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 Table of Contents  
Year : 2019  |  Volume : 4  |  Issue : 1  |  Page : 65-68

Patients' involvement and the improvement of patient blood management

Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran

Date of Web Publication22-Apr-2019

Correspondence Address:
Dr. Mahmoud Hadipour Dehshal
Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/GJTM.GJTM_20_19

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Introduction: Patient blood management (PBM) is of prime importance today for the preservation and conservation of health resources and for patient safety. To fulfill the goal of appropriate use of blood and blood components, all the shareholders involved in patient treatment, particularly patients themselves should play an effective role. Materials and Methods: The present research aims to evaluate the status of patients' rights, patient awareness-raising efforts, and the consequent informed consent for transfusion order purposes in hospitals. To this end, the interview was conducted on 181 patients under surgery. The data were finally analyzed using SPSS software version 23. Results: In the present study, 109 men and 72 women were interviewed, of whom only 15 patients (8.25%) were aware of the likelihood of blood transfusion pre- or perioperative and further only 5 (2.76%) had received the adequate information on (dis) advantages of blood transfusion. Finally, after we provided precise information about (dis) advantages of blood transfusion and the alternatives, it came out to be known that the patients' decision out of the four choices of (1) homologous transfusion, (2) preoperative anemia treatment, (3) postoperative anemia treatment, and (4) autologous transfusion is estimated to be significant before they were given information compared with that of after. Discussion: The status of information sharing with patients and that of the patient informed consent procedure in Iran hospitals are weak and require serious reconsideration as far as patients' rights are concerned. Informing patients on (dis) advantages of blood transfusion and the alternatives can be a very effective measure in PBM success in Iran.

Keywords: Patient blood management, patients' right, patients' involvement, appropriate use of blood

How to cite this article:
Pourfathollah AA, Karimi G, Namini MT, Darestani SY, Dehshal MH. Patients' involvement and the improvement of patient blood management. Glob J Transfus Med 2019;4:65-8

How to cite this URL:
Pourfathollah AA, Karimi G, Namini MT, Darestani SY, Dehshal MH. Patients' involvement and the improvement of patient blood management. Glob J Transfus Med [serial online] 2019 [cited 2020 Oct 25];4:65-8. Available from: https://www.gjtmonline.com/text.asp?2019/4/1/65/256740

  Introduction Top

The phrase of patient blood management (PBM) was given birth to by Prof. Isbister in 2005, with the focus on patients rather than blood products.[1] Today, the liberal strategy of blood use has imposed a lot of cost burden on the health systems, and it necessitates the reverse for the restrictive use of blood- and plasma-derived products to be practiced.[2] The world experiences indicate that PBM can lead to 10%–20% of cost reduction in blood use;[3] particularly in surgeries, it is likely for the significant reduction in blood use and avoidance of inappropriate blood use to happen. The strategies including preoperative anemia management and reduction in perioperative blood loss and bleeding can lower blood use in surgeries.[4],[5] As more research is conducted on PBM, more emphasis is placed on the importance of anemia management as the primary step in cost prevention of liberal blood use.[6] The methods to reduce blood loss in surgery are recognized as the next step in the PBM program.[7] The World Health Organization considers PBM as an approach for the enhancement of safety and better treatment that should be done multidisciplinary with different shareholders involved in fulfilling the goal in this program.[8]

The significance of patient-centered care signifies the patient as one of the important factors for decision-making about their own process of treatment.[9] The patient is entitled to be informed on the necessary information about their disease and the treatment process.[10] Based on this approach, the perspective of patients about blood transfusion is worthwhile and can help in the PBM program.[11]

PBM was initiated in Iran in 2015 mainly with much training emphasis on physicians and health-care professionals. The present study tries to shed light on the merits and drawbacks of the appropriate dissemination efforts for patients.

  Materials and Methods Top

This research was conducted in the Mehregan Drugstore, Tehran, Iran. The patients who referred to the cardiologist, endocrinologist, pulmonologist, hematologist-oncologist, and gastroenterologist were included in the interview. Of the total number of the patients, the ones who had undergone surgery during the prior 5 years were selected; the interview was done based on a standard questionnaire. The research exclusion criteria were (1) those suffering from hemoglobinopathy and coagulation disorders, (2) those with the age range less than 20 and above 60 to whom or whose parents the relevant information might have been disclosed prior to surgery, (3) those undergoing surgery below the legal age (in Iran this age is defined to be maturity) in which father or the paternal guardian exert the legal authority, (4) those having undergone surgery within a short period of time (<2 months) for several times, and (5) those undergoing surgery at outpatient centers (with limited liability). After screening, 181 patients were selected for the interview. A questionnaire-based interview was conducted to evaluate the rate of the information provided to them about blood transfusion at or prior to the surgery. At the end of the interview, they were asked what would be their choice in face of pre- or perisurgery anemia if they had their present knowledge about blood transfusion: (a) anemia treatment before surgery, (b) autologous transfusion, (c) homologous blood transfusion, and (d) postsurgery hospital stay. The choice priorities ranged from 4 for very high priority to 3 for high priority, 2 for average, and 1 for low priority.

At the end of the first phase of the interview, the awareness-raising pamphlets about adverse reactions of blood transfusion and anemia treatment guidelines prepared and approved by the Iran Therapy Deputyship of Ministry of Health were offered to patients and the (dis) advantages of presurgery anemia treatment, autologous transfusion, homologous transfusion, and postsurgery anemia treatment based on the guidelines were elaborated for the patients. After the precise awareness-raising efforts about all (dis) advantages of the above four options in accordance to the charter of the patients' rights of Iran Ministry of Health, the patients were again asked to inform us on their priorities for the interview question. Finally, the patients' responses prior and after the awareness-raising efforts were analyzed using SPSS software version 23 (IBM Corporation. New York, New York, USA).

  Results Top

The findings of the research show that 109 men (60.22%) and 72 women (39.78%) have participated in the interview; 68 patients (37.57%) were within the age range of 20–40 and 113 (62.43%) within 40–60. Of this number, 53 (29.44%) had undergone nonelective surgeries and the rest (70.56%) elective surgeries. Sixty-seven surgeries (37.02%) were done in private hospitals and 114 (62.98%) in public ones, though this proportion is not compatible with the referring rate of patients to private hospitals in Iran. Since the location of the drugstore where the interview was done was in the capital of the country and the interviewees were the middle-class urbanites, the reference rate to private hospitals was shown to be higher than that of the average rate across the country. Furthermore, 68 (37.5%) were under diploma, 44 (24.3%) had received diploma degree, and 49 (38.2%) were academic educated among whom 8 (4.4%) were working as health professionals that the statistics could not be compatible with the Iran society in general.

Of the total number of the patients, 162 (89.50%) had received blood transfusion perisurgery and 19 (10.50%) had no transfusion experience. All those without transfusion had undergone laparoscopic gallbladder removal and were under the supervision of gastroenterologist.

The findings showed that all patients had signed the consent form before surgery, and it was different from the informed consent form and it was obtained mostly to safeguard the care provider and disclaim liability from the side effects and adverse reactions of blood transfusion. Even though the consent had been obtained, only 15 patients (8.29%) announced that they were informed before surgery about the transfusion likelihood peri- or postsurgery. And still, out of these 15, only 5 (2.76%) had adequate information on the (dis) advantages of blood transfusion.

The hematology consultation and anemia evaluation had been implemented for 157 patients (86.74%); however, only 25 (15.92%) of them had been examined for anemia preadmission and 132 left (86.08%) were evaluated for anemia after being admitted to hospital and during stay before surgery.

Eventually, only 15 patients (8.29%) had signed their presurgery consent after being well-informed on the adverse reactions of transfusion, whereas in the case of the other 166 (91.71%), the consent was not “informed.”

Based on the estimation made by the SPSS software version 23 and the use of Wilcoxon signed-rank test, there is a significant correlation for the selection that patients make between blood transfusion and the alternatives prior and after the awareness-raising efforts and the dissemination of appropriate information (P < 0.05) [Table 1] and [Figure 1].
Table 1: Estimation made by the SPSS software version 23 and the use of Wilcoxon signed-rank test for the selection that patients make between blood transfusion and the alternatives prior and after the awareness

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Figure 1: The selection that patients make between blood transfusion and the alternatives prior and after the awareness

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  Discussion Top

PBM is prominently emphasized for its being beneficial both for patients and the health system,[2],[3] The regular transfusion need of 18,783 thalassemics under the coverage of Iran Health System necessitates a balance between blood safety and adequacy; thus, the efforts to prevent the growth of blood use and reduce the need for the first-time blood donors are important strategies of the Iranian Blood Transfusion Organization.[12] This specificity of the blood transfusion chain in Iran doubles the significance of PBM. Given the importance of shared decision-making in transfusion medicine, the emphasis has been placed on the role of patients and their concerns for blood transfusion.[13] Moreover, bearing in mind patients' concerns about transfusion risks can help specialists to highlight the likely adverse reactions of transfusion during the informed consent session, thereby involving patients in implementing PBM well to the end.[11] In fact, the efficiency improvement of the health system in all aspects depends on the increase in patients' knowledge and their persuasion to be involved in the treatment process; conversely, the deficiency in patients' knowledge and contradictory patients' beliefs with those of the health-care providers are the important factors for the treatment process to be aborted and fail.[14] PBM would not succeed without patient involvement and without precise and comprehensive information shared with patients about the (dis) advantages of blood transfusion during the informed consent session.[15]

Our research shows that despite the informed consent signed by all patients prior to surgery, the patient information dissemination about blood transfusion has been evaluated to be very weak, and the informed consent has changed to be an obligatory procedure. A very low rate of the patients who had signed the informed consent, particularly for blood transfusion has been shown to have done it informed, and it has been mostly a general consent obtained without information sharing. Only 2.76% of patients acknowledged that they had received adequate information about (dis) advantages of blood transfusion presurgery. This indicates that the medical centers in Iran require reconsidering their perception on patients' rights. Our research clearly shows that providing adequate information for patients compatible with patients' rights and informing patients on (dis) advantages of blood transfusion and medical alternatives would make great changes in patients' approach and be effective in patient decision on their treatment process. It is thus imperative to offer adequate information to patients before elective surgeries prior to any blood transfusion attempts, and the patient to be recognized as a stakeholder in decision-making in the treatment process. The precise abidance to principles of patients' rights can be a determining factor in PBM in Iran.

  Conclusions Top

The findings of the present research are compatible with previous research on the importance of abidance to patients' rights and the issuance of adequate information to patients for the ultimate goal of PBM to be fulfilled.

Medical centers in Iran should pay more attention to patients' rights, and instead of obligatory consents, they should obtain informed consents and increase patient information about the treatment process including blood transfusion. Knowledge improvement of patients about blood transfusion and consideration of their status as a stakeholder in decision-making in the treatment process can lead to further success of PBM program in Iran.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Isbister J. Why should health professionals be concerned about blood management and blood conservation? J Australas Assoc Blood Conserv 2005;2:3-7.  Back to cited text no. 1
Purvis TE, Goodwin CR, De la Garza-Ramos R, Ahmed AK, Lafage V, Neuman BJ, et al. Effect of liberal blood transfusion on clinical outcomes and cost in spine surgery patients. Spine J 2017;17:1255-63.  Back to cited text no. 2
Guerra R, Velati C, Liumbruno GM, Grazzini G. Patient blood management in Italy. Blood Transfus 2016;14:1-2.  Back to cited text no. 3
Gombotz H, Rehak PH, Shander A, Hofmann A. Blood use in elective surgery: The Austrian benchmark study. Transfusion 2007;47:1468-80.  Back to cited text no. 4
Theusinger OM, Kind SL, Seifert B, Borgeat L, Gerber C, Spahn DR, et al. Patient blood management in orthopaedic surgery: A four-year follow-up of transfusion requirements and blood loss from 2008 to 2011 at the Balgrist University Hospital in Zurich, Switzerland. Blood Transfus 2014;12:195-203.  Back to cited text no. 5
Heschl M, Gombotz H, Haslinger-Eisterer B, Hofmann A, Böhler N, Meier J, et al. The efficacy of pre-operative preparation with intravenous iron and/or erythropoietin in anaemic patients undergoing orthopaedic surgery: An observational study. Eur J Anaesthesiol 2018;35:289-97.  Back to cited text no. 6
Anesthetic Techniques to Reduce Blood Loss. Available from: https://www.nataonline.com/np/434/anesthetic-techniques-reduce-blood-loss. [Last accessed on 2019 Feb 08].  Back to cited text no. 7
Global Forum for Blood Safety: Patient Blood Management. Dubai, United Arab Emirates; 14-15 March, 2011. Available from: http://www.who.int/bloodsafety/events/gfbs_01_pbm_concept_paper.pdf. [Last accessed on 2019 Feb 12].  Back to cited text no. 8
Hadipour Dehshal M. The whys of patient-centered care. Thalassemia Rep 2015;5:1.  Back to cited text no. 9
Hadipour Dehshal M. Patient's rights: Legislation globally and in the region. Haematologica 2017;102:40-2.  Back to cited text no. 10
Vetter TR, Adhami LF, Porterfield JR Jr., Marques MB. Perceptions about blood transfusion: A survey of surgical patients and their anesthesiologists and surgeons. Anesth Analg 2014;118:1301-8.  Back to cited text no. 11
Pourfathollah AA, Hadipour Dehshal M. Thalassaemia in Iran: Thalassaemia prevention and blood adequacy for thalassaemia treatment. ISBT Sci Ser 2019;14:114-8.  Back to cited text no. 12
Graw JA, Eymann K, Kork F, Zoremba M, Burchard R. Risk perception of blood transfusions – A comparison of patients and allied healthcare professionals. BMC Health Serv Res 2018;18:122.  Back to cited text no. 13
Abdul-Aziz B, Lorencatto F, Stanworth S, Franci J. Patients' and health care professionals' perceptions of blood transfusion: a systematic review. Transfusion 2018;58:446-55.  Back to cited text no. 14
Moosavi A, Zare Bersiyani Z, Yousefi E, Gharasi Manshadi M, Moghimi A, Mirzaei M. Patients' attitudes toward receiving information and blood transfusion safety. Int J Adv Med 2017;4:609-13.  Back to cited text no. 15


  [Figure 1]

  [Table 1]


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