- [Change needed in blood management system ②]
Patient Blood Management (PBM) is a multidisciplinary, evidence-based approach to optimizing care for those who might need a blood transfusion. Australia is one country that successfully implemented the approach at a national level.
According to PBM specialist Axel Hofmann, the blood management system, which aims to minimize blood transfusions, holds evidence that fewer transfusions improved patient outcomes and lowered cost.
Hofmann, a visiting professor at the University Hospital Zurich, Switzerland, known for helping implement PBM programs in Australia, outlined the origin, process, and result of implementing PBM in an email interview with Korea Biomedical Review.
Question: When did you first take interests in patient blood management (PBM)?
Answer: Around 2003, the argument arose that transfusion is “free” and should remain the standard therapy to correct anemia. But my colleagues and I argued that transfusions are complex interventions that require numerous hospital resources such as clerical work, nursing time, and physician time. We found the actual cost of blood transfusion was somewhere between $500 and $1,200 per unit.
In 2009, we discovered two significant findings: the majority of transfusions seemed to be unnecessary, and a dose-dependent relationship exists between transfusions and adverse outcomes (such as morbidity and mortality). It has since become clear to me that we need other ways to manage anemia and hemorrhage and re-evaluate the old standard of care.
Q: We’ve heard that Australia is the only country in the world where PBM is universalized. What helped PBM gain footing in Australia?
A: All primary stakeholders were in the same boat, so to say. It all started in the late 1980s with one of the world’s first comprehensive “blood conservation programs” being established by Shannon Farmer, a well-published PBM expert, in Western Australia. This impacted practice across the state, helping it achieve one of the lowest transfusion rates in the developed world. Program results captured the interest of multiple clinical disciplines, professional societies, and health authorities.
Years later, Simon Towler became the chief medical officer of Western Australia (WA) and made PBM a public health issue. We were able to engage a large number of leading clinicians in the WA PBM project. The Australian Red Cross Blood Service and the National Blood Authority also played a crucial role in advancing PBM in Australia. Later on, the Australian Commission on Quality and Safety in Health Care and the National Safety and Quality Health Service Standards made PBM a national priority. So again, it was this broad support of diverse stakeholders that helped PBM gain footing in Australia.
Q: Were there some difficulties in implementing PBM?
A: Change is always challenging in medicine, and of course, there will still be some who resist change. Medical professionals, though, should treat their patients with the best available evidence.
With the support of well-published PBM opinion leaders from Australia, Europe, and the U.S., we formed a multidisciplinary faculty to convey the best evidence. Most encouraging, we saw significantly improved outcomes regarding morbidity, mortality and mean hospital length of stay. The majority of professionals changed practice quickly.
As I said before, we were fortunate in Australia because most, if not all, stakeholders supported the concept. Successful PBM requires involvement from all levels of the health system, from senior executives to health practitioners. Full implementation of a PBM program also involves re-engineering healthcare delivery. To this end, multidisciplinary hospital teams worked hard.
Q: How long did it take for Australia to change the official name of its transfusion guidelines to “Patient Blood Management Guidelines?”
A: Around 2007, Australia’s National Health and Medical Research Council and the Australasian Society of Blood Transfusion Clinical Practice Guidelines on the Use of Blood Components (2002) were due for review. In 2008, the National Blood Authority (NBA) initiated and governed the process of developing evidence-based Patient Blood Management Guidelines.
The concept of PBM had gained such acceptance by this time that the NBA saw the need to establish guidelines that focused more on clinical management of patients, rather than transfusion products. And thus the decision was made to develop comprehensive, evidence-based PBM Guidelines – the first in the world.
An expert working group developed the clinical questions that formed the basis for exhaustive systematic reviews of the literature from 2008 and 2016. Almost 2000 full-text papers were assessed and summarized to produce 52 evidence-based recommendations, 142 practice points, and 56 expert opinion points. Work has now commenced on reviewing and updating the guidelines.
Q: Are there any other countries aside from Australia that is actively implementing PBM?
A: South Korea is proactively working on PBM dissemination. My esteemed colleagues from the Korean Society for Patient Blood Management just organized a high-quality international symposium on PBM. As far as I understand, South Korea has almost reached the point to make PBM a national standard of care.
The European Commission recently issued two guides, one for hospitals and one for health authorities, to implement PBM as a standard of care across the entire European Union (EU). Italy, Spain, and Portugal are the early adaptors. In the U.S., Englewood Hospital and Medical Center in Englewood, New Jersey has the most extensive PBM history. Meanwhile, health authorities from other Asian countries, including China, Hong Kong, Malaysia, and Singapore, have started PBM activities.
Q: Do you have any advice for raising PBM awareness in Korea?
A: It is all about information and education. I can only advise making PBM an integral part of both under- and postgraduate medical training. And of course, it is incredibly useful to give PBM results to clinicians. Choosing PBM is a clinical, economic, ethical and also medico-legal necessity.