HAI 2018: PBM Implementation in clinical routines

Improvement of care quality and patient safety

HAI 2018, Berlin: The number of surgical interventions and thus the risk of perioperative blood loss with the necessary blood transfusions is currently on the rise, in part due to the aging population. WHO has been recommending since 2010 that this trend could be countered by the use of Patient Blood Management (PBM). Numerous studies clearly show that PMB measures can preserve the patient's own blood resources, improve treatment quality, outcomes, and patient safety, and reduce costs significantly due to savings on transfusions and shorter hospital stays. At the Capital City Congress of the German Society for Anaesthesiology and Intensive Medicine (HAI 2018) anaesthesiologists and surgeons discussed the implementation of PBM in clinical routines to improve care quality and patient safety.

By definition, PBM refers to the timely use of an evidence-based medical and surgical concept that aims to preserve the patient's own blood reserves where possible and thus to improve treatment quality and patient safety (1). "For clinicians, the basic cornerstones of PBM focus in particular on the diagnosis and treatment of anemia, followed by the avoidance of blood loss both in a conservative and surgical setting. However, this can only be effective if we improve interdisciplinary cooperation and put the patient first", stated Prof. Jochen Erhard, Senior Consultant at the Clinic for Surgery/Visceral and Vascular Surgery at Niederrhien Duisburg Hospital. The Austrian benchmark study by Gombotz and colleagues showed that over 90% of elective patients were not given any preoperative anemia treatment: an indication that not enough consideration is given to the treatment of the individual patient and his/her haemoglobin levels (Hb) (2).

Implementation suffers as a result of established transfusion pathways

In Erhard's experience, implementation of PBM also suffers as a result of the established transfusion pathways. In over 60% of cases, transfusion units are ordered on the basis of the planned operation but not then used (2). According to a current European multi-centre study on intraoperative transfusion practices, only 8.5% of the transfusions were done solely on the basis of diagnosed anemia values (3). "These are dramatic figures, a waste of resources, and a situation that harms patients", declared the PBM pioneer Erhard, who has spent the last 2 decades trying to introduce blood-saving measures in hospitals, with increasing success. The establishment of an algorithm-based PBM system could lead to a significant reduction in transfusion rates, as he proves with data from his own hospital. Of 157 patients who had elective surgery for colon cancer there between 2012 and 2016, almost half were anemic (47.2% with Hb 7.8-11.8 g/dl). All patients were able to be treated under the PBM concept. In all only 3 required transfusions.

PBM in a primary care hospital

Dr. med. Thomas Wiederrecht, Alb-Donau Hospital and Blaubeuren Health Centre (D.E.S.A.) has already been able to build on Erhard's preliminary work, and has reaped the benefits. Since introducing the first PBM measures in 2014, Wiederrecht and his team have managed to inspire practicing colleagues and affected patients with enthusiasm for the concept and to raise awareness of preoperative anemia and its treatment. The introduction of smaller blood monovettes and backflush systems for arterial blood pressure measurement in the intensive care stations as well as non-invasive Hb measurements in the premedication outpatient area soon produced convincing figures. A comparison of the necessary erythrozyte concentrates (EC) before and after the introduction of PBM (from the year 2013 versus 2017) showed a reduction of 1,541 EC per year, which works out to be 55%. This corresponds to a cost saving of around 155,000 Euros per year for transfusion units, or process-based overall costs of over 0.5 million Euros (conversion factor 3.5 according to Shander (4)).

PBM in the operating theatre

Dr. med. Hendrik Kohlhof, Clinic and Polyclinic for Orthopedics and Trauma Surgery at Bonn University Medical Centre, underlined the significance of PBM from the point of view of surgeons. If you take the criteria established by WHO for anemia (women Hb < 12 g/dl, men Hb < 13 g/dl)(5), around one in three patients suffers from preoperative anemia (6). Pre-existing anemia is an independent risk factor for the transfusion of erythrocyte concentrate (EC), for increased morbidity and mortality, a longer stay in hospital and a poorer recovery and quality of life (7, 8), explained the specialist in Orthopedics, Trauma Surgery and Endoprosthetics. In a global comparison this puts Germany as one of the countries with the highest transfusion rates -- more than five million EC (9). "With comprehensive PBM measures there is therefore a huge savings potential just here at home to the tune of over 100 million Euros per year", said Kohlhof. "In addition, with PBM we have a great many opportunities to improve the outcome of the operating procedure and thus patient satisfaction."

Most important measures in surgery

For him, the most important measures in surgery are the management of pre- and postoperative anemia through the use of intravenous iron supplements and erythropoietin-stimulating factors (EPO), the reduction of diagnostic and interventional blood loss e.g. through surgical haemostasis, minimally invasive access, the use of coagulation algorithms with the help of coagulation factor concentrates and antifibrinolytics such as tranexamic acid, as well as the restrictive use of allogeneic blood products by using individual anemia tolerance. "We can significantly reduce the transfusion rate simply by short-term preoperative administration of IV iron supplements or a combination with EPO drugs", claimed Kohlhof. A number of studies already show that PBM measures can be used to significantly reduce transfusion rates, e.g. in hip replacements from 38.5% in 2009 to 8.5% in 2015 (11). Why should we start the process with an anemic patient when I know from the data that I won't do the patient any good", concluded Kohlhof.

Using experiences from the PBM network

How the future development of PBM in Germany looks and to what extent the level can be further optimised with a shared approach was the subject of the presentation by Prof. Patrick Meybohm, Clinic of Anaesthesiology at Frankfurt University Hospital. The goal is to bring the clinics already using PBM together to form a network, partly in order to be able to act together in a political sphere, e.g. in the discussion with health insurance companies about selective agreements or better financial rewards for hospitals that spend more on PBM. A German multi-centre pilot study at the University Hospitals of Bonn, Frankfurt, Kiel and Muenster with 54,513 patients before and 75,206 patients after implementation of PBM has already shown that despite intensive training not all PBM measures could be implemented, but they depended on the respective circumstances (12). However, the study also showed that the rate of complications did not rise due to the PBM concept, while morbidity and hospital mortality, secondary parameters of transfusion rates, length of hospital stay and Hb values all improved. Founded in 2004, the Frankfurt-based German PBM network supports interested clinics both in the implementation of PBM and also during the ongoing project e.g. by providing SOPs or training material. Participating departments can also gain certification, currently done via a self-assessment process.

Literature

1. Gombotz H et al. Patient Blood Management. Thieme Verlag Stuttgart 2016
2. Gombotz H et al. Blood use in elective surgery. The Austrian benchmark study. Transfusion 2007; 47: 1468 ff.
3. Meier J et al. Intraoperative transfusion practices in Europe. BJA 2016; 116: 255-61
4. Shander A et al. Activity‐based costs of blood transfusions in surgical patients at four hospitals. Transfusion 2010; 50 (4): 753-765
5. World Health Organization. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Information System. World Health Organization, Geneva, Switzerland; 2011
6. Meybohm P et al. The Patient Blood Management Concept. Joint recommendation of the German Society of Anaesthesiology and Intensive Medicine and the German Society of Surgeons. Chirurg 2017; 88:867–870
7. Musallam KM et al. Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet 2011; 378: 1396–1407
8. Baron DM et al. Preoperative anaemia is associated with poor clinical outcome in non-cardiac surgery patients. Br J Anaesth. 2014 Sep;113(3):416-23
9. Health Report of the Federal Government 2015; Use of blood products through transfusions. Year 2015. www.gbe-bund.de
10. Goodnough LT et al. Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth. 2011; 106(1): 13–22.
11. Newman C et al. Patient blood management strategies in total hip and knee arthroplasty. Current Orthopaedic Practice 2018; 29 (1): 31-36
12. Meybohm P et al. Patient Blood Management is Associated With a Substantial Reduction of Red Blood Cell Utilization and Safe for Patient's Outcome: A Prospective, Multicenter Cohort Study With a Noninferiority Design. Ann Surg. 2016;264(2):203-11