Title: Development of a multi-modality blood conservation strategy in cardiothoracic surgery
Funder: Department of Health (England)

Abstract: Aims and objectives To 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. Background Inconsistent 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 plans Our 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 team The 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 environment The 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 NHS Dissemination 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 the introduction of new technologies into NHS practice. Public involvement Our Research Advisory Group has had a consultative role in the development of this proposal. They will also undertake roles in drafting COREC applications, research governance, and promoting the implementation of our research findings via their participation in the commissioning and management of local health services. Ethical implications All studies require ethical approval and will comply with the Research Governance Framework for Health and Social Care. Justification for resources requested Salary costs will include a senior researcher to coordinate scientific aspects of the studies and a programme manager with responsibility for completion and research governance, a statistician, research nurses and a biomedical scientist. We are also requesting funding for a platelet function reference assay system that will provide an additional service role.


Research activity codes: 6.4 SURGERY;5.4 SURGERY
Health categories: CARDIOVASCULAR