ISBAR - Introduction, Situation, Background, Assessment and Recommendation

ISBAR - Introduction, Situation, Background, Assessment and Recommendation

Single Unit Transfusion Guideline – Supporting Material

INTRODUCTION:

The Single Unit Transfusion guideline, based on a restrictive transfusion threshold, is part of Patient Blood Management (PBM); an evidence based patient centred strategy to improve patient outcomes by minimising blood transfusions.

In line with the Patient Blood Management Guidelines:

“Where indicated, transfusion of a single unit of RBC, followed by clinical reassessment to determine the need for further transfusion, is appropriate. This reassessment will also guide the decision on whether to retest the Hb level”.1,2

If one unit of blood adequately improved the symptoms, then no further transfusion should occur.

The single unit guideline applies to stable, normovolaemic inpatients who are NOT actively bleeding and NOT in an operating theatre.

SITUATION:

Current practice does not align with the evidence-based Patient Blood Management Guidelines.1,2The National Blood Authority has produced a single unit transfusion guideline to assist compliance with the Patient Blood Management Guidelines and compliance with the National Safety and Quality in Health Care Standards (NSQHS), Standard 7: Blood and Blood Products.3

Morbidity from transfusion has been shown to be dose dependent.4,5 Two units are commonly prescribed when one unit may have met the clinical expectation and outcome of the transfusion. Excessive / over-transfusion exposes patients to increased risk of adverse event without commensurate benefit to outcome.6,7

Emerging evidence reveals that transfusion is an independent risk factor for adverse outcomes including increased morbidity, mortality and hospital length of stay. There is a lack of evidence for the benefit of transfusion in the non-bleeding patient.8,9

BACKROUND:

Historically, two unit blood transfusions were considered normal. Transfusion was habitual /cultural, according to haemoglobin and not based on evidence of benefit. Current evidence now demonstrates the increased morbidity, mortality and length of hospital stay have been independently associated with transfusion.4,5 The Patient Blood Management Guidelines state “Where indicated, transfusion of a single unit of RBC, followed by clinical reassessment to determine the need for further transfusion, is appropriate. This reassessment will also guide the decision on whether to retest the Hb level”.1,2

ASSESSMENT:

Blood transfusion is a live tissue transplant.Emerging evidence of harm from transfusion requires a precautionary approach to balance risk with benefit for each unit.6,7 Restrictive transfusion thresholds and single unit transfusions are safe in patients who are not actively bleeding and reduce risk.10,11

Extensive education of medical, nursing and laboratory staff will be required, through broad- based forums such as Grand Rounds, as well as specialty group/ divisional meetings, seminars, and education days. The local website or intranet, local internal magazines (printed and electronic), training manuals and regular communication tools should be utilised. Posters and handouts may also be used. The National Blood Authority provides tools; printed and electronic education material for display and presentations. The catch-phrase “Be SINGLE minded” is suggested.

RECOMMENDATION:

With approval from hospital executive management, health services should involve quality and/or clinical governance staff to recruit clinical champions to assist promotion, education and implementation of the single-unit transfusion guideline.The National Blood Authority have a suite of educational material and tools to assist uptake of this guideline.

REFERENCES:

1.National Blood Authority Patient blood management guidelines: Module 3 – Medical. (National Blood Authority: Canberra, Australia, 2012).at

2.National Blood Authority Patient blood management guidelines: Module 4 – Critical Care. (Canberra, Australia, 2013).at

3.Australian Commission on Safety and Quality in Healthcare Safety and Quality Improvement Guide Standard 7: Blood and Blood Products. ACSQHC (2012).at

4.Koch CG Duncan AI et al, L. L. Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting. Crit Care Med 200634, 1608–1616 (2006).

5.Hajjar LA Vincent JL et al. Transfusion requirements after cardiac surgery: the TRACS randomised controlled trial. JAMA - Journal of the American Medical Association304, 304:1559–1567

6.Hofmann, A., Farmer, S. & Shander, A. Five drivers shifting the paradigm from product-focused transfusion practice to patient blood management. The oncologist16 Suppl 3, 3–11 (2011).

7.Hofmann, A., Farmer, S. & Towler, S. C. Strategies to preempt and reduce the use of blood products: an Australian perspective. Current opinion in anaesthesiology25, 66–73 (2012).

8.Popovsky, M. Transfusion-associated circulatory overload. ISBT Science Series 166–169 (2008).

9.Roback, J. D. Non-infectious complications of blood transfusion. AABBAABB Techn, (2011).

10.The British Committee for Standards in Haematology Guidelines on the Administration of Blood Components. Addendum to Administration of Blood Components, August 2012. 1–4 (2012).at

11.Carson, J. L., Carless, P. a & Hebert, P. C. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. The Cochrane database of systematic reviews4, CD002042 (2012).

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