Masterclass 6 - Patient Blood Management

Anemia is a pervasive disease, afflicting nearly a sixth of the world's population, with hospitalization frequently exacerbating the condition. Anemic patients are prone to prolonged hospital stays, heightened morbidity and increased mortality, making the improvement of care for anemic hospitalized patients an imperative in healthcare. Hospitalized patients routinely have multifactorial anemia.
To achieve this objective, evidence-based strategies must be implemented, including the incorporation of the main pillars of Patient Blood Management (PBM). PBM consists of four main concepts including: 1) identification, treatment and improving tolerance of anemia 2) Blood conservation techniques 3) Optimization of Coagulopathy and 4) Patient centered decision making.
Implementation of anemia management protocols has been demonstrated to reduce the time to treatment initiation and improve the accuracy of treatment decisions, leading to improved patient outcomes. In addition, there are methods to be used that improve patient’s tolerance of anemia.
Treatment of inpatients should also include methods to reduce blood loss in both procedures and also innocuous tasks such as phlebotomy. Other methods to reduce the chance of blood loss due to bleeding is the appropriate use of anticoagulants and urgent/directed reversal of coagulopathy secondary to either low quantities of clotting components or pharmacologic causes.
Lastly, focusing on the patient in front of you and moving away from treating numbers and instead on what is the current needs of the patient. Patient’s tolerance of anemia is wide varying. Patient education also plays a pivotal role in the improvement of care for anemic hospitalized patients. Patients must be apprised of the causes and consequences of anemia, as well as the significance of appropriate treatment. Education empowers patients to make informed decisions regarding their care, leading to improved outcomes.
 Further research is necessary to determine the optimal implementation of these strategies and to gain a deeper understanding of the most effective methods for improving care for anemic hospitalized patients.

Patient Blood Management (PBM) is defined as a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient’s own blood, while promoting patient safety and empowerment.1, 2 Billions of individuals suffer from anemia – most of them unknowingly – and hundreds of millions suffer from chronic and acute blood loss and bleeding disorders or from coagulopathies.2 For decades, these conditions did not receive the appropriate attention, particularly in hospitalized patients. Accumulating evidence shows that they are independent predictors for adverse outcomes including morbidity and mortality.3, 4 Rather than diagnosing the causes of these conditions, clinicians were and still are inclined to simply prompt them with transfusion of allogeneic blood products. However, the evidence shows, that transfusion is also an independent, dose-response predictor of adverse outcomes including morbidity and mortality. In toto, this is alerting evidence and requires practice change. Therefore, the World Health Organization (WHO) has called all 194 member states to implement (PBM) as a standard of care.2 To support this call, virtually any decision maker or stakeholder within the healthcare sector must understand the sound rationale behind PBM. This includes patients, health care providers, hospital systems, the public health sector and even payers/health insurances.5, 6 The evidence is clearly in favor of PBM with case-control cohort studies, including large, population-based studies,7-14 propensity score matched analyses,15, 16 randomized controlled trials (RCTs) of the therapeutic strategies of PBM,17-21 meta-analyses and systematic reviews of therapeutic strategies of PBM,22-28 The economics are also in favor of PBM7, 11, 18, 21, 28-31. With both favorable evidence and economics, the ethical imperative for immediate PBM implementation is self-evident.

Patient Blood Management (PBM) has now been emerging to be a patient care and management standard in many developed countries. With ample evidence from observational and prospective studies, patients’ outcomes have been shown to be maintained and even improved with less in-hospital complications with various PBM measures implemented. As by-products, frequencies and quantities of blood transfusion decreased and at the same time, those patients’ outcome improvements were associated with substantial cost saving. Since its introduction of PBM concept in 2011 and one of the strategic frameworks, World Health Organization (WHO) formally issued policy brief to its members countries in late 2021 to call for an urgent need of the PBM implementation. As a follow up, a guidance on the implementation published will be published in 2023.


In Hong Kong, the development of PBM begun in 2014 when the blood transfusion service invited experts to introduce the concept locally. At the same time, a number of PBM related programmes emerged were initiated by individual hospitals. After some months of preparation, Hospital Authority formally established the Patient Blood Management Steering Committee in 2018 with four strategic directions namely on – 1). Good Clinical Management; 2). Transfusion Best Practice; 3). Awareness; and 4) Establishment of Performance Indicators. Activities and works targeted at these 4 directions were then followed up at both central and hospital level.


Over the past few years, despite significant impacts from COVID-19 pandemic, progresses had been well seen at all 4 directions. These included development of corporate guidelines in management of menorrhagia, gastrointestinal bleeding, joint replacement, and iron therapy; local and corporate PBM awareness and educational programmes; locally initiated PBM programmes targeting at their patients’ groups of interest; best transfusion practices through introduction of targeted transfusion therapy, availability of fibrinogen concentrates, single unit transfusion; lastly but not the least development of basic performance indicators to capture the baseline and to facilitate trend monitoring with PBM implementation. Besides, efforts have also been extended outside Hospital Authority to private hospitals and doctors when they not only begun to implement PBM measures but had a far better understanding of anaemia diagnosis and management. 


Despite progresses made with encouraging results, there are still many rooms to follow with the ongoing PBM development and sustainability in our local settings. With knowledge and technological advances, evidence based practices would definitely be introduced. At the same time, continued awareness enhancement and education, and evaluation of health benefits gained including economics are the key area to pursuit.