Angela Paquette RNBN

Nurse Coordinator Blood Management Service

WRHA Blood

Management

Service

A Year in Review

Objectives

• Define Blood Management

• Share the benefit of timely blood

management interventions through case

studies from 2017 obstetrical, cardiac and

general surgery.

• Highlight current Blood Management

Service current strategies for blood

conservation in Manitoba.

Patient Blood Management

• Professionally defined as

“the timely application of evidence-based

medical and surgical concepts designed to

maintain hemoglobin concentration, optimize

hemostasis and minimize blood loss in an effort

to improve patient outcomes.”

Goal of Patient Blood

Management

1. Optimizing Coagulation,

2. Interdisciplinary Blood Conservation

Modalities

3. Managing Anemia

4. Patient-Centered Decision Making

We Got Your Back

• AABB

• SABM- Annual Meeting delivers the latest

science, best practices, and networking

opportunities. This event is held in

September of each year and offers

accreditation for physicians, perfusionists,

nurses, and laboratory personnel

• Choosing Wisely

Myths about Blood

Conservation

Why blood conservation?

• Donations are down, shortages

• Blood is part of surgical planning

• Patients will have a better post operative

outcome

• There is no harm?

Lets Talk Numbers $$

• It is estimated that nearly one-third of the

world’s population suffers from anemia.

The prevalence in North America is even

higher—approaching 40%. Iron-deficiency

is the most common cause

• The cost of transfusing one unit of red cells

is almost $1200 US. Each additional unit is

associated with $1480 US in increased

hospital costs ie. L.O.S

Canadian Blood Services

• Hospital orders (demand) and active whole blood donors for the past 5 years.

• An exciting highlight of the information as it relates to your presentation topic is

the positive impact of your blood conservation strategies; hospitals have

consistently decreased usage of red blood cells year over year since 2012/2013;

15.9% decrease at the Winnipeg Distribution Centre and 10.1% Nationally.

• Chart

Morbidity and Mortality rates for

blood transfusion intra-op

• Red cell transfusion is 1 of the 5 "overused"

procedures in medicine per the American

Medical Association and The Joint Commission.

• Application of patient blood management

principles and practices has led to up to 80%

reduction in transfusions

Preoperative Anemia- Predictor

of Mortality?

• Preoperative Anemia Is Associated with

Postoperative Mortality

• Statistical support that with each red cell

transfusion the risk increases.

Patient Safety/

Improved outcomes

Implementing meticulous surgical technique,

a goal-directed coagulation algorithm, and a

more restrictive transfusion threshold in

combination resulted in a substantial

decrease in RBC, FFP, and PLT

transfusions; less kidney injury; a shorter

length of hospital stay; and lower total direct

costs

Hospital Acquired Anemia

Recommendations

• Use of micro sampling tubes for blood

work

• Minimize blood samples post op

Our Efforts in the Management

of Blood

Blood Management efforts to

decrease utilization

• Iron Sucrose (Venofer) infusions through

consultation to our service (surgical and

obstetrical patients)

• Family Physcian info packsges.

• Awareness Posters (Obstetrical and ER

Venofer posters)

• Regional Blood Education

• Just One Campaign

• IVIG Utilization Management

The Proof

Obstetrical Consult

Reason for Consult:

•History of Iron Deficiency Anemia less than 80 g/L

and failed trial of oral iron and greater than 13

weeks gestation

•Low body weight (less than 60 Kg) pre-pregnancy

•Rare blood type or antibodies

•Non-consent for transfusion

•Increased risk of postpartum hemorrhage:

• Placental abnormality

• Multiple pregnancy

• Gestation Hypertension

• Large baby in current pregnancy

• Multiple previous deliveries

• Past history of postpartum hemorrhage

* Form can be found on Best Blood Manitoba website*

Obstetrical Case Study

26 y.o G2P1 10 wks gestating Screening Hgb 43

Otherwise Healthy

Labs:

Plan – improve oral Fe compliance, dietary Iron education

She delivered her 8 lbs 3 ounnce baby healthy pre delivery Hgb was 88 and post delivery

hgb was 77, discharged home with oral Iron..

Obstetrical Consult

Surgical Consult

Reason for Consult:

•Non-consent for transfusion

•High blood loss surgery

•History of anemia and current Hgb

•Staged or multiple surgeries

•Low body weight (less than 60 Kg)

•Difficult cross-match

* Form can be found on

Best Blood Manitoba website*

Cardiac Case Study #1

Non-consent to blood • 77 year old female

• Refuse blood for Jehovah Witness Faith

• PMHx: Aortic Stenosis, HTN, remote Hsterestomy

• Screening Hgb 82

• MCV HCT TIBC

• Required valve and also had an 80% blockage in her arteries.

• Other tests colonoscopy, Occult stool sample.

• Later then Dx with H Pylori and treated

• Target Hgb 140

• BMS interventions

• Time line: Feb 2017 2 doses of IV Iron sucrose

Cardiac Case Study

• ref # 2409 Cardiac

ref # 2409 Cardiac

Cardiac Case Study #2

Non- Consent

• 68 y. o female

• CABG

• Screening Hgb

• Plan Oral Fe OD, dietary iron, 2-3 doses

of 20000 i.u. of Eprex 4 weeks prior to

surgery.

• Results: Optimized with Hgb 131

Cardiac Case Study

ref # 24084 Cardiac

General Surgery Case Study

• 84 y.o. female

• Screening Hgb 88.

• Elective OR date TBA

• PMHx: HTN, DMII, difficult cross match

• Meds included beta blockers, antiglycemics and insulin.

• High blood loss multi organ procedure.

• Screening Labs Hgb 88, HCT 0.294 MCV 71.5. Within a month of

screening had rectal bleeding> based of Ht and wt and goal Hgb of 120.

Iron Deficit was 958. Unable to tolerate oral fe, and poor appetite due to

dx complications

• Plan- 3 doses of 300 mg IV Iron Sucrose.

• Tolerated the IV Infusions well and response was Hgb ? She was

scheduled for her procedure.

General Surgery Case Study

Blood Management efforts to

decrease utilization costs:

• Iron Sucrose (Venofer) infusions through

consultation to our service (surgical and

obstetrical patients)

• Awareness Posters (Obstetrical and ER

Venofer posters)

• Regional Blood Education

• Just One Campaign

• IVIG Utilization Management

Venofer Posters

Regional Blood Education

•Identify the 6 rights of transfusion

•Highlight the key elements of pre transfusion testing (how to avoid

wrong blood in tube)

•Describe the process for ordering blood products

•Focus on Choosing Wisely recommendation, “Why give two when one

will do?”

•Emphasize that blood can safely be returned to inventory up to 60

minutes after issue if no longer required

•Learn how to merge the patient and the product

•Review how to manage a transfusion reaction

Just One Campaign

• Collaboration between Shared

Health, Blood Management

Service and Choosing Wisely

Manitoba.

• Campaign that aims to reduce

unnecessary red cell transfusions

in hospitals by encouraging all

staff involved to order just one

unit of blood at a time and then

reassessing need for additional

units.

• Tags attached to blood bags.

• Piloted at HSC and soon to be

rolled out provincially.

Utilization in Manitoba

Purpose of Utilization Management

Increasing usage Cost

Evidence based practice

Sustainability

Product

shortages

IG Working Group

• Formed in 2014

• Provincial Transplant and Transfusion Service

• Shared Health, Diagnostics (formerly Diagnostic

Services of Manitoba)

• Blood Management Service

• Immunology

• Neurology

• Hematology

• Oncology

Blood Management Service

1. Receives form and enters information into database.

2. Identifies requests that may not be aligned with the

guidelines and initiate communication with

TM/prescriber.

3. Generates monthly list of patients with pending

expirations.

4. Notifies prescribers of pending expirations.

(Notifications will be discontinued as of January 2019).

5. Provides quarterly reports to stakeholders.

Any Questions??

July 13th 2016

July 13th 2016