UWA Medical Student shares essay on PBM

Essay about the impact of PBM on healthcare by University of Western Australia medical student Connor Simpson

The Social, Cultural and Intellectual Determinants of Quality and Safety in Healthcare by Connor Simpson

The Australian Commission on Safety and Quality in Healthcare defines safety as “prevention of error and adverse effects associated with healthcare,” and quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge,” summarised together as the right care, in the right place, at the right time.(1) Yet, the “right care” and“current professional knowledge” are not static, objective achievements but instead dynamic, dependent ideals which vary across time and space. By comparing three canonical blood management practices throughout medical history – namely bloodletting, transfusion, and patient blood management (PBM) – this essay argues that safety and quality in healthcare are intricately linked to sociocultural influences and limited by scientific knowledge and evidence. Thus, improving safety and quality in healthcare necessitates sociocultural change and scientific advancement.

If disease was defined by Hippocrates as an imbalance of the humours, then logically treatment involved removal of excessive humour through techniques such as bloodletting in which blood was extravasated in attempt to restore balance.(2) The practice persisted for millennia, evolving as society’s values and understanding of disease developed. For example, in the 18^th century Dr. Benjamin Rush professed that irregular convulsive action of the blood vessels was to blame for illness, thereby targeting vascular over-excitement through “depletion therapy” consisting of aggressive bloodletting which, among other “benefits,” “renders the pulse more frequent when it is preternaturally slow.”(2) It wasn’t until the 19^th century when Dr. Pierre Louis undertook an evidence-based assessment of the archaic practice by comparing bloodletting in the early versus late phase of pneumonia in 77 patients, concluding that its efficacy was “much less than has been commonly believed.”(2) Here, since the origins of Western medicine 2,500 years ago, the approach to patient safety and quality care was born from cultural values and contemporaneous medical knowledge. Despite growing evidence against its efficacy over the proceeding centuries, stubborn practitioners continued to rely on the procedure and successfully established a reputation of medicine being chronically slow to change. Today, bloodletting (or its euphemism, phlebotomy), is used to treat a small subset of disease including hemochromatosis, polycythaemia vera, and porphyria cutanea tarda.(2)

The 20^th century saw a reversal of bloodletting practice, literally and metaphorically, as it was replaced by a process which put blood back into the body instead of letting it out: transfusion. One conspicuous example of cultural values and morals impacting safety and quality in healthcare is the Jehovah’s Witnesses refusing blood transfusions. Due to their belief that it is against God’s will to receive blood, most followers of this religion refuse blood products, presenting an ethical dilemma for doctors.(3) Here, sociocultural values and morals trump the widely accepted gold standard in patient safety and quality healthcare. While blood transfusion can be a life-saving procedure, it is important to appreciate that blood transfusion carries a risk of adverse events such as allogenic reactions, infection, and other errors.(4, 5, 6) In fact, a systematic review(7) found that the risk of transfusion outweighed the benefit and aligns with existing literature by concluding that these adverse effects lead to an increase in morbidity, mortality, and length of stay.(8) Facing scientific and sociocultural opposition, the mainstream reliance on transfusion medicine would be expected to fade out. Alas, the practice is deeply engraved in medical culture causing resistance to change, forming a dichotomy between evidence and practice, á la 19^th century bloodletting.

With an increasing emphasis on patient-centred, evidence-based care in the 21^st century, a contemporary approach to safety and quality in healthcare has emerged: Patient Blood Management (PBM). 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.”(8) It rests on three pillars: 1. Detection and management of anaemia and iron deficiency, 2. Minimising blood loss, and 3. Optimising patient-specific tolerance of anaemia.(6) Between 2008 and 2014, a PBM program was employed at four major hospitals in Western Australia.(2) A retrospective study of 605,046 patients receiving care at these sites over that time found that, compared to usual care, PBM was associated with reductions in hospital mortality, length of stay, and hospital acquired infections, among other benefits.(9) These findings were consistent with the existing evidence and further research continues to support PBM. Hence, PBM is evidence-based in that its principles are derived from best evidence to uphold beneficence and non-maleficence, and patient-centred in that it respects the haematopoietic and circulatory systems in the same way as other body systems in line with modern societal values of autonomy and justice. However, the widespread implementation of PBM is limited by challenges such as resistance to change, limited resources, and culture change at multiple levels.(9)

Quality and safety in healthcare has historically been shaped by the forces of science and culture. As Greenstone put it, “That bloodletting survived for so long is not an intellectual anomaly—it resulted from the dynamic interaction of social, economic, and intellectual pressures, a process that continues to determine medical practice.”(2) As evidenced by its long history of stubbornness and resistance to change, the field of medicine often takes time to adapt to new evidence and social values, and will likely do so with the implementation of PBM. As the WHO puts it, “current patterns of practice are long-standing and deeply ingrained… PBM implementation requires a change in culture and behaviour, structural adjustments in health services delivery and redirection of scarce resources.”(10) Until these changes occur, safety and quality in healthcare will continue to be attenuated by clinical practice misaligning with contemporary sociocultural values and scientific evidence, leaching lessons learnt from bloodletting and blood transfusion. 

References

1. Australian Commission on Safety and Quality in Health Care [Internet]. About us. Sydney, Australia: Australian Commission on Safety and Quality in Health Care [cited 2023 Jul 13]. Available from: https://www.safetyandquality.gov.au/about-us
2. Greenstone G. The History of Bloodletting. BC Medical Journal. 2010 Jan; 52(1):12-14.
3. Medical Protection [Internet]. London (England): The Medical Protection Society Limited; 2023. The Challenges of Treating Jehovah’s Witnesses; [cited 2023 Aug 28]. Available from: https://www.medicalprotection.org/southafrica/casebook/casebook-may-2014/the-challenges-of-treating-jehovahs-witnesses
4. Fact Sheet: Patient Safety [Internet]. Geneva: World Health Organisation; 2019 September 13 [cited 2023 July 17]. Available from: https://www.who.int/news-room/fact-sheets/detail/patient-safety
5. Aide-mémoire for National Health Authorities and Hospital Management: clinical transfusion process and patient safety. Geneva: World Health Organisation; 2010.
6. Australian Commission on Safety and Quality in Health Care [Internet]. The National Patient Blood Management Collaborative. Sydney, Australia: Australian Commission on Safety and Quality in Health Care [cited 2023 Jul 13]. Available from: https://www.safetyandquality.gov.au/national-priorities/pbm-collaborative.
7. Marik PE, Corwin HL. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit Care Med. 2008;36(9):2667-74.
8. Shander A, Hardy J-F, Ozawa S, Farmer SL, Hofmann A, Frank SM, et al. A Global Definition of Patient Blood Management. Anesthesia and analgesia. 2022;135(3):476-88.
9. Leahy MF, Hofmann A, Towler S, Trentino KM, Burrows SA, Swain SG, et al. Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals. Transfusion. 2017;57(6):1347-58.
10. World Health Organisation (WHO). The urgent need to implement patient blood management: policy brief. Geneva: World Health Organization; 2021.