BLOOD AND BONES - ANZONA Conference · 2019-10-28 · recommendation(s ) But care should be taken...

BLOOD AND BONES

Angie Monk Patient Blood Management Clinical Nurse Consultant Joondalup Health Campus

ANZONA27th October 2017

London

Blood and blood products Standard 7

Hong Kong


Australia


Australian Nurse of the year 2016


Why PBM

• Preoperative anaemia has been shown to be associated with an increased risk of adverse outcomes

• Patients with preoperative anaemia are more than three times likely to have received transfusions than in those who did not.


WA leads the way in PBM

• In 2009 a PBM program was introduced into Fremantle hospital and was successful in significantly dropping the transfusion rate.

• 2011-2015 WA DOH funded PBM CNCs to develop and implement PBM programs in four main adult tertiary metropolitan hospitals with the support of a team including Trudi Gallagher WA PBM nurse co-ordinator.

• 2015 – Funding for PBM CNC was handed over individual tertiary hospitals

• 2017 - A PBM WA study of the 604,046 public patients undertaken by Professor Michael Leahy and showed :

28% reduction in hospital mortality15% reduction in average hospital length of stay21% decrease in hospital-acquired infections31% decrease in the incidence of heart attack or stroke.

My PBM Story

• 2011-Introduced PBM at JHC with support of WA PBM team .• 2012-Introduced thromboelestometry (ROTEM )• 2014 –Improved patient outcome measured by:

- THR transfusion rate dropped from 39- 8- TKR transfusion rate dropped from 17- 4

• 2015-2017The Australian Commission on Safety and Quality in Health Care led the National Patient Blood Management Collaborative to support improvements in the management of anaemia and iron deficiency for patients having elective gastrointestinal, gynaecological and orthopaedic surgical procedures. JHC was one of 12 hospitals selected to participate.


GRADE A Body of evidence can be trusted to guide practice

GRADE B Body of evidence can be trusted to guide practice in most situations

GRADE C Body of evidence provides some support for recommendation(s )But care should be taken in its application.

GRADED Body of evidence is weak and recommendations must be applied with caution

Engaging Clinicians in three pillars of PBM

Clinical engagement


Resource developmentfor use in anaemia clinic

– iron infusion prescribing chart which includes consent – preoperative anaemia pathway– Iron infusion patient leaflet with consumer input outlining

the procedure and necessary precautions.– Letters drafted and factsheets designed for provision to

patient and GPs outlining requirements for pre-operative anaemia assessment


Change Management Evidence based practice


Engaging primary health care teamGP anaemia workshop


Referral process

• Patients requiring joint replacement are referred to orthopaedic surgeon .

• urgent conditions are scheduled to be seen within 30 days.

• Routine conditions are given the next available appointment according to clinical need.


Practice engagement


Pre-operative screening


• All patient undergoing surgery where large blood loss can be anticipated, should be screened and managed preoperatively for iron deficiency/iron deficiency anaemia.

• Untreated anaemia, even to a small extent, increases the risk of complications and mortality in the context of surgery

Three Pillars OF PBM

Pillar 1 Pillar 2 Pillar 3

Anaemia management to optimise red cell

mass

Minimise blood loss Optimise tolerance of anaemia

• Detect & treat anaemia

• Time Sx with RBC mass optimisation

• Identify and Rx bleeding/bleeding risk

• Meticulous anaesthetic/surgical techniques

• Positioning/warming

• Minimise phlebotomy

• Only Tx when required

• Restrictive Tx practice: single unit guideline

Pillar 1: Optimise red cell mass


GP

Consulting Rooms

SMAC

Referred to PBM CNC

Booked for IV iron infusion

telephone consult with patient re-management plan

or send a letter to patient.

PBM letter to GP.

Meet with Clinical director of PBM –management plan

JHC Pre-Operative screening process


Management plan – IV iron


ANAEMIA TRENDS


207 178 154271 246

4

25092

345158

277

557431 454

8911042

611

443

84

419

704

746359

189 200

418

394

338

482

128

368

69

162

264

0

200

400

600

800

1000

1200

1400

1600

1800

HS1 HS2 HS3 HS4 HS5 HS6 HS7 HS8 HS9 HS10 HS11 HS12

Gastrointestinal(2182) Orthopaedic(6741) Gynaecology(3012)

Total procedures by surgical stream by health serviceas at end of February 2017

This total includes a small number of procedures which predate May 2015

Total 11 935

Percentage of patients receiving pre-operative assessment for anaemia per month – May 2015 to February 2017

60%

65%

70%

75%

80%

85%

90%

95%

100%

May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

Percentage of patients confirmed with anaemia per month – May 2015 to February 2017

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%


Percentage of patients with anaemia managed per month – May 2015 to February 2017

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%


IRON DEFICIENCY TRENDS


Percentage of patients receiving pre-operative assessment for iron deficiency per month – May 2015 to February 2017

0%

10%

20%

30%

40%

50%

60%

70%

80%

May Jul Sep Nov Jan Mar May Jul Sep Nov Jan

Percentage of patients confirmed with iron deficiency per month – May 2015 to February 2017

0%

5%

10%

15%

20%

25%

30%

35%


Percentage of patients with iron deficiency managed per month – May 2015 to February 2017

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%


SURGICAL STREAMS


Percentage of patients who were confirmed with iron deficiency by surgical stream by quarter

42%

49%

14%

51%48%

19%

52%

39%

19%

43%46%

17%

37%

41%

16%

42%

37%

17%

0%

10%

20%

30%

40%

50%

60%

Gynaecological Gastrointestinal Orthopaedic

Q1Jul-Sep15 Q2Oct-Dec15 Q3Jan-Mar16 Q4Apr-Jun16 Q5Jul-Sep16 Q6Oct-Dec16

Percentage of patients with iron deficiency who were managed by surgical stream by quarter

48%51%

56%

47%

59%64%

50%

58% 59%57%

75%

54%

70%66%

56%

71%68% 68%

0%

10%

20%

30%

40%

50%

60%

70%

80%



Percentage of patients with both anaemia and iron deficiency who were managed by surgical stream by quarter

54% 52%

33%

71%

53%

85%86%

54%60%

50%

81%

50%

90%

73%

38%

71%67%

70%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



Number of patients who received transfusions, by month

– May 2015 to February 2017

NB: Further data will be entered for these months

0

10

20

30

40

50

60

May-15

Jun-15

Jul-1

5

Aug-15

Sep-15

Oct-15

Nov-15

Dec-15

Jan-16

Feb-16

Mar-16

Apr-16

May-16

Jun-16

Jul-1

6

Aug-16

Sep-16

Oct-16

Nov-16

Dec-16

Jan-17

Feb-17

Num

bero

fpatients

Ante-natal Parental iron Infusion rate 2015-2017

Maternal Anaemia –evidence of association with adverse outcome in pregnancy. Including low birth weight and preterm birth, placental abruption, maternal mortality

and postnatal depression.( ref : NBA Patient Blood Management maternity guidelines 2016).

0

5

10

15

20

25

30

1 2 3 4 5 6 7 8 9 10 11 12

2015

2016

2017

0

10

20

30

40

50

60

1 2 3 4 5 6 7

Transfusion rate in obstetrics 2011- Aug 2017

PBM IN OBSTETRICS


Pillar 2: Minimise blood loss

How do we minimise blood loss?


Anaesthetic measures

• Pre op assessment• Type of anaesthetic • Drugs • Induced hypotension • Normothermia • Patient positioning• Acute normovolaemic

haemodilution (ANH)• Guidelines for massive

blood loss


Surgical Measures

• Prompt surgical Haemostasis

• Cell salvage• Tourniquet• Topical agents


Rotational Thromboelastometry(ROTEM)

Real time information about cause of bleeding

Targeted approach for management of bleeding • Surgical problem• Blood products• Drugs (TXA)


ROTEM Algorithm


Critical Bleeding Protocol (record)


Pillar 3: Optimise tolerance to anaemia

Appropriate Transfusion practice


Post-operative blood salvage


Blood sampling

• Over sampling ‘routine’• Small volume sample tubes• Point of care testing • Return dead space blood loss

Avoiding iatrogenic anaemia


Facts about blood


Transfusion versus IV Iron

Transfusion Indication• Bleeding• Bone marrow failure• Symptomatic anaemia• Iron content: ~ 100mg variable

depends on donor

Iron Indication• Iron deficiency• Replete iron stores when

significant blood loss• Predictable amount of iron• Usual adult dose 500-2000mg

Severe reactions: Transfusion 1:20,000 unitsIV iron 1: 200,000 infusions


Decision to transfuse

• Transfusions are independently associated with increased risk of morbidity and mortality.

• The decision to transfuse must be based on evidence best practice (PBM guidelines)based on a thorough clinical assessment, where the benefits of transfusion out weigh the potential risk.


Single unit policy

TRANSFUSION PLAN


Collecting blood products

Collection of blood products from hospital blood bank


The transfusion of blood products must begin as soon as possible after delivery to the ward or operating theatre.If this is not possible it must be returned to the blood bank within 30 minutes .Prior to collection of blood ensure ;

• Prescription for blood and consent is completed • IV in situ and patent.• Circumstances/situation appropriate and Staff are available .


Two staff must perform bedside check one must be the person hanging the blood.

Ensure right patient -right blood


Thankyou

BLOOD AND BONES - ANZONA Conference · 2019-10-28 · recommendation(s ) But care should be taken...

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Transcript of BLOOD AND BONES - ANZONA Conference · 2019-10-28 · recommendation(s ) But care should be taken...