Transfusion medicine

PBM guidelines have reduced perioperative transfusions – and costs

Patient blood management (PBM) guidelines introduced by the National Blood Authority  in 2012 have reduced blood transfusions in cardiac surgery without any adverse impact on patient outcomes, a study shows.

A before and after analysis of the PBM initiatives, which included lower haemoglobin triggers, shows there has been a significant reduction in red blood cell, platelet, and fresh-frozen plasma (FFP) transfusions in cardiac surgery.

There was also a significant reduction in hospital length of stay following the introduction of PBM guidelines, but no significant impact on cryoprecipitate, 30-day mortality, 30-day readmissions, or intensive care unit length of stay, according to Monash University researchers  who reviewed outcomes for 78,179 elective cardiac surgery procedures in the Australian & New Zealand Society of Cardiac & Thoracic Surgeons (ANZSCTS) Database.

The rate of RBC units transfused during cardiac surgery fell by 8.9% from 39.9% to 31.0% between the pre-guideline and post-guideline periods.

Platelet transfusion rates fell from 20.0% to 18.1% (-1.9%), FFP rates from 19.8% to 13.4% (-6.5%), while length of stay reduced from 12.0 to 11.8 days (-0.2%).

There was no difference in impact on blood product usage between public and private hospitals. The  study authors estimated that the guidelines saved around $31 million in costs for the almost 49,000 patients in the five-year post guideline era – equating to a savings of $647 per patient .

Writing in the Journal of Thoracic and Cardiovascular Surgery, they said the findings showed what could be achieved when evidence-based guidelines were implemented at a national level.

They noted the NBA recommendations had gone beyond lower haemoglobin thresholds to cover anaemia, haemostasis management, blood-conservation strategies, and appropriate transfusion practices, and specifically recommend against prophylactic use of platelets or fresh-frozen plasma (FFP).

“Assuming that the changes identified are a result of the guidelines, resources have been saved without negatively affecting health,” they concluded.

The findings won praise from US clinicians, who wrote in an accompanying commentary that no such changes had been seen at a national level in the US, “where, with the absence of a national health system, individual hospitals are not beholden to blood product transfusion practices stipulated by the federal government.”

“This report, founded upon a national set of guidelines, provides more evidence that adjudication and policy-making at the national level, replete with monetary incentives, might successfully influence and even reduce the utilisation of blood products,” they said.

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