Patient Blood Management: Moving Above and Beyond the Optimal Use of Blood!

Transfusion Science: Quality and safety focus

The practice of blood transfusion became increasingly sophisticated, standardized, and supervised in due course of time. Transfusion medicine developed as a branch of medicine to encompass the science, principles, and practices related to the transfusion of blood and blood components, including hemovigilance. The triggers of transfusion, the evaluation of bleeding tendency, and the anemia and physiologic tolerance to low hematocrit are several key variables that determine the transfusion as such or the decision to transfuse.^[10] However, the majority of the literature and best practice recommendations and guidance in transfusion medicine stresses on ensuring that all phases of the transfusion process, ranging from blood requisition to donor selection and screening routing through the process of phlebotomy, screening, and blood component preparation and separation before the blood component is finally issued are ensuring the absolute safety of the blood product.^[11] Every time a decision to transfuse is made, everyone involved in the blood bank and the transfusion process is responsible and accountable for the rational transfusion of safe blood products.

Optimal use of blood

In the past few years, there has been an impetus to ensure reasonable and clinical use of blood.^[12] The objective is to provide the right amount and type of blood to the right patient at the right time. The focus areas, usually, are quality systems for clinical transfusion, errors, adverse events, and adverse reactions, documentation for quality, essential indications for blood components, clinical transfusion process, evaluation of transfusion practice, methods around clinical audit, and implement a training program for safe and effective transfusion. Hence, all in all, most interests and activities are intended to ensure that the “product” is safe and of the highest quality.^[13] Moreover, this is very much a desired state as well. Only aspect missing is that there is minimal “patient” focus as such.

Clinical use of blood

The objectives of clinical use of blood are the use of blood and blood products appropriately at all levels of the healthcare system in any country without compromising standards of quality and safety.^[14] The focus area, usually, is appropriate use of blood and blood products, anemia, replacement fluids, clinical transfusion procedures, adverse effects of transfusion, clinical decisions on transfusion, transfusion in clinical practice setting specific, hospital transfusion committee, and education and training on the clinical use of blood. Although, with more and more thrust on “clinical use of blood, there has not been an increase in the overall effectiveness of not just the transfusion as such but the decisions to transfuse as well. This has certainly increased the confidence of the prescribing surgeons and physicians in terms of the efficacy of blood and blood products in the management of their patients. With more and more emphasis on the clinical use of blood, the engagement and collaboration between the prescribers and providers has increased encouragingly.^[15]

Product safety to patient safety: The changing focus

Advancements in the understating of and availability of the latest technology for blood testing over the decades and increased emphasis on donor selection and screening have significantly decreased transfusion-related adverse events, especially the transmission of infectious agents; however, noninfectious complications continue to be a serious risk.^[16] Noninfectious transfusion-related adverse events may happen due to various reasons specific to a blood component, the amount of blood transfused, and errors on the part of decision-making toward transfusion.^[17] The increasing number of issues and evidence on complications of transfusions, per se, has functioned as the activator of shifting the focus toward the “patient” rather than the “product.”

PBM: The paradigm change

PBM evolved in the past several years, focusing on the hematopoiesis as relevant and connecting links to all disciplines of medicine.^[18] Proposed in 1998 and introduced in 2005, PBM’s origins are traceable to the late 19^th century, when blood transfusion was not feasible for managing exsanguinating hemorrhage or critical anemia.^[19]

PBM is a patient-centered, systematic, and evidence-based approach to improve patient outcomes by managing and preserving a patient’s blood while promoting patient safety and empowerment.^[20] PBM involves the timely, multidisciplinary application of evidence-based medical and surgical concepts aimed at (1) screening for, diagnosing, and appropriately treating anemia; (2) minimizing surgical, procedural, and iatrogenic blood losses and managing coagulopathic bleeding throughout the care; and (3) supporting the patient while appropriate treatment is initiated. There are several reasons to shift from product-centered transfusion practice to patient-centered PBM: The aging population has a worked-out demand for blood products as against the reducing donor base; the increasing “consumer” awareness that transfusion is a complicated service involving several different cost centers within a healthcare institution and amounting to a multiple of the blood product cost; the ongoing efforts to protect blood banking systems from existing, evolving, or altered pathogens, the emerging global evidence that blood transfusion is an independent risk factor for adverse outcomes and, a paucity of concrete evidence toward benefits of transfusion for a vast majority of transfusion recipients.^[21]

PBM improves patient outcomes by improving the patient’s medical and surgical management in ways that boost and conserve the patient’s blood.^[22] PBM, as we now realize, is a comprehensive, collaborative, and consensus-based standard of care that incorporates system-driven, scientifically evidenced, and schematically managed people, policies, and protocols to ensure that the patient sits at the center of every step and consideration in blood and bleeding management. PBM, backed by the guidance and recommendations, is not only the need of the hour but also the standard of care.^[23]

Optimal use of blood vis-à-vis PBM

Optimal blood use and PBM are both truly relevant and effective concepts. It is just that PBM, as a practice, helps in addressing and managing a patient’s specific need with a goal directed approach^[24] [Table 1].