Patient Blood Management

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What is PBM?

The Patient Blood Management (PBM) program is a clinical project with the aim to increase patient safety. The concept, as shown in Figure 1,is built on three pillars, of which each contain a bundle of several individual measures. The aim is to improve, to preserve and exploit patient's own blood resources.

Figure 1: Three pillar concept of Patient Blood Management.

Based on our experience we know that the implementation may take some time to complete and under local conditions certain aspects of theproject might be difficult to establish. In this context, it is of great advantage that the PBM concept is implemented gradually. It is noteworthy that individual PBM measures often belong already to the routine of modern medical practice.
With whom do I have to talk before?


Figure 2 illustrates briefly the various entities that play a role during the process of implementation. The dotted circles highlight in addition to the stakeholders from the medical point of view (straight circles) important non-medical stakeholders. As advertent in the project name, an interdisciplinary cooperation is crucial for the successful implementation of PBM. Although the decisions on the blood formation and -saving measures as well as the administration of allogenic blood transfusion are taken from the medical side, the organization of the project, however, depends by many non-medical instances.

The initial step for the successful implementation of PBM is the approval by the executive board / the management and cooperation with transfusion medicine. Thus, the interaction with surgical partners is initiated. In order to implement all aspects of PBM and also to visualize the implementation successes statistically the involvement of the IT department, controlling, quality management, as well as hospital pharmacy and central laboratory is absolutely necessary.

Figure 2: Overview of the involved entities for a successful implementation of the PBM project. The PBM requires an interdisciplinary collaboration of medical (straight line circle) and non-medical departments (dotted line circle) that increase, with their networking, patient safety through careful handling of patient and donorblood.


To-Do-List as a „red thread” for implementation
As part of the PBM-German network, we already accompany some clinics during the implementation and realization of the PBM project. We provide the network subscribers a short guide in the form of a to-do list containing both organizational and administrative small steps for the successful introduction of PBM.


What costs canbe expected as part of the PBM implementation?
Pre-operative anemia diagnostic
The diagnosis and treatment of preoperative anemia is a key component of PBM, although it is the most difficult task to implement based on our experience. The two most common forms of anemia are iron deficiency anemia (40%) and the ''anemia of chronic disease" (infection, tumor, etc; 40%). To diagnose and treat anemia additional costs for employees and material resources might arise which are depending on your organization and planing.
- Laboratory diagnosis of iron deficiency anemia (transferrin saturation, ferritin, differential blood count, liver and kidney function, CrP) costs, depending on internal cost allocation between 8-30 EUR per patient.
- drug costs can be funded in different ways:


o clinic own budget,


o interdisciplinary sharing of costs with surgical departments,

o ambulant patients may billed through the insurance company after §14 Abs. 7 Apothekengesetz (then a small co-payment must be made by the patient himself, "pink" recipe ticket). Patients with iron administration confirm with their signature the administration of an iron infusion and a bill from the Hospital pharmacy for a copayment of around 10 EUR will be send home. The recipes can be redeemed through the Hospital pharmacy, thus no additional drug costs emerge for the hospital.


o For private patient laboratory and drug costs can be charged extra per invoice.
If you can reduce, by a successful implementation of PBM with all its components, the amount of blood products, you will move costs eventually, but probably do not have higher costs.
Is a patient consent required?
The introduction of the PBM concept relates ALL surgical patients of a clinic/ or department as the new standard of care. The epidemiological data analysis is a purely scientific objective. An individual informed consent statement is therefore not necessary.
What options for documenting the transfusion trigger exist?
There are three ways of documentation:


1) In the paper-based RBC request (usually applies to patients on general ward or in the operating theater when the indication already exists)

2) In the electronic RBC request (usually applies to patients on general ward or in the operating theater when the indication already exists)

3) as the accompanying note for RBCs etc. in paper form during the transfusion

4) in the electronic batch documentation (after transfusion)


How do I become a part of the German PBM network?
We are pleased about every network participant and assist hospitals implementing PBM. Figure 3 provides a summary of the order of the network.


Figure 3: History chart for inclusion in the German PBM network. Please * message to PBM initiators to send; ** For many hospitals in Germany already ethics vote exist (Figure 4), in that an informal letter with a request for a two-vote is usually sufficient.



Figure 4: Affirmative ethical votes in Germany.Positive feedback from the ethics committees (white text) are for red markedstates. Abbreviations: AEK = MedicalAssociation; LÄK = Landesärztekammer; EK =ethic committee.



What data are commonly evaluated as part of the project?
As part of the network, we accompany the effects of the PBM-introduction epidemiologically; i.e. after obtaining an ethic vote from the appropriate ethic committee PBM-indicators such as RBC-consumption are evaluated. There by, the whole evaluation period consist of a minimum of 12-month control phase prior to the first training, 3-6 months introductory phase and at least 18 months PBM phase.
What characteristics are collected as part of the PBM network?
The following data are applicable to all inpatient surgical patients older than 18 years:

- ICD-10 encrypted admission and discharge and secondary diagnoses


- Hemoglobin levels at admission and discharge of patients (incidence of anemia)


- Total length of stay in the ICU and in the hospital


- Consumption of blood products and coagulation factors

When does the training begin?
You can always start with training. The date of the first training is regarded as the starting time of the introduction phase.
In which time interval should the data be transmitted?
We recommend a data transmission in three-month intervals.