Praiseldy Langi Sasongko

35 Past, present, and future of red blood cells 20 or 25 units of blood … [now] 75% of our liver transplants do not require transfusion.” (International Expert 32) Thirty-three articles mentioned how this driver was key to the overall decline, with several examples in the fields of orthopedics, cardiothoracic surgery, and prostate cancer.33–35 Further, one of these studies highlighted how the decline of RBCs had been solely due to the decline of surgical patients.10 Conversely, one study reports increased demand across a broad range of surgical patients,36 while another showed no changes in total hip and knee arthroplasty.37 All of this contributed to different organizational and operational changes for blood banks and hospitals, which was the third driver to reducing demand. Experts overall shared how blood banks underwent cost-saving efforts, such as consolidation of the organization and improving monitoring and efficiency of the supply chain. Those with 21+ years of experience could provide multiple illustrations of how this occurred while those with less experience provided only one (the Dutch clinical chemist). More specifically, Dutch experts identified how, in the Netherlands, clinical chemists and transfusion committees created an environment of consensus practice and feedback loops for monitoring usage, which expedited RBC reduction within hospitals. (Here, the clinical chemist is head of the hospital laboratory but has direct responsibility for blood transfusion in the hospitals through ensuring adherence to guidelines, monitoring usage and providing feedback across specialties, and being active in transfusion decision making, thereby being called the “gatekeeper”). Interestingly, two international experts (with 21+ years of experience) strongly vouched that the decline of RBCs was due to clinical management focusing on using algorithms and the improved logistics of the blood bank and hospitals instead of the aforementioned scientific evidence (because of the poor to mediocre quality of those studies). Thirty articles (30/107; 28%) discuss a wide range of organizational/ operational issues; of note were the studies involving implementation of clinical decision support tools that enabled physicians to order and use less blood.38–41 Drivers of the increase of RBC demand Simultaneously, irrespective of the RBC decline seen in other specialties, non-Sanquin and international experts (4/42; 10%, all with 21+ years of experience) shared how they had seen increased demand in specialties such as oncology and hematology. These specialties already require consistent transfusion for their patients and yet have seen increased demand. This is due to the aging population who suffer the most from cancers and other noncommunicable diseases, requiring treatments.

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