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Using pre-operative preparation to aid the appropriate use of blood

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Background

Giving a patient inappropriate levels of blood has consequences, not just in terms of cost or a potential shortage of blood, but also in terms of patient safety. In 1996 the Serious Hazards of Transfusion (SHoT) scheme was launched to collect data on adverse events of transfusion and to make recommendations to improve transfusion safety.

This shows that 75% of all incidents involved patients receiving the wrong blood product. Of these over 40 patients died and over 200 suffered major morbidity.

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Correct procedure

Health professionals need to ensure that patients are transfused only when necessary, and that samples for group and save and cross-matching are taken only as part of a formalised protocol, such as the guidance in your trust's maximum surgical blood ordering schedule (MSBOS).

With the advent of appropriate patient preparation in pre-operative assessment clinics, much can be done to ensure that a patient's haemoglobin is optimised, to help prevent the need for transfusion.

Patients who are considered to be anaemic should be managed to increase their haemoglobin before surgery. This may involve further referral to a haematologist, GP or anaemia clinic for treatment with iron tablets, erythropoietin and/or IV iron.

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Pre-operative assessment

Pre-operative assessment can provide the appropriate environment to obtain the patient's haematological state - that is, to determine any underlying issues (for example, illnesses or religious beliefs) that may cause concern during or after surgery.

During the assessment the assessor can elicit a drug history that may include medications such as anticoagulants, NSAIDs or indeed any complementary medications such as garlic that are reputed to inhibit platelet aggregation.

In 2002 the Department of Health made it clear that NHS care had to ensure that better blood transfusions were integral to patient care. To help achieve this pre-operative assessment, which was in a position to offer patients more reliable information, was key.

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Trust guidelines

An MSBOS, established in each trust by the transfusion committee, is determined by examining the historical use of blood, the presurgical condition of the patient, age, surgical procedure and surgical protocols. It is important to recognise that the MSBOS will be unique to every trust and that it is open to revisions.

This will ensure that the group and save or cross-matched blood is available for the correct patient on the correct day for the correct procedure. Discussions with patients regarding their care are essential and should cover issues such as:

  • Would the patient want to have a blood transfusion?
  • Is the patient a Jehovah's Witness?
  • Has the patient been given a blood transfusion patient information leaflet? And if so, have they had the opportunity to read it and ask questions or had a discussion regarding the risks, benefits and alternatives of receiving a transfusion with clinic staff?
  • Intra-operatively, have the alternatives to transfusion (cell salvage, both intra- and post-operative; the use of antifibrinolytics such as aprotinin, hypotensive surgery) been discussed with the patient?

The health professional will also need to take certain factors into account:

  • Does the trust have access to near-patient testing systems available for the estimation of patients' clotting function? (this often gives an earlier and clearer picture of abnormal clotting)
  • Post-operatively are the lower transfusion triggers of 8g/dl accepted unless the patient is symptomatic?
  • How many units should be given to the patient? (best practice as suggested by the Blood Transfusion Service is that a unit at a time should be transfused until the transfusion trigger is reached)

All of these issues need to be considered and written into the trust guidelines for safer blood transfusion.

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Patient buy-in

As health professionals we need to ensure that our patients are prepared for and - in light of the risks and benefits - fully understand their treatment plans, including the possibility of receiving blood or blood products. In 2001, the Department of Health issued a statement regarding good practice in obtaining consent, saying:

'Every patient has the fundamental and ethical right to determine what happens to his or her body'.

This should not be ignored.

Jenny Bramhall, consultant nurse pre-operative assessment, Heart of England Foundation Trust

jenny.bramhall@heartofengland.nhs.uk

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