The art of storytelling in patient blood management: a narrative review on bridging the gap between complex data and understandable information

Introduction

Background

Patient blood management (PBM) requires conveying complex medical data to a diverse audience, and storytelling is one of the most effective tools for this purpose. Since the dawn of human civilization, storytelling has been instrumental in sharing wisdom, advancing scientific knowledge, and pioneering innovation. As technology advances in healthcare, digital storytelling is emerging as an innovative method for addressing the complex challenges of disseminating and transferring knowledge to key stakeholders (1). A successful PBM program involves the active participation of different stakeholders, including healthcare workers, policymakers, and patients (2). A balanced approach using a data-driven and persuasive narrative is essential for fostering meaningful engagement and effective implementation of PBM strategies, interventions and education. This article discusses the application of storytelling within PBM, illustrating its role in translating complex data into relatable and impactful information across academic presentations, journal articles, and social media.

Similar to the three tenets of PBM (optimization of red cell mass, minimizing blood loss and optimizing the patient’s anemia tolerance), effective storytelling has three integral components: logos (logic), ethos (value), and pathos (emotional connection). This framework can be applied in PBM to craft informative, motivating, and persuasive narratives.

Logos

Applying logos requires a firm grounding in evidence-based practices. Anchoring the narrative with pertinent and true scientific facts and logical reasoning ensures that the message is compelling and credible. This approach highlights the importance of presenting data and outcomes in a manner that underscores the logical foundations of PBM, making the case for its adoption through clear and rational argumentation.

Ethos

This storytelling aspect emphasizes the value offered by PBM programs, highlighting the benefits that make PBM a vital component of patient care. The narrative seeks to align with all stakeholders’ ethical standards and responsibilities, from healthcare providers to policymakers, fostering a sense of shared purpose and commitment.

Pathos

Pathos aims to connect emotionally with the audience by centering on patient experiences and outcomes. It illustrates how PBM practices impact patient lives directly. Humanizing the data through patient stories engages the narrative, transforming statistics into a deeper understanding of PBM’s critical role in healthcare. This approach is not just about relaying information; it is about creating connections, inspiring change, and emphasizing the importance of evidence-based practices in an understandable and actionable way. It has been described in Figure 1 as a flowchart.

Figure 1 A flowchart describing how to use a storytelling framework for PBM. PBM, patient blood management.

Rationale and knowledge gap

A literature search across PubMed, Google Scholar, and CINAHL databases with the keywords “Patient Blood Management” and “Storytelling” yielded no results. A repeated search with the terms “Blood Management” and “Storytelling” also had zero results, demonstrating a gap in the literature on this topic. We present this article in accordance with the Narrative Review reporting checklist (available at https://aob.amegroups.com/article/view/10.21037/aob-24-24/rc).

Methods

Subject matter experts (SMEs) [from the Association for the Advancement of Blood and Biotherapies (AABB) Transfusion Safety and PBM Subsection] were invited to participate in the project, and initial planning was conducted through online meetings and discussions. A thorough literature search was performed, knowledge gaps identified, and a narrative review structure was prepared. A literature search with keywords including Patient Blood Management, PBM Education, Metrics, Benchmarking, program development, and other related terms was carried out to review related literature, returning 103 results (English language and limited to the last 10 years, Feb 2014 to Feb 2024). The details of the literature search carried out in PubMed are presented in a tabular format in Table 1.

Storytelling in PBM

To present complex data in accessible formats for the target audience, a range of tools and media were explored. These included peer-reviewed articles, case reports, infographics, scientific surveys, webinars, podcasts, and social media platforms. The article briefly discusses these in the context of PBM.

Scientific literature

Case studies describe the nuances related to specific individuals or groups, offering valuable insights applicable to broader populations. However, their interpretive nature often introduces subjectivity, complicating the generalizability of findings. The summary of literature review with different keywords is presented in Table 2 and the detailed article list has been uploaded as a supplementary file (available at https://cdn.amegroups.cn/static/public/aob-24-24-1.pdf). The literature review identified 29 relevant publications using the search terms “Patient Blood Management” and “case study” or “report”. After excluding two articles unrelated to either blood transfusion therapy or PBM, we categorized the remaining literature into distinct subgroups: blood transfusion management, implementation of PBM strategies, and scenarios involving the refusal of blood products or where blood is not an option. Notably, 37% of the articles focused on managing patients with allo-antibodies, of which five did not incorporate PBM strategies but centered solely on transfusion therapy. Furthermore, the term “Patient Blood Management” is often misinterpreted by healthcare professionals who are not directly involved with PBM, as reliance on blood transfusion as a primary treatment modality, deviating from its comprehensive global definition (3).

PBM success stories in managing patients with antibodies prior to surgery

In a case study focused on transfusion management, a neurosurgery patient with an anti-e (ISBT Number: 004005) antibody was effectively treated through collaborative efforts between the transfusion service, the anesthesiologist, and the surgeon. The approach involved preoperative autologous blood donation to address the patient’s specific needs (4). Similarly, in a cardiac surgery scenario involving a patient with a rare antibody, the team ensured the availability of compatible packed red blood cells (RBCs) and implemented acute normovolemic hemodilution before anesthesia. Additionally, adjustments were made to the cardiopulmonary bypass procedure to optimize the outcomes by reducing the number of transfusions required (5). In another case, various PBM strategies were implemented to successfully manage a liver transplant patient with multiple antibodies by minimizing transfusion requirements. These included preoperative erythropoietin administration, intraoperative cell salvage, antifibrinolytic drugs, and real-time coagulation monitoring using thromboelastography (6). Identifying antibodies close to the surgical date can pose challenges in obtaining compatible blood, prompting Garcia and colleagues to advocate for proactive preoperative anemia management, particularly in fast-track or enhanced recovery settings. It ensures that the patient’s RBC levels are optimized before surgery and reduces the need for transfusions (7). Although these cases initially involved the consideration of blood transfusion in response to bleeding and blood loss, the integration of PBM strategies offers additional supportive options, enhancing patient care and outcomes.

Case studies detailing patients declining blood transfusion therapy for religious reasons exemplify the application of the three pillars of PBM. These studies showcase PBM strategies and advocate for a comprehensive multidisciplinary approach to care delivery (8). Healthcare teams must navigate the complexities of determining which blood derivatives and technologies are acceptable for patients based on their religious beliefs. For instance, in Jehovah’s Witness patients undergoing major spine surgery, tools that include the Hypotension Prediction Index (HPI) have proven valuable (9). Hospitals equipped to provide sophisticated care without resorting to blood transfusion often receive patient transfers from external organizations (10).

However, while published case studies offer valuable insights, their direct impact on treating blood-refusal patients remains uncertain because these studies often involve small sample sizes or specific clinical scenarios that may not be directly generalizable to all patients. The options explored, such as anemia management, blood loss mitigation, and coagulation control, can generally be applied across various clinical contexts. Yet, the effectiveness and applicability of these options to blood-refusal patients may vary due to their unique medical and ethical considerations. Therefore, while these studies enhance our understanding, they might not fully address the complexities of treating patients who decline blood products, emphasizing the need for a specialized approach.

Another category of literature focuses on how hospitals or health systems implement PBM strategies, including intravenous iron administration (11), intraoperative techniques, and overall program integration (12). These articles typically provide data comparing outcomes before and after implementing PBM interventions. For instance, leveraging computerized physician order entry (CPOE) systems for blood product ordering has significantly reduced the number of multiple units of orders and transfusions (13). These findings can be depicted graphically in charts and tables, offering clear visualizations for easy interpretation.

Effective use of data for better storytelling

A clear and comprehensive understanding of the current state of PBM requires a compelling and well-structured organization of the available data. Institutions must carefully monitor current performance in blood utilization across multiple domains with adequate analysis of performance metrics against both external and internal benchmarks. For example, the performance of utilizing individual blood products (e.g., RBCs, plasma, platelets) with benchmarking between internal departments and hospitals within a single healthcare system can be routinely monitored. However, data must be presented eloquently and clearly, allowing institutional leadership to have compelling information and understanding of the current performance state, gaining insight into areas of success and opportunities for enhanced efforts.

To enhance the actionable elements of current data, storytelling requires complete, accurate, and current data that can be carefully analyzed for effective communication. Data analytics can be descriptive, diagnostic, predictive, and prescriptive (14).

Descriptive analysis is a simple approach—e.g., an Excel spreadsheet—where the current performance of individual variables can be compared with the identification of trends over time and relationships between data variables. For example, blood utilization may be higher in certain hospitals within a healthcare system or a specific service line. There is no further insight into the rationale for this relationship, yet it allows identifying an area for further detailed assessment using diagnostic analysis (15).

Diagnostic analysis is the statistical evaluation of the current data, allowing for deeper insight into performance. This type of analysis allows for hypothesis testing, providing direction for further efforts. A relevant concept is understanding the relationship between variables, especially correlation versus causation. Regression analysis, whether univariate or multivariate, can be performed to gain deeper insight into the characteristics and dynamics of these relationships. For example, multivariate regression in hospitals with higher blood utilization can help identify the most vulnerable population(s) associated with this outcome or the most common clinical scenarios. These data can be used in predictive analysis to forecast future behaviors.

Predictive analysis helps to understand historical data and based on their diagnostic evaluation with regression analysis, allows for forecasting future performance. For example, understanding that a certain month is associated with a spike in blood transfusions correlates with factors like the entry of new trainees into healthcare and increased sport-related deaths (e.g., motorcycle accidents during the summer). This type of analysis can ensure that during these months, efforts are implemented to educate new colleagues about conservative blood utilization strategies and ensure adequate blood bank supplies.

Prescriptive analysis utilizes all the previous strategies for data-driven decision-making, which can then be used by machine learning algorithms. For example, this data can help in Maximum Surgical Blood Order Schedule (MSBOS)—predicting the potential need for blood transfusion during specific types of surgery and customizing blood management strategies accordingly.

Storyline and data visualization

Data presentation needs a formal storyline where the learning and conclusions from the data are shared with an audience to convey a message and potential recommendations. This requires a compelling visual display and presentation of data, promoting better understanding, and audience engagement (16). These displays can be charts, visual abstracts, diagrams, etc. Less is more when it comes to visual display, and clarity in the message is fundamental. For example, a bar chart comparing blood utilization between hospitals can promote positive competition to enhance performance; similar graphics can compare performance over the years, showcasing overall improvements or opportunities.

PBM and social media

The literature on the use of social media in promoting awareness of PBM principles is limited at this time, as PBM itself is still relatively new. For example, a 2020 study in Italy found that 92.3% of nurses agreed there should be wide dissemination of knowledge about PBM, and 86.6% felt continuous training would be useful to nursing. The same study also revealed that 64.3% of the surveyed nurses were unaware of the PBM program (17). However, most respondents were unaware of PBM concepts. Currently, most articles focus on promoting the importance of blood donation using social media. Encouraging blood donation is an important aspect of providing blood within a hospital, in line with PBM principles of transfusing blood only to those who need it. However, social media users might be confused if these sites also provide PBM information. Blood donation collection facilities tend to work with many younger, tech-savvy volunteers to spread the message about the importance of blood donation. However, social media has issues creating sustained change due to its nature and engagement patterns. Social media sites provide brief content disseminated through an algorithm that analyzes page views and duration. Thus, any social media campaign focused on promoting PBM principles would have to create engaging, frequently updated, search-engine-optimized (SEO) content. Even the most avid social media user is unlikely to continue engaging with a page unless there is continually updated new content. The niche knowledge of PBM may make it difficult for the algorithm to disseminate information on PBM, except to those already interested in the subject.

One study from Brazil illustrates these issues (18). From 2016–2020, evidence-based pop-up cards were created focusing on the most frequent incorrect indications for RBC transfusions, such as transfusion for stable iron-deficient patients or reaching a target hemoglobin of >9 g/dL. Another practice was the routine prescription of two units of RBCs without an intervening clinical assessment. These cards were sent through WhatsApp, Facebook, and Instagram to various medical and health professional student groups and intra-hospital transfusion committees. As the project grew, the authors made additional content reinforcing PBM lessons, such as short educational videos, infographics, and presentations. The content was updated whenever new situations were identified, or new evidence in transfusion medicine became available. Overall, they identified a trend of reduced RBC transfusions and increased single-unit transfusions in Ceara, Brazil. However, due to the nature of social media, it is difficult to correlate these findings with engagement with the content. At its height in 2021, there were 8,000 members of the group, but the study could not distinguish active users from those who had registered but no longer visited. A social media campaign may be one tool that PBM proponents could use to disseminate education on best transfusion practices. Other resources like highlighting PBM success stories on a hospital website’s front page or targeted education to house staff may have longer-lasting effects. One area where social media may benefit PBM is targeted social media groups.

The initial formation of a PBM group is often similar across different sites. Usually, a few healthcare practitioners develop an interest in PBM, after which they then work to put together a formal PBM committee by gathering the appropriate SMEs and stakeholders. This often creates a sense of urgency around PBM from promoting the (in)availability of blood, the (un)safety of the available blood, or the (high) cost of acquiring a unit of blood (19). The first few individuals or the committee may then seek additional support from high-level administrators about the value of PBM, so they are given the authority to propose change. Finally, the committee oversees transfusion practices within a hospital and provides targeted education based on utilization patterns. Additional phases of the PBM pathway include creating and communicating a vision of PBM within the organization, adopting short-term wins, and embedding PBM practices within the culture. At each step, obstacles and barriers exist to overcome, from identifying appropriate SMEs to sit on the committee, to showcasing the value to the C-suite. Given the shared experience in the initial formulation of a hospital PBM group, a social media site could be an important resource. These platforms could serve as repositories for important PBM information, such as foundational PBM articles, order set templates, cost analysis savings from other hospitals, and focal points for new developments in PBM. More importantly, these platforms fill a critical unmet need; they would be a gathering point for proponents of PBM to collaborate and share ideas at all stages of a PBM program’s development. Having such a resource may help proponents of PBM to navigate the difficulties and barriers to establishing a solid PBM program more effectively than an individualized approach.

A PBM user group could provide practical tips, emotional support, and a roadmap to the journey ahead (20). Such a site could be a library of information and a focal point for discussing various PBM projects across the country, lessons learned, and successful implementations. One notable podcast that is a good source of up-to-date information about PBM is “Let’s Talk Patient Blood Management”, hosted by MaryAnn Sromoski and Sarah Wolbot (21). Other single episodes of podcasts from “The Blood Bank Guy” (22) and “Take 5: Blood Transfusion” from the Joint Commission (23) also offer important perspectives on PBM. Other technology-focused approaches to promoting PBM within a hospital include the development of a short animation with a focus on PBM principles (24). However, a limitation is the lack of awareness of these resources, as well as the differences and preferences of each type of learner—e.g., visual, auditory, etc. Creating PBM “bundles”, which represent “a straightforward set of evidence-based interventions for a defined patient population that, when implemented together, will result in significantly better, more penetrating, and sustainable outcomes than when implemented individually”, has also shown success in the United Kingdom (UK) (25).

Role of educational tools and surveys

Evidence shows physicians lack adequate transfusion medicine knowledge, which greatly contributes to the overutilization of blood products (26). Therefore, educational tools and surveys are crucial in developing, supporting, and maintaining a successful PBM program.

Educational tools can take various forms, such as online modules, training sessions, workshops, and printed materials. They are designed to educate healthcare professionals, including physicians, nurses, and laboratory technical staff, about the latest guidelines, techniques, and best practices in blood transfusion and PBM. Many online resources exist to access education and information about PBM. These include but are not limited to the AABB PBM Toolkit (27), which hosts a collection of PBM articles, textbooks, and posters covering various PBM topics as well as clinical practice guidelines; The Joint Commission (28), which provides information on PBM Certification (a joint project with AABB); Society for the Advancement of Patient Blood Management (SABM) (29), which hosts various presentations covering aspects of PBM; the International Society of Blood Transfusion (ISBT) (30); and the World Health Organization (WHO) (31), which posted its Policy Brief titled “The Urgent Need to Implement Patient Blood Management”; among others. Published case reports and educational case studies (i.e., fictional cases discussing the principles of PBM) also serve as resources for PBM education (32). However, a major problem with these passive learning resources is that providers (i.e., physicians, residents and fellows, physician assistants, nurses, etc.) do not typically engage these sources and as a result do not gain any benefit in terms of PBM education.

Nonetheless, in quality improvement implementation, educational interventions are often considered of low strength and durability. Therefore, the emphasis on personalized storytelling and case-based teaching can make PBM education more direct, relevant, and interesting to learners with consequent enhanced impact and effectiveness. Thus, active forms of PBM education are necessary to communicate with providers. Implementation of a computer-physician order entry with a clinical decision support system (CPOE-CDSS) is one such tool that provides best practice alerts (BPAs), which actively engage providers and direct them to follow PBM principles, such as single-unit RBC orders instead of routine two-unit orders, as well as adhering to clinical practice guidelines recommending a transfusion threshold of 7 g/dL for anemia management in most cases (33). Leveraging the CPOE-CDSS is a very robust human factors engineering strategy to have a more direct influence on clinical decision-making (34). Direct communication with providers who order blood product transfusions is another essential means of educating them. Although labor-intensive and potentially confrontational, prospective audits of blood product orders, that is, engaging providers who order transfusions that do not meet clinical practice guidelines before issuing the blood products, provide direct communication to discuss PBM principles (35). Nevertheless, one study utilized qualitative research methodology to evaluate current transfusion education among junior doctors in the UK and found that reliance on online learning and on-the-job training was insufficient for ensuring safe transfusion practices. The authors recommended face-to-face and simulation-based training reflecting real-life scenarios, continuous education throughout a physician’s career, and better evaluation methods for educational programs and decision-support tools to promote evidence-based transfusion practices effectively (36).

Periodic surveys to assess transfusion medicine knowledge and PBM protocols across a healthcare system are other means to promote best practices and reduce the overutilization of blood products (26). Developing key performance measures and benchmarking to provide critical feedback to providers are other important strategies for PBM education and improvement (37). Finally, just as important as monitoring for overutilization, monitoring for blood product underutilization, although typically less problematic, is good practice in a well-established PBM program. For example, a program may audit orders for plasma transfusions that were not based on weight (i.e., 10–15 mL/kg), especially single-unit plasma orders, many of which will be underdosed or unnecessary transfusions (38). Cryoprecipitate transfusions for fibrinogen replacement in select patients, such as those undergoing extracorporeal membrane oxygenation (ECMO), may also be a source of underutilization to be aware of (39).

Challenges in storytelling in PBM

For storytelling to be effective, it must be clear, understandable, relatable, and applicable to the intended audience. Certain challenges may preclude the persuasiveness of the story, making it imperative to identify and overcome these challenges when implementing successful PBM programs or strategies. First, as PBM initiatives commence globally, challenges may arise if there are inconsistencies in the terminology and definitions used across clinical departments, hospitals, or countries. Common definitions allow for a clear and shared understanding of concepts, multidisciplinary application of strategies, and, once established, ease of growth and evolution. Acknowledging this, in 2022, a group of international experts sought to establish a global definition of PBM as “a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient’s own blood, while promoting patient safety and empowerment” (3). The publication also provided a glossary of terms with definitions and a “PBM toolbox” to address anemia, blood loss, and coagulation. Commonly used definitions help facilitate PBM implementation and encourage interdepartmental and international collaboration. A second challenge in storytelling is using appropriate language and determining the need for translation or interpretation.

The global PBM definition emphasizes a patient-centered approach to maintaining patient safety through good clinical practice while acknowledging and adhering to the patient’s values and preferences. Therefore, the challenge lies in the language used in patient-centered discussions, which often differs from that used among healthcare providers. This language is even more important when coordinating care with those who chose not to receive blood products (i.e., Jehovah’s Witnesses). As part of PBM, bloodless medicine/blood conservation programs have been developed to provide equal access to healthcare tailored to patients whose religious or personal values prohibit the receipt of allogeneic blood transfusion. Many programs attribute their success to team members (i.e., nurses or care coordinators), who are also of the Jehovah’s Witnesses faith and can “speak the language”. These personnel understand the belief system behind the transfusion restrictions and can conduct efficient patient-centered conversations through translation and interpretation of medical needs into a language the patient understands to establish the best possible care plan. In these situations, an appropriate storyteller who speaks the language can promote and simplify historically challenging conversations in healthcare.

A final challenge is ensuring that the story’s message applies to the intended audience. There are many effective PBM strategies available, ranging from inexpensive treatments for preoperative anemia (i.e., iron, folate, vitamin B12 repletion) to more expensive anesthesia or surgical techniques (i.e., blood salvage, ultrasonic scalpel, minimally invasive robotic surgery) or novel automated data collection technologies (e.g., PBM data system). Although in high-income countries (HIC), large academic medical centers and bloodless medicine programs may have access to various strategies, these resources are often limited or inaccessible in low- and middle-income countries (LMIC). Many LMIC countries face challenges in maintaining adequate and safe blood supplies, with insufficient inventories resulting in delays or hurdles to safe and adequate transfusion (40). Considering these challenges, resource-limited settings may benefit substantially from establishing PBM programs and reducing the demand for blood while treating anemia through other options. Therefore, when using storytelling, it is important to tell a story with available implementation strategies that can be heard and applied to all those who may benefit.

Strength and limitations of the review

One of the key strengths of this review is its identification of a significant gap in the literature concerning the use of storytelling within PBM, highlighting the need for further research in this area. The review explores both, traditional methods such as scientific literature, and newer modes like social media, websites and podcasts. While various tools that can be utilized for this purpose have been discussed, this article has not addressed the development of tailored storytelling frameworks for various audiences, which is an important limitation of this article.

Conclusions

Integrating storytelling as a component of PBM facilitates better understanding and engagement and drives meaningful change in patient care. Effective data presentation through descriptive, diagnostic, predictive, and prescriptive analysis is crucial for enhancing understanding and driving the adoption of PBM practices. Social media participation in PBM education will also provide the impetus to this cause. Efforts to develop and disseminate effective PBM strategies through storytelling will be pivotal in improving patient outcomes and healthcare practices worldwide. By leveraging the power of narrative, we can foster a more informed, engaged, and proactive healthcare environment, ultimately enhancing patient safety and optimizing the use of blood resources.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Blood for the series “Patient Blood Management’s Role in Current Healthcare Environment”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aob.amegroups.org/article/view/10.21037/aob-24-24/rc

Peer Review File: Available at https://aob.amegroups.org/article/view/10.21037/aob-24-24/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aob.amegroups.com/article/view/10.21037/aob-24-24/coif). The series “Patient Blood Management’s Role in Current Healthcare Environment” was commissioned by the editorial office without any funding or sponsorship. R.G. served as the unpaid Guest Editor of the series. M.F. serves as an unpaid editorial board member of Annals of Blood from November 2024 to October 2026. C.L.C. reports Mayo Consultant reimbursement fund for attending meetings. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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