Appendix 3: Handout of Information
Handout of Information
Single Unit Transfusion Guideline - Supporting Material
This information has been adapted from the Single Unit Transfusion Guideline developed by the
National Blood Authority, Australia.1 It is intended for use by all clinicians responsible for prescribing
blood transfusion to stable normovolaemic patients who are not actively bleeding and not in an
operating theatre.
The Single Unit Transfusion Guideline1, based on a restrictive transfusion threshold, is part of Patient
Blood Management (PBM); an evidence-based patient centred strategy to improve safety by minimising
blood transfusions.
In line with the Patient Blood Management Guidelines: “Where indicated, transfusion of a single unit of
RBC, followed by clinical reassessment to determine the need for further transfusion, is appropriate. This
reassessment will also guide the decision on whether to retest the Hb level”.2,3 Ensure haemoglobin
levels are aligned with the Patient Blood Management Guidelines.2–4
If the patient is symptomatic, and Hb is consistent with the Patient Blood Management Guidelines, then
transfuse 1 unit, and reassess patient for clinical symptoms of anaemia before transfusing further
units. It may take more than 24 hours for patients to report an improvement in symptoms after a
transfusion.2
Minimise risks of transfusion by restricting the number of units where possible, as evidence suggests
transfusion risks are dose dependant.5,6 While blood is very safe from known infectious agents, other
risks including transfusion related circulatory overload (TACO), transfusion related acute lung injury
(TRALI) and immune modulation are more common than previously thought.2–4,7,8
Practice evidence based transfusion, by assessing the patient and symptoms, together with
haemoglobin, rather than transfusion based on habit, or tradition.
If one unit of blood adequately improved the symptoms, then no further transfusion should occur.
Modern health systems need to change transfusion practice for the following reasons:
 Current practice does not always align with current evidence based recommendations.
 The Patient Blood Management Guidelines (Module 2 - Perioperative; Module 3 - Medical and
Module 4 - Critical Care)2–4 support restrictive transfusion and a single unit strategy.
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The National Safety and Quality Health Service Standards (Standard 7: Blood and Blood
Products) require blood and blood product policies and procedures to be consistent with
national evidence based guidelines for pre-transfusion practices, prescribing and clinical use of
blood and blood products.9 The single-unit guideline complies with sections 7.1.1, 7.1.3, 7.2.2
and 7.4.1. http://www.safetyandquality.gov.au/wpcontent/uploads/2012/10/Standard7_Oct_2012_WEB.pdf
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Single unit transfusions are safe in stable, normovolaemic patients who are not actively
bleeding or in an operating theatre and reduce transfusion associated morbidity and
mortality.10,11
National Blood Authority
pg. 1
Appendix 3: Handout of Information
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If one unit has achieved the stated outcome for the transfusion, for example improvement in
haemoglobin or symptoms, further units will only increase the risks without adding benefit.
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Transfusion is a live tissue transplant. Risks associated with transfusion are dose dependent.12,13
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A two unit transfusion increases the risk of nosocomial infection and other long term
morbidities.12,13
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Transfusion Associated Circulatory Overload (TACO) is among the high risks, estimated at 1 in
100 per unit transfused.2–4,
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Historically, two unit red blood cell transfusions were normal practice. Single unit transfusions
remain only a small proportion of all transfusion.
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In addition to exposing patients to increased risk without commensurate benefit to patient
outcome, red blood cell transfusion also poses on-going challenges in balancing supply and
demand due to the increasing age of the population: demand for blood will increase but the
available donor pool will decrease. Although blood is extremely safe from the currently known
infectious agents, the potential threat from as yet unknown, or re-emerging pathogens deserves
cautious consideration.5
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Patient Blood Management has been shown to be more effective than “appropriateness” in
pre-empting the need for blood components, reducing over-all use and improving patient
outcomes.
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Emerging evidence reveals that transfusion is an independent risk factor for adverse outcomes
including increased morbidity, mortality and hospital length of stay.6
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There is a lack of evidence for the benefit of transfusion in the non-bleeding patient.6
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The Single Unit Transfusion Guideline and restrictive transfusion will align with Health Service’s
Strategic Plans, Organisational Values, Vision and Mission statements.
Implementation and Resources:
With approval from Hospital Executive management, health services should involve Quality and/or
Clinical Governance staff to recruit clinical champions or staff to assist promotion, education and
implementation of the single-unit transfusion guideline.
Staff will need to be identified to provide education and promotion. Transfusion nurse specialists,
hospital educators or equivalent may already be available.
Identify an appropriate current patient safety committee or create a Transfusion Governance
Committee / Patient Blood Management Committee to promote and provide a conduit for patient
blood management through local meetings, policy and procedures. This committee can co-ordinate data
collection and analysis, report outcomes, address problems or issues arising and centralise feedback.
Extensive education of medical, nursing and laboratory staff will be required, through broad- based
forums such as Grand Rounds, as well as specialty group/ divisional meetings, seminars, and education
days. The local website or intranet, local internal magazines (printed and electronic), training manuals
and regular communication tools should be utilised. Posters and handouts and may also be used. The
National Blood Authority provides tools; printed and electronic education material for display and
presentations. The catch-phrase “Be SINGLE minded” is suggested.
National Blood Authority
pg. 2
Appendix 3: Handout of Information
Patient information should be made available in all patient accessible areas; pre-operative and other
clinics, outpatient and emergency areas, treatment rooms and public access websites.
Empower nursing and laboratory staff to monitor prescription and requests for blood, by providing
support from senior champions / haematologists. Access to the guideline, suggested questions to pose if
challenging a request, and access to educational material to support challenges will assist with guiding
compliance to the guideline.
Changes to programs may be required where computerised physician order entry of transfusion
requests is utilised.
Monitoring and Reporting Data:
Data collection can include simple measures such as a log of requests submitted that do not fall within
the guideline criteria, and manual audits of transfusion episodes in patient medical records.
Electronic data may be available, such as the number of units ordered daily from the Blood Service,
(BloodNet statistics) or if available from the IT system, the number of units transfused, the number of
patients transfused, and the number of units transfused per patient. Comparing time periods pre and
post-implementation of the guideline should be informative.
Results may be reported through the Transfusion Governance Committee / Patient Blood Management
Committee, quality committees, to clinical governance and executive meetings, and to each medical
specialty / division where transfusion is practised. Feedback to Laboratory and nursing groups is
encouraged.
Data can be benchmarked within departments, local hospital groups, across area health networks, and
nationally / internationally if desired.
National Blood Authority
pg. 3
Appendix 3: Handout of Information
References:
1.
National Blood Authority Single Unit Transfusion Guideline (Currently in Development). (2013).
2.
National Blood Authority Patient blood management guidelines: Module 3 – Medical. (National
Blood Authority: Canberra, Australia, 2012).at http://www.blood.gov.au/pbm-guidelines
3.
National Blood Authority Patient blood management guidelines: Module 4 – Critical Care.
(Canberra, Australia, 2013).at http://www.blood.gov.au/pbm-guidelines
4.
National Blood Authority Patient blood management guidelines: Module 2 – Perioperative.
(Canberra, Australia, 2012).at http://www.blood.gov.au/pbm-guidelines
5.
Hofmann, A., Farmer, S. & Shander, A. Five drivers shifting the paradigm from product-focused
transfusion practice to patient blood management. The oncologist 16 Suppl 3, 3–11 (2011).
6.
Hofmann, A., Farmer, S. & Towler, S. C. Strategies to preempt and reduce the use of blood
products: an Australian perspective. Current opinion in anaesthesiology 25, 66–73 (2012).
7.
Roback, J. D. Non-infectious complications of blood transfusion. AABB AABB Techn, (2011).
8.
Popovsky, M. Transfusion-associated circulatory overload. ISBT Science Series 166–169 (2008).
9.
Australian Commission on Safety and Quality in Healthcare Safety and Quality Improvement
Guide Standard 7: Blood and Blood Products. ACSQHC (2012).at
http://www.safetyandquality.gov.au/wpcontent/uploads/2012/10/Standard7_Oct_2012_WEB.pdf
10.
The British Committee for Standards in Haematology Guidelines on the Administration of Blood
Components. Addendum to Administration of Blood Components, August 2012. 1–4 (2012).at
http://www.bcshguidelines.com/documents/BCSH_Blood_Admin__addendum_August_2012.pdf
11.
Carson, J. L., Carless, P. a & Hebert, P. C. Transfusion thresholds and other strategies for guiding
allogeneic red blood cell transfusion. The Cochrane database of systematic reviews 4, CD002042
(2012).
12.
Koch CG Duncan AI et al, L. L. Morbidity and mortality risk associated with red blood cell and
blood-component transfusion in isolated coronary artery bypass grafting. Crit Care Med 2006 34,
1608–1616 (2006).
13.
Hajjar LA Vincent JL et al. Transfusion requirements after cardiac surgery: the TRACS randomised
controlled trial. JAMA - Journal of the American Medical Association 304, 304:1559–1567
National Blood Authority
pg. 4
Appendix 3: Handout of Information
Bibliography: *List provided on separate page, to use with handout, or only on request.
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National Blood Authority (NBA) (2012). Patient blood management guidelines: Module 2 –
Perioperative. NBA, Canberra, Australia. http://www.blood.gov.au/pbm-module-2
National Blood Authority (NBA) (2012). Patient blood management guidelines: Module 3 –
Medical. NBA, Canberra, Australia. http://www.blood.gov.au/pbm-module-3
National Blood Authority (NBA) (2013). Patient blood management guidelines: Module 4 –
Critical Care. NBA, Canberra, Australia. http://www.blood.gov.au/pbm-module-4
World Health Organisation, World Health Assembly, 2010, 63rd Assembly. WHA63.12 Agenda
item 11.17: Availability, safety and quality of blood products. 21 May 2010.Page 3:
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Hofmann A, Farmer S, Shander A (2011). Five Drivers Shifting the paradigm from Productfocused Transfusion Practice to Patient Blood Management” The Oncologist;16(suppl 3):3-11
Hofmann, A et al. (2012). Strategies to preempt and reduce the use of blood products: an
Australian perspective. Curr Opin Anesthesiol , 25:66-73.
Australian Commission on Safety and Quality in Health Care (2012). Safety and Quality
Improvement Guide Standard 7: Blood and Blood Products (October 2012). Sydney. ACSQHC.
http://www.safetyandquality.gov.au/wpcontent/uploads/2012/10/Standard7_Oct_2012_WEB.pdf
Shander A, et al.Review. (2012). A new perspective on best transfusion practices. Blood Transfus
DOI 1032450/2012.0195-12
Berger M, Gerber B, Arn K, Senn O, Schanz U, Stussi G. (2012). Significant reduction of red blood
cell transfusion requirements by changing from a double-unit to a single-unit transfusion policy
in patients receiving intensive chemotherapy or stem cell transplantation. EHA Haematologica:
January 1, 2012 vol. 97 no. 1 116-122 http://www.haematologica.org/content/97/1/116.full
Herbert PC, Wells G et al (1999). A Multicenter, Randomised, Controlled Clinical Trial of
Transfusion Requirements in Critical Care. N Engl J Med 1999;340 (6):409-17
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Administration of Blood Components. Addendum to Administration of Blood Components,
National Blood Authority
pg. 5
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August 2012 pdf.http://www.bcshguidelines.com/documents/BCSH_Blood_Admin__addendum_August_2012.pdf
Western Australia Patient Blood Management Project. Executive Summary, 2011. Booklet of
Government of Western Australia, Department of Health.
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Transfusion Committee, Dr Kerry Gunn. Article by. Public Sector, 2013 April, Volume 36:1.
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create centre for Patient blood management.” 2012, September 13.
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Management Program. www.emmc.org/blood
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109(1):55-68.
National Blood Authority
pg. 6