Appropriate Red Cell Use in Adults Royal Derby Hospital Learning - - PowerPoint PPT Presentation

“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

• ptimising 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 miss 2016 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 resources from the “Toolkit” visit hospital.blood.co.uk

• r 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 Production in 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 Low microcytic anaemia High macrocytic 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

• ld

Attended pre-op clinic - heavy periods Blood test results: Hb 70g/L MCV 65 MCH 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 is admitted to MAU after attending her GP with tiredness 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 3

Clinical 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, creatinine 120 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

• utcome

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 fl Is 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 YES YES YES NO YES N O YES NO 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
• f 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?