Where Blood Matters AIMS. National Scientific Meeting. Darwin Convention Centre September Morteza Mohajeri, MD, FRACS ( Cardiothoracic )

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1 Where Blood Matters AIMS National Scientific Meeting Darwin Convention Centre September 2012 Morteza Mohajeri, MD, FRACS ( Cardiothoracic ) Senior Medical Advisor QBMP 1

2 National Blood Agreement November 2002 National Blood Agreement 2

3 National Blood Authority Australia 3

4 National Blood Agreement States and Territories must: Develop & implement best practice Planning and management Supply, distribution and use Promote efficiency Minimise waste Provide information and advice to NBA 4

5 National Blood Agreement States and Territories must: Obtain information and advice from NBA Product availability Product price Comply with financial arrangements Joint funding Commonwealth 63% : States 37% Current Blood Matters Variation in transfusion practices Transfusion reactions & adverse events Supply & Demand Costs 5

6 Variation in Transfusion Practices Wide variation in transfusion practices based on anecdotal experience 12 87% transfusion rate for similar orthopaedic operation in 18 Austrian hospitals Gombotz et al. Transfusion 2007;47: % transfusion rate for cardiac surgery operations in 12 Australasian hospitals Daly et al. Anaesth Intensive Care 2007;35: Austria Queensland Patients % Transfused Patients % Transfused Median THR % THR I03B % 26% TKR % TKR I04B % 9% CABG % CABG F06B % 29% THR I03A % 63% TKR I04A % 29% CABG F06A % 35% Tony Ghent, Queensland Blood Mangement Program April

7 All Drs I04B Knee Replacement W/O C Patients (168/1214) Patients D55 D7 D54 D118 D18 D80 D112 D115 D15 D52 D79 D28 D47 D60 D37 D24 D44 D114 D120 D13 D27 D5 D59 D98 D1 D86 D29 D57 D21 D82 D122 D16 D43 D17 D40 D46 D53 D70 D71 D92 D93 D113 D83 D99 D10 D2 D22 D25 D36 D123 D124 D32 D38 D61 D26 D125 D106 D31 D56 D65 D121 D51 D58 D84 D104 D23 D9 D109 D14 D94 D96 D105 D11 D33 D35 D101 D119 D12 D90 D91 D107 D4 D45 D62 D69 D81 D85 D108 D30 D6 D102 D110 D111 D116 D117 D20 D3 D39 D48 D66 D68 D76 D8 D95 D97 Doctors 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% TX. Not TX. % Tx Median 75th Percentile Tony Ghent, Queensland Blood Management Program April F06B Coronary Bypass W/O Invas-179 Patients (35/144) Patients E F I Hos pital 40% 30% 20% 10% 0% TX. Not TX. % Tx F06B Coronary Bypass W/O Invas Patients (35/144) D50 D51 D81 D22 D54 D21 D12 D85 D27 D46 D16 D25 D28 D23 D48 D82 D15 D20 D30 D14 D18 D19 D26 D33 D66 D67 Patients 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Doctors TX. Not TX. % Tx Median 75th Percentile Tony Ghent, Queensland Blood Management Program April

8 Current Risk Estimates of transfusion transmitted infections HCV 1 : 500,000 1,000,000 HIV < 1 : 1,000,000 HBV 1 : 500,000 1,000,000 HTLV < 1 : 1,000,000 CMV 1 : 66,000 VCJD Possible, Not reported in Australia Bacterial Sepsis Platelet 1 : 75,000 RBC 1 : 500,000 Malaria < 1 : 1,000,000 Source: Australian Red Cross Blood Service, June Transfusion Related Adverse Events Adverse Reaction Risk per Unit Transfused Acute haemolytic reactions 1 : 12,000 77,000 Delayed haemolytic reaction 1 : 4,000 9,000 TRALI 1 : 5, ,000 Anaphylaxis 1 : 20,000 50,000 G v H disease Rare TACO Up to 1% of Pts transfused Post-Transfusion Purpura Uncommon Incorrect blood component transfused Uncommon Febrile transfusion reactions Common Source: Blood component information. Australian Red Cross Blood Service 8

9 Transfusion Related Adverse Events Pneumonia Sugical site infection Slow wound healing Prolonged ventilation Increased length of ICU stay Increased length of hospital stay Increased mortality Australian Bureau of Statistics 2011, 9

10 Novoseven rviia 1 mg $1,173 2 mg $2,347 5 mg $5,867 Gold 1 oz $ 1,700 rfviia 1 oz (28.3 g) $ 33.3 M 10

11 NBA Annual Report NBA Annual Report

12 NBA Annual Report Blood Dilemma Variations = Inappropriate use Tx-reactions/adverse events = Unnecessary risk Supply / Demand gap Costs 12

13 Is there a solution? Solution: Appropriate Transfusion / Education Transfusion Nurse Scheme Blood Budget devolution Haemovigilance Pre-operative anemia clinics Higher Standards 13

14 What is appropriate transfusion? Evidence based Trigers: Hb, APTT, INR, Platelet count ± function, Fibrinogen Symptoms Adverse events Disease Process / Co-Morbidities Alternatives to Transfusion What is the aim of Transfusion? Treating patient symptoms Treating patient s blood results Transfusion Best Practice Clinical decisions are rarely simple Balance Risks vs Benefits vs Costs NBA Patient Blood Management Guidelines aim to improve clinical outcomes by avoiding unnecessary exposure to blood products based on 3 principles: Optimisation of blood volume & red cells Minimisation of blood loss Optimisation of patient s tolerance of anemia 14

15 NBA Patient Blood Management Guidelines Contributors: Australasian College for Emergency Medicine Australian & New Zealand College of Anaesthetists Australian & New Zealand Intensive Care Society Australian & New Zealand Society of Blood Transfusion Australian Orthopaedic Association Australian Red Cross blood service College of Intensive Care Medicine of Australia & New Zealand Haematology Society of Australia & New Zealand Royal Australian and New Zealand College of Obstetericians & Gynaecologists Royal Australasian College of Physicians Royal Australasian College of Surgeons Royal College of Nursing Australia Royal College of Pathologists of Australia Thalassaemia Australia 15

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17 NBA Patient Blood Management Guidelines 6 Patient Blood Management Modules Critical Bleeding / Massive Transfusion Perioperative Medical Critical Care Obstetrics Paediatric / neonatal 17

18 Transfusion nurse scheme Role is integral in the safe & effective use of blood & in promoting best transfusion practice by: Introducing / promoting national transfusion guidelines Monitoring current transfusion practice against guidelines Multi-disciplinary transfusion audits Providing education for healthcare professionals Facilitating transfusion reaction incident reporting & follow up Promoting and ensuring documentation of informed transfusion consent 18

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20 Blood Budget Devolvement Centrally managed budget model Blood is free! Increased unnecessary risk for patients Lack of accountability for $$$ spent on supply of blood Rising costs of supply of blood 20

21 Blood Budget devolvement ( Cont. ) Blood Budget Devolution model Price signalling / Gate Keeping Quality management processes Minimising usage inline with best clinical practice guidelines Reducing transfusion related adverse events Minimising wastage resulting from inappropriate handling & storage of blood Raising the profile of blood transfusion within the hospital/hsd Re-channelling any savings to other areas of service improvements Haemovigilance Australian National Haemovigilance Program Haemovigilance Advisory Committee/ NBA Development and implementation of national approach to Haemovigilance States and territories haemovigilance systems Transfusion safety & quality for better patient outcomes Adverse transfusion events: Product & patient charactristics Clerical & procedural errors 21

22 State-wide Haemovigilance System Queensland incidents in Transfusion QiiT 2008 Drivers for haemovigilance: Patient safety & education National Blood Agreement Provision of data to national haemovigilance system NSQHS Standards/ ACSQH QiiT data set Febrile non-haemolytic TR Severe allergic reaction Anaphylaxis Incorrect blood component transfused TACO TRALI PTP TTI TaGVHD Acute non-abo HTR Delayed HTR ABO HTR ( Sentinel event ) 22

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24 Pre-operative anemia Impact on post-operative outcomes Management Society of Thoracic Surgeons Blood Conservation Guideline Task Force Ann Thorac Surg 2007;83:

25 Optimisation of blood Volume & red cell mass High-Risk Patients Advanced Age Preop. Anemia Small Body Size Urgency of Operation Preop. Anticoagulation & Platelet Inhibitors Congenital or Acquired Coagulopathies Multiple Co-morbidities Complexity of Operation Naturopathic Medications Ann Thorac Surg 2007; 83:27-86 Age Reduced Physiologic Reserves Cardiovascular Diseases Cerebrovascular Diseases Neoplastic Diseases Anemia 18% Healthy Octogenerians 24-53% Inpatient Octogenerians Inflamatory, Renal Failure, Neoplastic: 1/3 Global Malnutrition: 1/3 Unknown: 1/3 25

26 Studies Highlights Anemia is common among surgical patients & independently & significantly associated with increased 30 day adjusted mortality & morbidity Musallam et al. Lancet 2011;378(15): Anemia is very common in surgical patients & independently associated with increased mortality Beattie et al. Anesthesiology 2009;110(3): Even mild degrees of preop anemia is associated with increased postop mortality & cardiac events in older patients Wu et al. JAMA 2007;297(22): Dose-dependent significant increase in adverse outcomes with decreasing Hb levels The extent of pre-existing comorbidities substantially affects periop anemia tolerance Kulier et al. Circulation 2007;116:

27 Minimisation of blood loss Intraoperative Surgical blood conservation techniques Meticulous Surgical Technique Intraoperative Autologous Blood Donation Acute Normovolemic Haemodilution Cell Salvaging / Autotransfusion Normothermia (exception: cardiac surgery ) Antifibrinolytics Controlled Induced Hypotension Point-of-Care Testing of Coagulation Biologic Glues & Topical Sealants Minimized Cardiopulmonary Bypass Circuits Haemofiltration 27

28 by Lippincott Williams & Wilkins Thromboelastogram A point-of-care viscoelastic measure of clot formation and clot dissolution that measures: Coagulation Platelet function Platelet-fibrinogen interaction Fibrinolysis All in one test! 28

29 Restrictive Blood Transfusion Anaerobic metabolism Hb < g/l Weskopf et al. JAMA 1998;279: Lieberman et al. Anesthesiology 2000;92: Randomised multicentre controlled prospective study comparing liberal vs restricted transfusion in > 800 ICU patients Liberal Tx Hb<100g/L, maintain g/l Restricted Tx Hb<70 g/l, maintain g/l Conclusion: No significant Mortality difference Less ARDS and APO in restricted group No benefit from liberal transfusion Herbert et al. N Engl J Med 1999;340: Herbert et al. Crit Care Med 2001;29:

30 Restricted Blood Transfusion TRACS study 2010 Randomised noninferiority controlled trial Restricted Tx: 186 Pt. Hct < 24% Liberal Tx: 195 Pt. Hct < 30% Conclusion Restrictive strategy with one unit at a time is at least as effective as and possibly superior to liberal transfusion strategy Transfusion of 5 or more RBC units was associated with higher mortality Hajjar et al. JAMA 2010;1304(14):

31 NSQHS Std 7 Blood and Blood Products Governance and systems Safe and appropriate Prescribing Clinical use Documenting patient information Transfusion history Indications for use Transfusion reactions & related adverse events 31

32 NSQHS Std 7 Blood and Blood Products Managing product safety Storage and transport Wastage Communicate with patients and carers Information on risks and benefits Alternatives to blood products Informed consent summary Appropriate transfusion Good outcomes Education PBM Guidelines Transfusion Nurse Scheme Haemovigilance Blood Budget Devolution Higher Standards Alternatives to Transfusion Pre-operative Anaemia Management Single Unit Policy New Technology 32