Abstract

The creation of a patient blood management (PBM) certification program by The Joint Commission (TJC) and Association for the Advancement of Blood and Biotherapies (AABB) provides validation of an existing PBM program. A team of subject matter experts in PBM formed a working group to develop a structured approach to guide PBM programs through the PBM certification. Program challenges and metrics were reviewed. Initial steps to establishing PBM certification include a multidisciplinary working group and hospital administration buy-in. Development of policies and procedures individualized to the facility will standardize practice. An institutional transfusion committee can provide PBM oversight including enforcing compliance. Using resources such as TJC and AABB standards and tools including electronic medical records (EMR) can track and trend hospital PBM performance and identify improvement opportunities. A gap analysis tool helps implementation. Challenges might include maintaining a PBM program during a merger, slow responsiveness of information systems (IS) to requests, PBM education for both the Transfusion Safety Officer (TSO) and hospital staff with constant turnover. Available metrics from one hospital system showed good compliance with transfusion thresholds (average all products: 97.9%, 2019, 2020). In 2020, through educational efforts the cost savings were $124,856.70 compared to 2019. Regarding single unit transfusion of RBCs, this was 62.25% (2019), 63.75% (2020), 72.00% (2021), and surpassed the target goal of 60%. Obtaining PBM certification highlights the success of an institution's PBM program. Facilities that have achieved PBM certification have seen significant reductions in transfusions and considerable cost savings.

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