CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 3, July/August 2023 AFRICA 167 number of cross-matched but not transfused blood components decreased from 9 482 in 2018 to 7 753 in 2019. A total of 98.6% of transfusions in the ED were administered to the Cardiology Department. Despite the rule mandating that between the hours of 18:00 and 08:00, patients in the ED or in-patient services who required transfusions would be transferred to the coronary ICU, 6 573 patients were transfused with 1 977 units in 2018 versus 6 540 patients transfused with 1 794 units in 2019, a statistically insignificant difference (p > 0.05). The cross-match count was 21 576 in 2019 and 16 045 in 2018, whereas the cross-match/transfusion ratio value (1.53) remained the same. While the number of PRBC units that were cross-matched and not transfused was 9 482 in 2018, this number decreased to 7 753 in 2019 (p < 0.05). Discussion This work comprehensively reviewed the outcomes of the HBM programme recently established in our hospital. The programme is directed towards patient safety and awareness of transfusion costs and adverse events. Many established but illogical and, frankly, unreasonable transfusion practices were corrected. The most important outcome was that despite an increase or no significant change in the numbers of in-patients, and ED and ICU patients, the overall use of blood components declined by 23.2% from 2018 (before the HBM was established) to 2019 (after the HBM was established). The greatest reductions were with FFP (38.4%) and FWB (46.7%), which met our target of reducing the unnecessary use of these two blood components. We attribute the improved transfusion data to penetration of guidelines and awareness of the staff of HBM policies. The cost-effectiveness of this HBM programme has been studied in detail. We determined that the economic savings with this programme were approximately 15%.17 Many improvements in our transfusion policies were likely responsible for the reduction in blood-product use. One of these was the institution of the 9-g/dl Hb threshold for transfusions. Although this threshold is still high according to guidelines,7,14 it was low enough to prompt changes in clinician behaviour. An even lower threshold was not chosen to avoid possible resistance to implementing the new policy by clinicians who were accustomed to transfusing patients at Hb values of 10–11 g/dl. Clinicians followed the one-unit transfusion rule and carefully reviewed their transfusion orders. A second policy improvement was a 12-fold increase in perioperative autologous blood use. The most important explanation for this achievement was the designation of anaesthesiologists. FFP was the most-often ordered blood component in the ED and coronary ICU, and it was routinely administered to reverse high INR. A flowchart that could easily be implemented in the ED, called ‘the approach to a high INR patient’, was prepared, and its use was frequently reviewed.18,19 The number of transfusions in the ED decreased by 76.0% after enactment of the rule requiring transfer of patients to the ICU for transfusions. Despite this rule, the number of transfusions given in the ICU did not increase, rather, it decreased by 9.26%. In addition, FFP transfusions were discouraged in patients other than those who needed massive blood transfusions or had elevated INR, and the practice of transfusing two units of FFP with protamine after stopping CBP was discontinued. The busiest time and service for blood-component orders was in the surgical ICU at 17:00 during the change of shift; about one-third of all transfusions was administered after this visit. Therefore, a practice was instituted that the ICU clinician reviewed the decision to transfuse after the visit ended. This practice became routine and decreased the review workload of the blood bank. The number of cross-matches also decreased significantly with the HBM programme, which further reduced the blood centre’s workload. An unexpected but worthwhile outcome of this study was an increase in reported transfusion reactions from 2018 to 2019. We suspect that this difference reflected an increased vigilance and reporting of the transfusion enterprise after institution of the HBM programme. This report on our HBM programme reflects some unique characteristics of our insitution and practices. We did not consider prohibiting FWB transfusions because of concern that such a policy would incite clinicians’ resistance to the entire programme. During this project, the new policies were accepted by our clinicians, except for a few who had 25 to 30 years of experience in the field and resisted many changes initially, but gradually came on board. The support of the hospital management played an important role in the success of this project.20 The HBM programme contrasts in several ways with PBM, which is a multidisciplinary, evidence-based, patient-centred approach to blood management.7-10,21 In contrast to PBM, HBM is not a patient-specific method; it is a healthcare workerorientated programme. Correction of pre-operative anaemia is not its primary goal, as it is with PBM. HBM aims to improve transfusion practice through evidence-based clinical pathways. Implementation of PBM often faces clinicians’ resistance. Despite dissimilarities beween HBM and PBM, our programme resulted in blood conservation (over 20%), which was in line with the 10–15% achieved with PBM programmes in CV surgery around the world.22 We acknowledge, though, that our HBM programme is not an alternative to PBM; the HBM programme can be considered a first step for PBM implementation. Our study has limitataions. First, it has been tested in only a single institution. Nonetheless, it has features, such as emphasis on quality improvement, patient safety and awareness of transfusion costs and adverse events that may be broadly applicable to blood-product utilisation. Second, the HMB has been tested during one year only; the sustainability of the programme needs to be ascertained over a longer period. Third, pre-operative anaemia protocols have not been integrated into our system, but they should be in future research. Conclusion HBM is a dynamic programme with significant benefits. A multidisciplinary, evidence-based approach to blood-component transfusion reduced the use of blood components by more than 20% in our hospital. The programme can be adjusted to meet the individual requirements of departments, and unit and target blood components. The programme is a practical way to avoid transfusions while achieving significant savings that may be applicable to other tertiary-care hospitals and non-tertiary hospitals as well.23
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