환자 혈액 관리에 대한 전문가 인터뷰
Expert Interview on Patient Blood Management
June 13, 2017
Dr. Axel Hofmann is an international expert in the field of Patient Blood Management (PBM) and was one of the key figures responsible for the implementation of the statewide PBM Program for the Government of Western Australia. He kindly agreed to give us an interview to share his experiences and knowledge on PBM with us.
What is PBM and what are the goals of PBM? A short synopsis.
PBM is defined as an evidence-based bundle of care to optimize medical and surgical patient outcomes by clinically managing and preserving a patient’s own blood. This concept is based on three pillars: First optimize the endogenous red blood cell volume, second minimize blood loss and finally harness the patient’s physiological tolerance of anaemia. In more simple terms, make sure the ‘tank is full’ before the patient embarks on the clinical journey, prevent and stop leakage as far as possible and, when the situation might get a bit critical, use treatment modalities to ensure sufficient oxygen supply for the patient.
Why is the application of a PBM-concept of increasing importance?
Blood loss induces or exacerbates anaemia, which often leads to blood transfusion. However, a growing body of evidence clearly shows that anaemia, blood loss and transfusion are three independent risk factors for adverse patient outcomes. With PBM, these risk factors become modifiable.
PBM is basically a quality, safety and effectiveness initiative with tremendous economic implications. We have recently published the results of a large observational PBM study with more than 605,000 patients in four major adult tertiary-care hospitals in Western Australia (WA). Over a period of six years and compared to baseline, the implementation of a PBM program led to a 41% reduction in blood component utilization, equivalent to product cost savings of $18.5 million and activity-based-cost savings between $80 million and $100 million. At the same time, we saw a 28% reduction of in-hospital mortality, 15% reduction in mean length of hospital stay, 21% reduction in infection and 31% reduction in acute myocardial infarction and stroke, and all numbers were statistically significant. When the program started, the transfusion rate was already one of the lowest in the developed world, but our latest results are even more impressive.
About 10% of the world’s gross expenditures are currently spent on health. According to many experts in the field of health economics, the ceiling has been reached and finding more cost-effective standards of care has become crucial. PBM offers one of the rare opportunities where patients get more and payers spend less.
What is the role of the coagulation management within the PBM-concept?
Coagulation management is at the core of PBM. It is one of the most important treatment modalities within the second pillar of the PBM. The rationale is simple: what is not lost must not be replaced.
How can a POC solution for coagulation management impact PBM?
In a bleeding patient, time is of course critical. Particularly in complex heart surgery, transplant surgery or any other intervention where higher blood loss is not unusual, it is important to identify the cause of the bleeding event. Is it a surgical or a systemic problem? A timely , patient near assessment to identify and correct the problem is certainly beneficial for these patients. Over the last decade, an overwhelming body of evidence has shown that POC solutions help to significantly reduce blood loss, transfusion and cost. In WA, but also in other Australian jurisdictions, the use of POC has clearly become part of the PBM culture.
Do you have any recommendations or tips for those who plan to implement the PBM-concept?
Implementing PBM is a challenge because it is a culture change. For decades, millions of clinicians around the world have had a default position when blood loss occurred or anemia was diagnosed: they transfused. To shift this long-standing paradigm and to jolt people out of complacency, an approved implementation methodology is an absolute necessity. In WA, we applied Kotter’s famous change management principles. John Kotter, Konosuke Matsushita Professor of Leadership at Harvard Business School – now Professor Emeritus
– developed an eight-step model for change and we found this was a perfect fit for the implementation of the WA PBM project.
Another critical factor to success was the development of a robust system-wide electronic PBM data collection and reporting system. This allowed for the comparison and reporting of patient-level outcomes and transfusion data versus the baseline. Comparisons were made by hospital, department, procedure, surgeon and anesthesiologist.