Implementation: getting started

This section highlights 2 areas of the blood transfusion guideline that could have a big impact on practice and be challenging to implement, along with the reasons why these areas are important (given in the box at the start of each area). We identified these with the help of stakeholders and guideline committee members (see section 10 of developing NICE guidelines: the manual). NICE has also produced tools and resources to help you put this guideline into practice.

The challenge: Using tranexamic acid as an alternative to transfusion

See recommendation 1.1.5.

Hospitals may improve clinical outcomes and cut costs (see the guideline tools and resources) by reducing the need for blood transfusions (with their associated risks) whenever possible. Tranexamic acid is an an inexpensive antifibrinolytic pharmacological agent that can be administered before and during surgery to reduce bleeding and therefore the need for blood transfusions. There is strong evidence that this is clinically effective and that its use will reduce mortality and costs.

Reducing variation in practice

Clinicians are not consistently offering tranexamic acid to adults undergoing surgery who are expected to have at least moderate blood loss (greater than 500 ml). Clinical opinion is that current usage may be as low as 10–20%. This may be due to a lack of awareness and of inclusion in local clinical protocols.

To promote its use, medical directors and hospital transfusion committees could:

  • Use the NICE baseline assessment tool for this guideline, and consider carrying out a clinical audit to establish current practice. Awareness‑raising and training initiatives can then be targeted at areas of most need.

  • Use the NICE guideline algorithm (PDF only) to include using tranexamic acid as part of the hospital protocol for adults undergoing surgery who are expected to have at least moderate blood loss.

  • Use the NICE costing statement to estimate possible cost savings. Depending on the reduction in the number of units of blood transfused, there may be a saving in the range of £146–£689 per person. Use of tranexamic acid may also reduce length of hospital stay, which will result in efficiency savings.

The challenge: using electronic patient identification systems

See recommendation 1.7.3.

Human error is the main cause of adverse events related to transfusion. The most serious of these are the wrong patient being given a transfusion or the incorrect blood product being given. These errors are caused by misidentification during pre‑transfusion sampling or when giving a transfusion. Electronic patient identification systems prompt staff to carry out key steps in the correct order, and ensure that transfusions are given to the right patients through scanning of compatible wristbands and blood component containers.

Making the case for investment

Many hospitals do not have such a system in place, and for these hospitals implementation will involve a redesign of hospital blood transfusion services to incorporate patient identification and bedside handheld computers that prompt staff through each step and verify that the correct transfusions are given. There will be an initial cost to implementing these systems, as well as annual maintenance costs. However, the systems will provide substantial efficiency gains, including savings in nursing and laboratory staff time and reduced blood product wastage.

To develop a business case, hospital managers could:

  • Refer to resources such as the NHS right patient, right blood safer practice notice.

  • Use the NICE costing statement to assess potential costs, including ongoing costs for maintenance and administrative support. In addition, consider efficiency savings such as improved traceability and availability of data.

  • Use published data (such as SHOT) to demonstrate the patient safety benefits of implementing such a system and provide examples of where the system would have prevented errors, in particular where a potential NHS England Never Event would be avoided.

  • Gain high‑level support from influential patient safety representatives and the Hospital Transfusion Committee.

  • Use examples from practice in other NHS hospitals to learn about how such a system has been implemented.

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