Evolution of blood transfusion in Hospital General San Jorge Change in blood consume during ten years. Red cell concentrate, platelets and plasma reduction is possible Patient Blood Management and Transfusion with common sense

1. Change of red cell transfusion use and
distribution in a General Hospital
(2008-2015)
J.A. García-Erce 1$, C. Usón *, S. Gómez-Ramírez**, M Quintan Diaz $, M.
Muñoz**
Servicio Hematología y Hemoterapia 1 and * Servicio de Cirugía Ortopédica
y Traumatológica, Hospital General San Jorge, Huesca (Spain). ** GIEMSA,
Medicina Transfusional Perioperatoria, Universidad de Málaga, Málaga
(Spain). IDI-PAZ 49 Hospital Universitario La Paz (Madrid)
Grupo de Trabajo “Hemoterapia basada en el sentido común”

2. Conflictos de interés
Asesor externo
- AMGEN Oncología 2010/2012
- Roche Anemia 2009
- Ditassa-Ferrer 2004
Charlas, estudios investigación y ayudas a congresos
-Vifor-Uriach/Ferralinze
-Janssen-Cilag/Braun/Sandoz/Zambon
-Astra-Tech de Aztra Zeneca/Well-Health?/GSK
-Sanofi Aventis/Esteve/Novartis/Octapharma
-Cobe-Caridian/Roche Oncología/AMGEN Oncologia
Miembro del CAT 2002-2005
Miembro del Documento de Sevilla “Alternativas a la
Transfusión”
Miembro del Documento LatinoAmericano de la Anemia
Miembro de GIEMSA/ Secretario AWGE/Socio
SETS/AEHH/NATA
Editor Asociado Revista ANEMIA www.revistaanemia.org
Miembro Comité Científico NATA y TATM

3. Background
Historically, up to one-half of hospital red blood cell
concentrate (RBC) transfusions were attributed to surgical
departments (mostly orthopaedic, vascular, ginecological,
cardiac and general surgeries).
Classically pre-transfusional compatibility test include:
group typing, irregular antibodies screening (Type &
screening; T&S) and cross-match (CM).
Surgical patients usually required Cross-Match and the
reserve of several units (2-5) during 48-72 hours
However, the combination of increasing RBCT costs and
possible shortages, as well as growing awareness of RBCT
side-effects has prompted the interest in multidisciplinary,
multimodal “Patient Blood Management” programs.
García-Erce JA et al. NATA Dublin 2016

4. Change of red cell transfusion use
García-Erce JA et al. NATA Dublin 2016
Background

5. New “PARADIGM”
At our centre, the RBC Transfusion Protocol during last years includes a
progressive replacement of cross-matching (CM) & save by type & screening
(T&S) and recently a prospective daily Haemovigilance and extend Rh typing.
Since January 2015, “Universal” CM was replaced by: T&S plus “electronic
CM” and only “selected CM” in case of Antibodies(+); “Dinamical” stocks
without reserves.
We have promote with continous several educational sessions:
 "restrictive" transfusion criteria
 single-unit RBC transfusion (“one by one”)
 Recommendation to manage perioperative anaemia.
 Optimize the pre-transfusion samples (72 h & week) and request
Everyday, in the Laboratory we validate all complete blood counts, study and
inform the unknown anaemias, and review all transfusion request
García-Erce JA et al. NATA Dublin 2016

6. “CHOOSING WISELY” IN TRANSFUSION

7. CHOOSING WISELY IN TRANSFUSION
Don’t transfuse more units of blood than absolutely necessary.
Eachunit of bloodcarriesrisks. Arestrictivethreshold(7.0-8.0g/dL)shouldbeusedforthevast majorityof hospitalized,stablepatientswithout evidence
of inadequatetissueoxygenation(evidencesupportsathresholdof 8.0g/dLinpatientswithpre-existingcardiovascular disease). Transfusiondecisions
shouldbeinflunced by sympt oms and hemogl obi nconcent rat ion. Singleunit redcell transfusionsshouldbethestandardfor non-bleeding,hospitalized
patients. Additional unitsshould only beprescribed after re-assessment of the patient and their hemoglobin value.
Don’t transfuse red blood cells for iron deficiency without
hemodynamic instability.
Bloodtransfusionhasbecomearoutinemedical responsedespitecheaper andsafer alternativesinsomesettings. Pre-operativepatientswithiron
defic
i
ency and pat ient swi th chroni ciron def ici
e
ncy wit hout hemodynami c i ns tability(evenwithlowhemoglobinlevels)shouldbegivenoral and/or
intravenousiron.
Don’t routinely use blood products to reverse warfarin.
Patientsrequiring reversal of warfarincanoftenbereversed withvitaminKalone. Prothromobincomplexconcentratesor plasmashould onlybe
used for patientswithseriousbleeding or requiring emergencysurgery.
Don’t perform serial blood counts on clinically stable patients.
Transfusion of red blood cellsor plateletsshould be based on the first laboratory value of thedayunlessthe patient isbleeding or otherwise
unstable. Multipleblood drawstorecheck whether apatient’sparameter hasfallenbelowthetransfusionthreshold(or unnecessaryblooddraws
for other laboratory tests)canlead to excessive phlebotomy and unnecessary transfusions.
Don’t transfuse O negative blood except to O negative patients and in
emergencies for women of child bearing potential with un nown blood group.
Onegativebloodunitsareinchronicshort supplydueinpart tooverutilizationfor patientswhoarenot Onegative. Onegativeredbloodcellsshould
berestrictedto: (1)Onegativepatients; or (2)womenof childbearingpotential withunknownbloodgroupwhorequireemergencytransfusionbefore
blood group testing canbe performed.
3
1
2
Five Things Physicians
and Patients Should Question
5
4
Don’t transfuse more units of blood than absolutely necessary.
Eachunit of bloodcarriesrisks.Arestrictivethreshold(7.0-8.0g/dL)shouldbeusedfor thevast majorityof hospitalized,stablepatientswithout evidence
of inadequatetissueoxygenation(evidencesupportsathresholdof 8.0g/dLinpatientswithpre-existingcardiovascular disease). Transfusiondecisions
shouldbeinflunced by sympt oms and hemogl obi nconcent rat ion. Singleunit redcell transfusionsshouldbethestandardfornon-bleeding,hospitalized
patients. Additional unitsshould onlybe prescribed after re-assessment of the patient and their hemoglobin value.
Don’t transfuse red blood cells for iron deficiency without
hemodynamic instability.
Bloodtransfusionhasbecomearoutinemedical responsedespitecheaper andsafer alternativesinsomesettings. Pre-operativepatientswithiron
defic
i
ency and pat ient swi th chroni ciron def ici
e
ncy wit hout hemodynami c i ns tability(evenwithlowhemoglobinlevels)shouldbegivenoral and/or
intravenousiron.
Don’t routinely use blood products to reverse warfarin.
Patientsrequiring reversal of warfarincanoftenbereversedwithvitaminKalone. Prothromobincomplexconcentratesor plasmashould onlybe
used for patientswithseriousbleeding or requiring emergency surgery.
Don’t perform serial blood counts on clinically stable patients.
Transfusion of red blood cellsor plateletsshould be based onthe first laboratory value of thedayunlessthe patient isbleeding or otherwise
unstable. Multipleblooddrawstorecheck whether apatient’sparameter hasfallenbelowthetransfusionthreshold(or unnecessaryblooddraws
for other laboratorytests)canlead to excessive phlebotomy and unnecessary transfusions.
Don’t transfuse O negative blood except to O negative patients and in
emergencies for women of child bearing potential with un nown blood group.
Onegativebloodunitsareinchronicshort supplydueinpart tooverutilizationfor patientswhoarenot Onegative. Onegativeredbloodcellsshould
berestrictedto: (1)Onegativepatients; or (2)womenof childbearingpotential withunknownbloodgroupwhorequireemergencytransfusionbefore
blood grouptesting can be performed.
3
1
2
Five Things Physicians
and Patients Should Question
5
4

8. Objectives
We reviewed Transfusion Service activity from 2008 to 2015:
- Requests
- RCC Requests
- Groups, T&S and CM; Irregular Antibodies (+)
- RCC Transfused (and platelets and plasma)
- RCC Outdated
We reviewed the hospital activity (admission, stays, surgeries,
stays, birth, death, long of stays, etc) and the possible influences of
anaemia management with iron carboxymaltose (since 2010), and
a restrictive RBCT policy.
García-Erce JA et al. NATA Dublin 2016

9. Objectives
García-Erce JA et al. NATA Dublin 2016
RBCT data were retrieved from the Regional Donation Centre
management program and analysed according to departments of
use: all surgical, critical care, emergencies, and all medical,
except haematology and oncology.
Results are expressed as RBCT per department/service, both per
year (units/year) and as percentage of total annual hospital RBTC
(% of total).
We have reviewed the evolution of patient´s age

10. Results
García-Erce JA et al. NATA Dublin 2016
Evolution in Hospital´s Activity

11. Results
García-Erce JA et al. NATA Dublin 2016
Evolution in Hospital´s Activity
Stay media
(days) 6,97 6,79 6,21 5,89 5,81 6,11 5,99 5,81

12. Results
García-Erce JA et al. NATA Dublin 2016
Evolution Transfusion (I)

13. Results
García-Erce JA et al. NATA Dublin 2016
Evolution Transfusion (II)
-27,27 %
-80,55 %

14. Results
García-Erce JA et al. NATA Dublin 2016
Evolution Transfusion adapted to activity

15. Results
García-Erce JA et al. NATA Dublin 2016
Evolution Transfusion by services

16. Results
García-Erce JA et al. NATA Dublin 2016
Evolution Transfusion by services (II)
-62,58%
-60,06%
-46,50%
-57,42%
-45,05%
-51,24%
3,17%
-51,40%

17. Results
García-Erce JA et al. NATA Dublin 2016
Evolution Outdated RCC
8,36 % 1,60 %

18. Results
García-Erce JA et al. NATA Dublin 2016
“Goldies” ( ≥ 70 y/o): 73,7%  60,8%
Change in the receptor: Age (years old)

20. Conclusions
We halved RBTC use, while overall hospital activity remained
unchanged. We have also reduced platelets transfusion and
plasma use (80%)
This reduction was almost uniform across departments,
except for haematology (which could be attributed explained
to complexity and severity of new patients).
We have found a reduction in length of stay (6,97 to 5,81)
(16,7%).
We had safe and effectively eliminated the universal cross-
matching & save policy, with a significant decrease in both
Blood Bank work-load and rate of outdate RBC unit wasting.

21. WHA 63.12 (resolution). Availability, safety and quality of blood products,
2010.
Available at: http://apps.who.int/gb/ebwha/pdf_files/WHA63/A63_R12-en.pdf.

22. Thank you for your kind attention!
THANKS AND CONGRATULATIONS TO
HOSPITAL SAN JORGE
BLOOD BANK/TRANSFUSION SERVICE NURSERY

23. UNIVERSIDAD DE ZARAGOZA
“PATIENT BLOOD MANAGEMENT”
CASTYM
JAC (HUESCA) 20 – 22 JULIO 2016
Dr José Antonio García-Erce
GIEMSA. AWGE. NATA. Investigador del IACS y IdiPAz 49
Grupo de Trabajo de la SETS “Hemoterapia basada en el sentido común”
Servicio Hematología y Hemoterapia. H San Jorge (Huesca).