Development of a multi-modality blood conservation strategy in cardiothoracic surgery

Aims and objectivesTo develop an evidence base that will underpin high quality and cost effective blood transfusion practice, with direct benefits, in terms of improved outcomes for patients and reduced resource use for the wider NHS.BackgroundInconsistent transfusion practice, particularly within surgical specialties, is a cause of unnecessary morbidity to patients, as well as an important resource issue for the NHS. Unnecessary transfusion has direct resource implications, compounded by increasing pressure on the donor supply, as well as indirect resource implications as a consequence of morbidity associated with transfusion. In cardiac surgery complications associated with transfusion increase hospitalisation costs by over 40%. Cardiac surgery is a high volume user of donor blood, using almost 20% of all blood components nationally. There is wide variation (25%-95%) in transfusion rates across the country however. This suggests that many transfusions are avoidable. Variation occurs because of the poor evidence base underpinning transfusion decisions. Developing this evidence base requires adequately funded cross-specialty research into integrated, multimodality strategies for improving transfusion practice. NIHR funding provides the means to undertake such research. This programme in cardiac surgery will serve as a template for the development of Better Blood Transfusion in other specialties.Research plansOur programme focuses on: A. the development of models that predict transfusion and bleeding before surgery enabling targeted use of blood conservation strategies, B. reducing the unnecessary use of blood by defining indications for transfusion and, C. increasing the safety of blood transfusion. This application represents a continuation of our work to date in each of these research themes. We will validate a RBC transfusion risk prediction score developed in Bristol, in a nationwide dataset (A1) and examine the cost-effectiveness of preoperative platelet function testing as a predictor of bleeding and transfusion requirement (A2). The application includes two randomised trials that consider the cost effectiveness of using simple techniques, already in common usage, to improve blood transfusion safety. These challenge prevailing paradigms, notably that transfusion should be determined by haematocrit (B1) and also that stored red blood cells should simply be transfused to patients without modification of potentially toxic by products of storage (C). We will also consider current indications for platelet and plasma transfusion by assessing the diagnostic accuracy of current point of care algorithms for postoperative bleeding (B2).Research teamThe multidisciplinary team (clinical academics from cardiac surgery, critical care, transfusion medicine, haematology, NHS managers, and researchers in inflammation, blood transfusion science and health services research) have an established track record in blood conservation, translational research, and the delivery of high quality, low cost clinical services. Research environmentThe Bristol Heart Institute is the setting for the programme (grant income >£50 million, >160 separate grants, >900 peer-reviewed papers in the last 5 years). The Bristol Heart Institute-UBHT partnership has an international reputation for translational research. Anticipated outputs, outcomes and impact of this research on the health of patients and/or the public, and on the NHSDissemination of our research and incorporation into local and national NHS care pathways will be facilitated by members of our research team who have key roles in local, regional and national committees concerned with the generation of practice guidelines, policy development and delivery of high quality transfusion practice. We also describe specific proposals for the incorporation and audit of introducing our research findings into local practice within 5 years. Cost effectiveness data from these studies will aid decision making as to