Patient blood management – what's the problem with implementation?

Patient blood management has been utilised increasingly over the past 20 years [1]. Whilst there is not an agreed definition, a recent expert consensus paper emphasises that patient blood management is a patient-centred, evidence-based approach to preserving the patient's own blood, improving safety and, crucially, improving patient outcomes [1]. The world's first comprehensive patient blood management programme began in Western Australia, where data from over 600,000 patients admitted to four major tertiary care hospitals from 2008 to 2014 showed risk-adjusted reductions in hospital mortality (odds ratio (OR) 0.72, 95%CI 0.67–0.77, p < 0.001); duration 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). In addition, the programme resulted in an estimated £63–78 (US$78–97, €75–94) million in activity-based cost savings of transfusion [2]. A subsequent systematic review published in 2019 (17 studies) showed that the implementation of patient blood management significantly reduced transfusion rates (risk ratio (RR) 0.61, 95%CI 0.55–0.68, p < 0.001); number of red blood cell units per patient (mean difference -0.43, 95%CI -0.54 to -0.31, p < 0.001); hospital duration of stay (mean difference -0.45, 95%CI -0.65 to -0.25, p < 0.001); total number of complications (RR 0.80, 95%CI 0.74–0.88, p < 0.001); and mortality (RR 0.89, 95%CI 0.80–0.98, p = 0.02) [3]. The Australian experience would suggest that the widespread implementation of patient blood management would achieve major improvements, in both patient outcomes and health economics. However, although patient blood management is simple, effective and evidence-based, uptake is slow and not just in the UK. The World Health Organisation, a staunch advocate of patient blood management, has raised the importance of managing anaemia and, in many instances, blood loss and coagulopathy, because "taken together, these conditions represent one of the world's biggest, largely preventable, yet greatly underestimated public health and health-economic burdens" [4]. Warnakulasuriya et al. report on the results of their survey of patient blood management measures in 123 UK hospitals [5]. They found that 30% of hospitals taking part in the survey had no anaemia pathway, with inconsistent policies for haemoglobin optimisation. They also found that only 39% of centres had a tranexamic acid policy and half had access to point-of-care testing. Local policies for the use of cell salvage were not present in 59% of centres overall and in 34% of sites offering obstetric services. Given the clear advantages of implementing patient blood management, the question we must ask is why there is such disparity throughout the UK in its implementation. One answer may lie in the conflicting evidence surrounding its benefits. A network meta-analysis of common patient blood management interventions identified five systematic reviews with over 390 trials including > 50,000 patients and concluded that "in randomised trials, patient blood management interventions do not have important clinical benefits beyond reducing bleeding and transfusion in people undergoing major surgery" [6]. Conversely, Althoff et al. in their meta-analysis found that "a comprehensive patient blood management program addressing all three patient blood management pillars is associated with reduced transfusion, need of red blood cell units, lower complication and mortality rate, and thereby improving clinical outcome" [3]. The publication of the PREVENTT study has also been considered a barrier to the support for pre-operative intravenous iron after the widely anticipated trial concluded that pre-operative intravenous iron administration did not improve survival or reduce transfusion requirements [7]. This lack of consensus may make it easier for NHS Trusts to avoid putting scarce resources into patient blood management. Similarly, the evidence concerning point-of-care testing is muddled. Whilst there are several studies which show a benefit in terms of reduction in transfusion in cardiac surgery, the routine use of viscoelastic point-of-care testing has not been shown to improve clinical outcomes [8]. A systematic review and meta-analysis of 15 studies in cardiac surgery showed that there was no difference in re-operation for bleeding, duration of stay or mortality [8]. In addition, there have been concerns about the accuracy of point-of-care tests [9], their standardisation and quality control [10], as well as the inevitable issues concerning education and training. The use of erythropoietic stimulating drugs in patient blood management is not common. These are not included on the Australian pre-operative anaemia management template [11]; however, they are recommended by the French National Authority for Health [12]. One concern has been the associated risk of thrombosis, particularly in patients with malignancy (the French guidelines specify their use in cardiac and orthopaedics only). In our opinion, the resources (in both training personnel and cost of the drugs) would be better spent concentrating on elements of patient blood management which are easier to achieve and are more likely to be adopted, such as more widespread use of oral iron and tranexamic acid. Another reason for the lack of implementation of patient blood management strategies is also financial; specifically, we must answer these questions: whose responsibility is it to pay for patient blood management and how do we prove its financial benefits? The financial outlay and resources required to set up a good patient blood management system include addressing pre-operative anaemia and the management of ongoing coagulopathies. If we would like to implement patient blood management earlier in the patient's journey, whose responsibility it is to pay for this? For example, if we would like patients to commence anaemia management when they are first referred to specialist services by their GP, this incurs an expense to primary care, yet the benefit costs (reduction in transfusion and duration of stay) are beneficial to secondary care. As such, primary care, with strained budgets, may understandably be reluctant to bear this expense. Patients presenting with bleeding or anaemia are referred rapidly to the appropriate speciality; at this point, the emphasis is on diagnosis, risk stratification and the treatment pathway. The patient may not be referred to the pre-operative anaemia service until later in the treatment pathway, sometimes a matter of days before the planned surgical date. Patients with malignancy may well be referred for pre-operative chemotherapy but again, management of anaemia is not a primary concern of this care team. Yet the NHS, as a state-funded all-encompassing healthcare system, should be in an ideal position to provide integrated holistic care with funding coming from both primary and secondary care. In 2022, the importance of pre-operative haemoglobin optimisation was recognised by NHS England, with the creation of the pre-operative anaemia Commissioning for Quality and Innovation (CQUIN) framework, which provided a financial incentive for improving management in this area [13]. However, it is likely that, in some instances, the costs of implementing the service would exceed the CQUIN payment. Ultimately, Trusts were allowed to choose their own CQUIN targets to achieve the financial reward. Similarly, with intra-operative cell salvage, there is no unified NHS approach to funding or provision. This is a technique which is well-established internationally, with benefits that may include the reduction in peri-operative allogeneic red cell transfusion (and thus reduced risk of transfusion reactions and errors) as well as offering red cell replacement that has better oxygen carriage and reduced risk of initiating transfusion-related immunomodulation [14, 15]. However, the lack of a unified NHS policy has meant that services have evolved locally with differing business models, relying upon budgets arising from pathology, surgery, operating theatre or anaesthesia. The financial benefits of cell salvage are seen in reductions in duration of stay and hospital readmission, and may not necessarily be of direct financial benefit to the department paying for the service. Superficially, transfusing donor blood is easier and may be cheaper than funding and supporting cell salvage for the operating theatre budget; staffing, education and equipment are all necessary commodities that an underfunded service may not be keen not to pay for. It is important to recognise that there is no requirement to collect data on cell salvage use in the UK and it is not known how much peri-operative allogeneic transfusion is avoided by cell salvage. A survey of UK practice in 2019 estimated that cell salvage provided an equivalent of 8800 units of packed red cells. However, the authors stressed the incompleteness of data with only 114 hospitals of the 225 contacted being able to provide data [16]. In comparison, the latest data (from 2014) estimated that peri-operative transfusion accounted for 15,216 units of allogeneic packed red cells in England and Wales [17]. There are no data that identifies what proportion of donor transfusion could be replaced with cell-saved blood [18]. Tranexamic acid is a low-cost, low-risk and effective intervention which has been proven to reduce blood loss in a variety of surgical and trauma situations [19, 20]. Why then do only 39% of UK centres have a policy for its use? There are several perceived barriers to the routine use of tranexamic acid. At the start of a case we often ask if the surgeons expect a blood loss of > 500 ml, yet it is well known that surgeons and anaesthetists are unreliable at estimating blood loss [21]. Should we instead define a list of procedures where we believe tranexamic acid is indicated? Another barrier is the concern about adverse effects, specifically stroke and other thrombo-embolic disease. However, there is no evidence that tranexamic acid (at an intravenous dose of 1 g for an adult) increases adverse events [22, 23]. Perhaps we should instead adopt an approach where 1 g of tranexamic acid is given to all surgical patients unless there is a known contraindication. The reduction in blood loss (even if it is not to the extent that requires transfusion) may allow a quicker recovery from surgery and reduce the risk of postoperative anaemia or requirement for transfusion. Once the reluctance to giving tranexamic acid is overcome, the literature is unclear as to the best dose to use (and what route to administer this by). A review by the Cochrane group on tranexamic acid use in hip and knee surgery suggested that a total peri-operative dose of > 3 g has the greatest effect on reduction on blood loss; the authors were unable to find any evidence of harm, although they commented that they were not able to draw definitive conclusions based on the trials included within the review [24]. The Royal College of Surgeons has recently advocated a 1 g bolus of tranexamic acid at the beginning and end of surgery, in line with the dosage regime in the POISE-3 study [25]. The dose of tranexamic acid used in the CRASH-2 study (1 g bolus followed by 1 g over 8 h) offers yet another treatment regimen [19]. In our opinion, the lack of a nationally agreed dosing regimen is contributing to the inconsistent and suboptimal use of this antifibrinolytic drug. Although tranexamic acid is an extremely cheap component of patient blood management, other modalities such as a pre-operative anaemia service or cell salvage cost time and money and require clinical and managerial investment, and ongoing support. Very commonly the investment will need to come from one service, with the benefits being achieved much later in the patient journey. Put simply, the money is invested by one department, but the benefits are seen by others. Whilst some studies have shown a financial benefit to the implementation of patient blood management, there remain other studies which do not. Key amongst these is the PREVENTT trial [7] which, for various reasons, did not show a benefit in the treatment of pre-operative anaemia [26]. However, patients in the trial who received intravenous iron were less likely to require re-admission following surgery at 8 weeks (RR 0.61, 95%CI 0.40–0.91) and 6 months (RR 0.78, 95%CI 0.58–1.04). This decreased rate of re-admission was associated with a greater increase in haemoglobin in the intervention group at 8 weeks and 6 months. In addition, there are likely to be other, more subtle benefits to treating anaemia including improvement in quality of life, readmission rates and improvements in heart failure management [27], which may not be amenable to economic analysis. Education is another challenge that impedes adoption of patient blood management. Despite the numerous studies that have shown the benefits of patient blood management [2, 3], there remain several sceptics. This includes those who perceive anaemia as a very common, but minimally significant, condition and one that can be 'fixed' with transfusion. Part of this culture is one of the ongoing dismissal of women's health issues, as anaemia is more common in women with heavy menstrual bleeding and affects several hundred million women worldwide. The failure to address this and to perceive anaemia as a variation of normal, represents a catastrophic failure of healthcare to address the needs of a significant section of the population. And whilst transfusion does increase the patient's haemoglobin, it has little (or even a negative) effect on the patient's ability to manufacture red cells. An interesting illustration of the counterproductive effect of transfusion on red blood cell manufacture has been reported by Holm et al. who showed that postpartum transfusion suppressed erythropoiesis, resulting in reduced haemoglobin when compared with those patients receiving intravenous iron [28]. We suggest that patient blood management should form part of medical school teaching and postgraduate nursing education, and that there should be awareness and an obligation at Trust level. It should remain a facet of training in surgical and anaesthetic specialities, and be considered a core skill with key importance in ensuring optimal patient care; it should not be seen as an optional extra. What does good look like for patient blood management in peri-operative care? The deficiencies in UK practice identified in the study by Warnakulasuriya et al. are critically important [5]. The reduction in bleeding associated with patient blood management, and therefore the lower demand for blood, will help to reduce alerts from critically low blood stock levels. Leadership is vital to develop a national service; Farmer et al. describe a comprehensive patient blood management programme implementation and assessment tool which includes executive leadership; administrative support; education; and engaged community stakeholders [29]. In our opinion, the improvements in UK practice must begin even before the first point of contact with secondary healthcare. Anaemia should be screened for and prevented in the community, with public health measures and education to improve diet and attention paid to chronic bleeding. At the point of contact with primary care, the patient with anaemia should have the cause identified and measures instigated to reduce ongoing blood loss and to replace the loss of haematinic factors. Primary care should have the resources to investigate and treat iron deficiency, with the feasibility of community iron hubs being considered. Surgical pathways for benign and malignant disease should have anaemia screening at the beginning of their pathways and Trusts be incentivised to support anaemia optimisation. The World Health Organization surgical checklist should pay specific attention to bleeding issues; the question should be 'is there a reason not to give tranexamic acid?'. When blood loss could be > 500 ml, cell salvage should be available, and cell saved blood should be the preferred first line red blood cell product for all patients when clinically appropriate. In addition, although the evidence for use of point-of-care testing of coagulation is incomplete, the aspiration for clinicians should be optimisation of coagulation, to avoid both coagulopathy and thrombotic phenomena. There are significant wins with patient blood management. A holistic approach to implementation can improve the health and clinical outcomes of surgical, medical and obstetric patients; reduce healthcare costs; improve patient safety; advance patient education and empowerment; and reduce the demand for allogeneic blood components and thus the national dependency on transfusion. The urgency for implementation is undeniable. SA is an Editor of Anaesthesia and has received honoraria from Haemonetics and Octapharma. CC is a member of the Board of the Association of Anaesthetists, chairs the Northwest Transfusion Committee and the UK Cell Salvage Action Group and has received honoraria from Vifor Pharma.