A content-validated framework for a patient blood management toolkit for South Africa: A mixed-methods e-Delphi study

South African hospitals face a high anaemia burden, variable access to patient blood management (PBM) modalities and uneven adoption of evidence-informed transfusion practice. Pragmatic, context-appropriate tools are needed to standardise practice and support implementation.

We conducted semi-structured interviews with PBM champions (n = 16, across six provinces in South Africa) to generate candidate toolkit items, then validated these via a three-round e-Delphi with a panel of 11 subject experts. Items were rated on a 3-point Likert scale (1 = Essential; 2 = Useful; 3 = Unnecessary). Consensus was defined as ≥80% of the panel selecting the same option. Stability was defined as ≤20% (two or fewer) panellists who changed their response by Round 3.

Round 1 included 793 statements; consensus was reached on 49.1% of items. Round 2 presented 400 non-consensus statements remaining after Round 1, and an additional set reached consensus, raising the cumulative total to 72.5%. Round 3 included 214 statements; by the end of Round 3, cumulative consensus was 88.1%. A further 10.8% of items met the predefined stability criterion without reaching consensus. Only eight items were unresolved.

This mixed-methods process yielded a context-aware PBM toolkit framework for South Africa. It prioritises pre-operative anaemia optimisation, restrictive transfusion practice, standardised peri-operative haemorrhage protocols, fit-for-purpose education and practical monitoring and accountability tools with clear ownership.