost equivalent to 16 triple coronary artery bypass surgeries (Table 5). As depicted in Table 6, the reasons for the destruction of blood and blood products were quite striking.
Table 5: Ankara Numune Training and Research Hospital - Used and destroyed blood products
Table 6: Ankara Numune Training and Research Hospital-Reasons for the destruction of blood products
In 2018, hospital-wide blood and blood product usage dropped to 29,500 units, approximately. Therefore, a reduction in blood and blood product usage by 3% could be achieved in one year by conducting multidisciplinary scientific meetings and initiatives in surgical clinics of Numune Training and Research Hospital (Figure 3).
The data obtained from the Numune Hospital were published in various journals and presented at international congresses.[18-22] Subsequently, international training programs were launched in Turkey. The EuroAsia Heart Foundation decided to organize PBM Schools in Turkey, and the first meeting entitled Interdisciplinary Meeting on Bleeding Management in (Cardiac) Surgery and Obstetrics was held with 55 participants from 11 countries in Izmir in April 2019.
Consensus Meeting on PBM
The second stage of Numune Hospital's PBM
program was decided to be continued in a larger
scale hospital, which was established by the
transportation of Ankara's largest state hospitals and
put into service in December 2018. The city hospital
comprises of 3,804 hospital beds, 735 outpatient clinics, and 128 operating theaters. The PBM has
become one of the most important targets in the city
hospital. The main objective of PBM implementation
is to portray a good example for other hospitals in
Turkey. The data gathered from the City Hospital on
blood product usage and destruction are detailed in
Tables 7 and 8.
A strong organization, coupled with a multidisciplinary approach, is a prerequisite to cope with similar challenges during the implementation of PBM program in City Hospital.
Aiming at kick-off building a multidisciplinary PBM program in this extremely large hospital setting, a consensus meeting was organized to provide a platform where all components may come together to fix problems, discuss, and propose solutions. Over 150 participants in the meeting included members from the departments of anesthesiology, surgery, transplantation, ICU, perfusion, blood bank, nursing, pharmacy, and Ministry of Health. Professor Donat Spahn from the University Hospital of Zurich, being one of the leaders in the implementation of the PBM program, was invited and acted as a consultant.
In this multidisciplinary meeting, international and domestic experiences were shared, the importance of coordination and execution of different pillars in PBM was discussed, and the problems of the blood transfusion system were also explored with a proposal for solutions. Based on these data, it was aimed to develop a standard protocol for PBM which could be used as a guide by similar large-volume tertiary hospitals.[23,24]
There is not any purpose of comparison of any previous data with each other and/or with current situation. The geographic and background conditions of each instant are completely different. The main idea is to present different PBM protocols in various hospital settings.
Synopsis of Problems/Solutions
The following problems and proposals for the
solutions were documented, discussed with managers,
and a final consensus report was submitted for the
hospital directorate.
1) Anesthesiology and Reanimation
2) Blood Transfusion Center
3) Nursing Services
The blood transfusion procedures of our hospital
are prepared following the national guidelines, National
Blood and Blood Components Preparation, Use and
Quality Assurance Guideline-2016,[25] and National
Hemovigilance Guideline-2016.[26] According to these
blood transfusion procedures, monitoring, educating,
reporting, analysis, and documentation of blood transfusion applications are the responsibilities of our
hemovigilance nurses.
4) Intensive care unit
5) Transplantation Services
6) Perfusion Services
Despite the demonstrated benefits of PBM, several challenges limit the application of PBM guidelines into clinical practice worldwide, particularly due to the lack of knowledge, lack of interdisciplinary commitment, lack of resources, and general concerns. It should enable PBM's patient-centered approach to be delivered in a way that is also hospital centered and, therefore, compatible with each institution. The initial success achieved from the institution should impart further motivation and activities in the field of PBM.[28,29]
Pillars need to be adapted with respect to characteristics of the region and legislations available. For instance, there are specific reimbursement policies for IV iron therapy in Turkey. Also, limitations of the use of EPO and vitamin B12/folic acid by nephrologists may become a burden for cardiac surgeons to implement perioperative anemia correction. Successful PBM implementation involves structural changes, logistic reorganizations and leadership with psychological skills, a monitoring, and feedback program, and persistence. An individualized program must be established by the hospitals with the consensus of participants.
The Ankara City Hospital is the largest hospital in Turkey. Current practice with the use of more than 60,000 units of blood and blood products in one year necessitates the need for a PBM program.
We believe that this consensus report would accelerate the cooperation within disciplines and provoke more optimal results in the short-term. Furthermore, it is valuable as it represents a guide for similar large-volume hospital settings.
Acknowledgement
We thank to Figen Yavuz, MD (Turkiye Klinikleri) for her
valuable assistance in the writing process of this review.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect to
the authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.