Patient Blood Management (PBM) is an evidence-based approach to improve patient outcomes by promoting best practice in blood transfusion and blood conservation strategies.
This is a collaborative initiative that was launched in England in 2012 between the National Blood Transfusion Committee and NHS Blood and Transplant (NHSBT). It follows in the wake of several initiatives over the past 20 years to support the safe and appropriate use of blood. In 2014, the National Blood Transfusion Committee produced national recommendations for the implementation of PBM in hospitals (National Blood Transfusion Committee, 2014). Recommendations on defining a clinical and laboratory blood transfusion strategy for England over the next 5 years are also expected this year.
Collaboration with key NHS organisations, including NHS England and Improvement and Health Education England aligns PBM activity with the wider NHS strategy and the aims of the NHS Long Term Plan (NHS England and NHS Improvement, 2019a). PBM also fully supports the principles of the NHS Patient Safety Strategy (NHS England and NHS Improvement, 2019b), promoting a safer culture and systems for the benefit of patients.
What does PBM mean?
The initiative aims to develop high-quality transfusion medicine evidence for application in practice. When high-quality evidence is not available, PBM leaders nationally and internationally work with other stakeholders to gain consensus on best practice.
PBM principles incorporate a multidisciplinary approach to optimising the care of patients who might need a blood transfusion. In some cases, use of appropriate PBM strategies can reduce or completely avoid the need for a blood transfusion. Where this is not possible, PBM aims to ensure patients receive transfusion safely.
Key elements of PBM emphasise appropriate anaemia management (eg the use of oral or intravenous iron preparations to manage iron deficiency anaemia), management of chronic illnesses that may result in anaemia, and surgical strategies to reduce surgical blood loss. Table 1 shows the three pillars of PBM, with a focus on surgical strategies. These are often referred to as alternatives to transfusion. PBM strategies aim to achieve two key desirable outcomes:
| Pillar one: optimise red blood cell mass | Pillar two: minimise blood loss | Pillar three: manage anaemia | |
|---|---|---|---|
| Preoperative |
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| Intraoperative |
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| Postoperative |
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Adapted from Hofman et al, 2012; Isbister, 2013; Spahn and Goodnough, 2013
Recent research has suggested (Faulds et al, 2019) that, when PBM strategies are followed, patients develop fewer complications, resulting in improved recovery rates and reduced length of stay in some clinical scenarios. Incorporating a robust PBM programme ensures that decisions are reached in partnership with patients and transfusion occurs only when there are no alternatives and the benefits outweigh the risks.
Application of the PBM principles has contributed to overall red-cell demand steadily decreasing, with a 22.7% fall since 2008, equivalent to 416 000 fewer red cells over a decade. England is a leader in this area worldwide and has one of the lowest rates of issue per population.
Team remit
The NHSBT PBM team consists of practitioners, haematology consultants and a senior leadership team who lead the delivery of key messages to the wider clinical and academic community (Box 1).
There is synergy with the Blood Stocks Management Scheme and the National Comparative Audit of Blood Transfusion, with both teams sitting within the PBM structure.
The team provides expert input into the development and completion of these audit programmes, as well as promoting and supporting the implementation of audit recommendations in clinical practice.
There is also a strong partnership between the PBM team and the Serious Hazards of Transfusion (SHOT) UK haemovigilance scheme, which involves the systematic surveillance of adverse transfusion reactions and events, with the aim of improving transfusion safety. The principles of PBM build on good clinical transfusion strategies and lessons learnt from haemovigilance. To support this shared working, a dedicated member of the PBM leadership team has joint PBM/SHOT responsibilities.
The PBM team also has a close relationship with the National Blood Transfusion Committee for England, which is accountable to NHS England and whose primary purpose is to promote safe transfusion practice in hospitals. The national committee is supported by a network of regional transfusion committees, who in turn support a network of hospital transfusion teams.
The PBM team's ‘core’ business centres on strategic aims and national drivers relating to transfusion activity, safety and education. The team monitors and interprets blood component demand and wastage data, together with information gathered directly from hospitals on transfusion practice and clinical activity. This information is analysed for key themes and trends, translated into viable feedback for hospitals to support changes in practice, and for NHSBT to support demand planning.
Models for delivering PBM include using frameworks to translate evidence into practice using education, data, technology, audit and benchmarking. The aim is to drive change in transfusion practice through continuous improvement.
Practitioners
PBM practitioners are a blend of highly skilled, experienced nurses and biomedical scientists from a variety of clinical backgrounds, with great knowledge and expertise, and a strong interpersonal and professional skill set.
These practitioners are the link between hospitals and NHSBT and, together with our customer service colleagues, are the first point of contact for transfusion-related issues and queries from hospital transfusion teams.
The PBM team liaises with a range of multidisciplinary health professionals and transfusion teams. The primary link is through a network of hospital-based transfusion practitioners, whose role includes responsibility for haemovigilance, PBM, transfusion training and change management. These relationships facilitate shared learning and quality improvement projects in clinical areas.
Education
Education is central to the successful adoption of PBM principles and implementation of PBM strategies. The team's education lead manages a portfolio of conventional and digital educational resources, promoting transfusion initiatives and safety campaigns. The resources, aimed at clinical staff, patients and the general public, include apps, patient information leaflets, toolkits and our Hospitals and Science website (https://hospital.blood.co.uk), to name a few. A library of SHOT resources relevant to PBM activity is available from the SHOT website (www.shotuk.org).
We also work with experts from across NHSBT to deliver our non-medical authorisation of blood components course. This provides senior nurses and other health professionals with the theoretical foundation to support the competency process required to become an independent authoriser of blood components.
On a larger scale, the PBM practitioner team organises and facilitates a programme of multiprofessional, transfusion-based, educational symposiums across England. The SHOT team also participates in PBM educational programmes, including transfusion practitioner and biomedical scientist training and education.
Our practitioners attend regional, national and international conferences to deliver PBM-related presentations and education sessions. We also contribute to professional journals, and there is an established library of articles about PBM and blood components.
Supporting clinicians to improve practice
The PBM team is committed to improving patient care and transfusion practice with sustainable, long-term interventions. Acknowledging and demonstrating the impact that PBM has on practice is key to determining measurable success criteria and planning future initiatives.
Bedside check video
In collaboration with SHOT, the team developed a short animated safety video to promote the importance of having an established bedside checking process to reduce administration errors (The Pre-Administration Blood Component Bedside Checklist, https://youtu.be/vhhgltwyk5M).
Blood sampling video
Building on the success of the bedside check, in 2018, again working with SHOT, we developed a second patient safety video. This short video covers the essential steps in the pre-transfusion sampling process where errors may occur, highlighting the need for robust sampling procedures to avoid incompatible blood transfusions (Pre-Transfusion Blood Sampling Process, https://youtu.be/xQTws6v9uH8).
PBM toolkit
This year has seen the launch of the PBM Toolkit. Developed in partnership with clinical specialists and the National Blood Transfusion Committee, this online resource covers core PBM initiatives to support practitioners implement and embed robust PBM processes.
Blood Assist app
Blood Assist, our blood administration app, is due for launch early 2021. The app will offer information on blood administration, including consent, compatibility and adverse reactions, and will support SHOT safety recommendations (SHOT, 2019). The app will be available on app stores and suitable for download to NHS devices for use at the patient's bedside.
Single unit project
Single-unit transfusion applies to stable, normovolaemic adult inpatients who do not have evidence of clinically significant bleeding. They reduce the risk of transfusion-related circulatory overload, which is a leading cause of transfusion-related morbidity.
The PBM team has undertaken a single-unit project, with hospitals across the country participating. This led to the development of resources and presentations to help other hospitals implement a single-use policy (NHSBT, 2018).
Audit of the management of major haemorrhage
An audit of blood transfusion involving 166 trusts/hospitals was undertaken in 2018 to look at major haemorrhage processes (National Comparative Audit of Blood Transfusion and NHSBT, 2018). This resulted in organisational and clinical recommendations, including;
PBM and National Comparative Audit of Blood Transfusion aim to provide audit summaries, regional presentations and educational resources tailored to the key messages to support hospitals in implementing recommendations for all national comparative audits.
PBM survey
A PBM survey that was undertaken in 2018 showed significant improvements in PBM activity since the previous survey undertaken in 2015 (Box 2).
The two audits show improvement in PBM activity but, together with related audits looking at blood component usage, also indicate that inappropriate blood usage continues, indicating the need for further work.
Working in PBM
The NHSBT PBM practitioner role has no direct patient contact. However, although it is not based in the clinical setting, the role has broad influence across patient groups and has significant potential to impact positively on patient care and safety.
The role is different to traditional nursing roles, and qualifications, experiential learning and clinical experience from previous roles are all recognised and valued equally. PBM practitioners work autonomously, focusing their time and resources on the most appropriate area; they identify and plan future development; influence and negotiate change in practice and behaviours; and lead and deliver on complex or multiprofessional projects. This scope of practice provides huge job satisfaction with new opportunities constantly on the horizon.
PBM continues to grow and expand, with new projects and initiatives ahead it is an exciting time and a fantastic opportunity to make a real difference to patient care. There are challenges, but the benefits that exist within NHSBT such as professional development and flexible working, together with the autonomy and variety within PBM, all result in a satisfying work–life balance.