This article is open access

and can be freely distributed

Clinical Practice Keywords Haemophilia/Clotting/

Bleeding/Factor replacement therapy
Review
Haematology This article has been
double-blind peer reviewed

In this article...
● C
 auses of haemophilia and how it affects patients
● Current treatments and future developments
● Nurse’s role in supporting people with haemophilia

Haemophilia: diagnosis, management

and nursing care of patients
Key points
Author Kate Khair is consultant nurse and clinical academic careers fellow, Great
Congenital Ormond Street Hospital.
haemophilia is a
lifelong, inherited Abstract Haemophilia is a rare bleeding disorder associated with a lack of coagulation
bleeding disorder factor VIII (type A) or IX (type B). Haemophilia A is the most common, affecting 1 in
NT SELF- associated with a 5,000 male births. The hallmark of severe haemophilia is recurrent and spontaneous
ASSESSMENT lack of clotting joint bleeds, which can cause permanent joint damage and bleeding in other
Test your factor locations, such as the skull; they can be life threatening. However, recombinant
knowledge. clotting factor and non-factor replacement therapies are transforming the outlook for
After reading this There are two main people with haemophilia, and more people are living with the disorder into old age.
article go to
types of This article describes haemophilia and its management.
nursingtimes.net/
NTSAHaemophilia
haemophilia, which
If you score 80% have identical Citation Khair K (2021) Haemophilia: diagnosis, management and nursing care of
or more, you will symptoms, but patients. Nursing Times [online]; 117: 10, 34-38.
receive a certificate treatment depends

A
that you can use
on which clotting
as revalidation
evidence. factor is missing dvances in the treatment and and 1980s – is still being felt, highlighted
care of haemophilia have by the revelations of an ongoing public
The hallmark of transformed this rare bleeding inquiry (infectedbloodinquiry.org.uk).
severe haemophilia disorder from a fatal disease Described as “the worst treatment disaster
is recurrent and into a long-term condition, with which in NHS history” (Reed, 2021), it led to more
spontaneous joint people are increasingly living into old age. than 3,000 deaths from hepatitis and HIV
bleeds which, if left However, the legacy of the contaminated in people with blood disorders. The UK
untreated, can cause blood scandal – in which around 5,000 began using recombinant (manufactured)
deformity people with haemophilia and other blood clotting therapies in the late 1990s, guar-
disorders in the UK were infected with anteeing such a tragedy will never happen
Some bleeds, such contaminated blood products in the 1970s again, but it took over 30 years to launch an
as those in the skull independent public inquiry into the
and soft tissue scandal (Bit.ly/THSMHSupport).
around airways or
other internal What is haemophilia?
organs, can be life Haemophilia is a rare bleeding disorder in
threatening which the body does not produce enough
of a protein that helps the blood to clot.
Recombinant There are two main types:
clotting factor and ● Haemophilia A – caused by deficiency
non-factor of the functional plasma clotting
replacement factor VIII;
therapies mean ● Haemophilia B (also known as
more people with Christmas disease, after the first
haemophilia are patient diagnosed) – caused by
living into old age Protests over “the worst treatment disaster deficiency of the functional plasma
ALAMY

in NHS history” clotting factor IX.

Nursing Times [online] October 2021 / Vol 117 Issue 10 34 www.nursingtimes.net
 This article is open access
and can be freely distributed

Clinical Practice
Review

Congenital haemophilia
Most haemophilia is congenital, caused by
an inherited X chromosome genetic muta-
tion that mainly occurs in males, although
female carriers may have mild, or rarely
severe, bleeding symptoms (Bit.ly/NORD-
HemophiliaA). People with haemophilia
usually have a family history of the dis-
order, but around a third of males diag-
nosed have no family history due to a
spontaneous mutation in the female line
that has not been inherited by a male
family member before (Srivastava et al,
2020; Khair, 2019).

Who is affected by congenital haemophilia?

There are an estimated 10,000 people with
haemophilia in the UK (Khair, 2019). Hae-
mophilia A is the most common type,
affecting around 1 in 5,000 male births,
with around 60% experiencing a severe
form; haemophilia B is less common, Legs of an 18-year-old with haemophilia and bleeding in the knee joint after surgery
affecting around 1 in 25,000 male births
(Khair, 2019; Bit.ly/NORDHemophiliaA). percentage of circulating factor in the
Around 20% of people with mild blood compared with normal levels:
haemophilia are women; moderate-to- ● Severe (less than 1%) – this causes
severe forms in women are rare (Bit.ly/ frequent bleeding, often for no
HaemophiliaFemale). apparent reason, most commonly in
the joints or muscles;
Acquired haemophilia ● Moderate (1% to 5%) – this is associated
Haemophilia can also be an acquired con- with less-frequent bleeding, which is
dition that is not caused by a genetic usually not spontaneous but can be
defect. This is a rarer and lesser-known prolonged after injury, surgery or a
condition in which people with previously dental procedure;
normal haemostasis (clotting) develop ● Mild (6% to 40%) – this causes bleeding
autoantibodies (inhibitors) against clot- that is usually only prolonged after
ting factors, most frequently factor VIII injury or surgery and may never be
(Kruse-Jarres et al, 2017). It occurs mostly spontaneous (Srivastava et al, 2020;
in frail, older people but can occasionally Makris et al, 2018; The Haemophilia
be associated with pregnancy, particularly Bleeding in the knee joint can occur Society, 2017).
occurring post partum, and with autoim- spontaneously in patients with haemophilia Haemorrhage is a main cause of mor-
mune disease in younger people. In around bidity and death in people with haemo-
half of all cases, it has no known cause; in is associated with a high mortality risk due philia, although infectious diseases from
others, it is associated with malignancy, to underlying comorbidities, bleeding or contaminated blood products have fea-
autoimmune disorders and other condi- treatment. The main treatment is haemo- tured prominently in recent decades, par-
tions (Kruse-Jarres et al, 2017; Bit.ly/NORD- static management and eradicating inhibi- ticularly in people treated with clotting
HemophiliaA). tors; recommendations for management factors before 1985 (Darby et al, 1995).
People with acquired haemophilia are provided in Kruse-Jarres et al’s (2017) Without treatment, the prognosis is poor;
develop potentially life-threatening com- consensus paper. Although acquired hae- however, the development of recombinant
plications associated with abnormal, mophilia is estimated to account for at clotting-factor replacement therapies and
uncontrolled bleeding that is often sponta- least a third of all haemophilia cases, it is non-factor replacement therapy has
neous and severe (Kruse-Jarres et al, 2017). likely that it is underdiagnosed and misdi- recently improved the outlook for patients
This includes bleeding into the muscles, agnosed in real-world clinical practice (Khair, 2019).
skin and soft tissue, as well as during sur- (Kruse-Jarres et al, 2017).
gery or after trauma. Symptoms of Diagnosis
acquired haemophilia include nosebleeds, Clinical features When there is a family history of haemo-
bruising, haematomas (solid swellings of Haemophilia A and B have the same clin- philia, the disorder will be suspected and
congealed blood), blood in the urine and ical features, although treatment depends diagnosed before, at, or soon after birth. If
gastrointestinal or urogenital bleeding on which clotting factor is missing and the there is no family history or the family is
(Bit.ly/NORDHemophiliaA). severity of symptoms (The Haemophilia unaware of it (for example, if recent gener-
SPL, ALAMY

Acquired haemophilia in frail, older Society, 2017). There are three levels of ations have only included female carriers),
people can be challenging to manage and severity (phenotypes), defined by the diagnosis will only be made when bleeding

Nursing Times [online] October 2021 / Vol 117 Issue 10 35 www.nursingtimes.net
 This article is open access
and can be freely distributed

Clinical Practice
Review

Box 1. Common types of bleed in congenital haemophilia ● Prophylactically – replacement therapy

is given regularly to prevent bleeding
● Newborn – birth trauma, immunisation, circumcision, heel pricks and long-term damage caused by
● Toddler – bruising, buttocks, scrotum, mouth, head trauma bleeding into joints and muscles, and
● Pre-school and school age – joints and muscles (particularly ankles, knees, elbows) bleeding from minor injuries. This is
● Adolescents and adults – joints and muscles (particularly ankles, knees, elbows), mainly used for children and some
sometimes more-serious muscle bleeds (such as in the iliopsoas related to sexual adults with severe haemophilia and
activity), heavy menstrual bleeding in young women some with moderate haemophilia who
Source: Bit.ly/RareBleeding
have frequent bleeding problems;
● On demand – replacement therapy is
given to stop bleeding when it occurs.
problems arise. Most cases of severe hae- Box 2. Treating acute bleeds This is generally used for people with
mophilia are diagnosed in the first year of mild-to-moderate haemophilia, very
life, but mild or even moderate cases may World Federation of Haemophilia young children and some adults with
not be diagnosed for years, possibly into guidelines (Srivastava et al, 2020) severe haemophilia who choose not to
adulthood, usually following prolonged recommend immediate treatment of take prophylaxis (The Haemophilia
bleeding after injury or as a complication acute bleeds – ideally within two hours Society, 2017).
of surgery or dental treatment. – and say that in “severe bleeding International guidelines from the WFH
Diagnostic investigations include: episodes that are potentially life (2013) recommend prophylaxis for severe
● Patient history; threatening, especially in the head, neck, haemophilia, although patients who dis-
● Signs and symptoms of bleeding; chest and gastrointestinal tract, like regular infusions may prefer treatment
● Family history of bleeding; treatment with factor should be initiated on demand (Bit.ly/HaemophiliaTreat).
● Blood tests, including coagulation immediately, even before diagnostic Prophylaxis is especially important in
screening and factor levels, to confirm assessment is completed”. children, because their articular cartilage
diagnosis. Close coordination with the specialist is more vulnerable to permanent damage;
haematology team is needed, and it is usually started at around the age of
Signs and symptoms additional support can include rest, ice, one, after the first or second joint bleed
Haemophilia should be suspected in compression and elevation (Srivastava (Khair, 2019). Infusions are usually three
people presenting with a history of: et al, 2020). Pain management should times a week for haemophilia A, and twice
● Easy bruising in early childhood; also be part of any treatment plan, a week for haemophilia B; patients and
● Spontaneous bleeding for no apparent avoiding medicines containing aspirin or carers learn to administer them at home.
or known reason, particularly into the non-steroidal anti-inflammatories. For very young children, or children whose
joints, muscles and soft tissues; veins are difficult to access, this can often
● Excessive bleeding after trauma or necessitate a central venous access device
surgery (Srivastava et al, 2020). adulthood, hypertension and increasing (Khair, 2019).
Common types of bleed in people with age are also associated with ICH (Zanon Minor bleeds can often be treated at
congenital haemophilia are shown in and Pasca, 2019). Other bleeding episodes home, but acute bleeds need to be man-
Box 1. The hallmark of severe haemophilia requiring prompt treatment include: aged in hospital; the treatment for acute
is recurrent and spontaneous joint bleeds ● Nerve compression from bleeding in bleeds is outlined in Box 2. More than one
that, left untreated, can result in crippling deep muscles, such as the iliopsoas infusion may be needed, depending on the
deformity (Khair, 2019). These usually (inner hip muscle), often presenting as site and severity of the bleed (The Haemo-
appear when young children begin numbness and pins and needles; philia Society, 2017). People with mild-to-
walking and moving around; the first signs ● Haematuria (blood in the urine); moderate haemophilia can sometimes
can be discomfort and crying, along with ● Deep lacerations; bleed as much as those with severe haemo-
limping or reluctance to use the affected ● Epistaxis (acute nasal haemorrhage); philia, who usually have their bleeding
limb (Khair, 2019; The Haemophilia ● Bleeding from the mouth or tongue controlled by prophylaxis. However,
Society, 2017). The joint may be swollen, (Khair, 2019; Butler, 2012). patients having prophylaxis may still have
warm and difficult to straighten, but with Affected women can present with all of bleeds that require extra factor infusions,
no external discolouration or bruising these symptoms as well as heavy men- particularly after injuries.
(Srivastava et al, 2020; Khair, 2019; The strual bleeding (Hirayama et al, 2019). People with haemophilia who are about
Haemophilia Society, 2017). to undergo a surgical or dental procedure
Bleeds can also occur elsewhere in the Treatment may need extra treatment, including factor
body, and complications depend on the The mainstay of treatment for haemo- infusions or other haemostatic agents.
affected site: bleeds into the head, neck, philia is preventing and managing
abdomen or gastrointestinal tract are life bleeding episodes by replacing the missing Extended half-life treatments
threatening and must be treated as an clotting factor in the blood. A newer type of factor replacement
emergency (Butler, 2012). Intracranial therapy uses extended half-life factors, in
haemorrhage (ICH) is a particular concern Standard factor replacement therapy which the factor molecule has been modi-
in babies and young children, as it can This involves an intravenous infusion of fied by the addition of stabilising mole-
cause seizures and paralysis, and remains a recombinant factor VIII (for haemo- cules, which extend the half-life of the
significant cause of morbidity and mor- philia A) or factor IX (for haemophilia B), infused factor. These can last longer in the
tality after birth trauma (Khair, 2019). In delivered in one of two regimens: bloodstream than standard factor, so

Nursing Times [online] October 2021 / Vol 117 Issue 10 36 www.nursingtimes.net
 This article is open access
and can be freely distributed

Clinical Practice For more articles

on haematology, go to
Review nursingtimes.net/haematology

prophylactic infusions can be given less Tranexamic acid and can result in chronic joint disease,
frequently: This drug helps hold a clot in place once it functional impairment and disability
● Twice a week for haemophilia A; has formed, and is helpful for mouth (Khair, 2019). Bleeding into joints is a par-
● Weekly or fortnightly for bleeds, nosebleeds and heavy menstrua- ticular problem, as it can damage the syn-
haemophilia B. tion (The Haemophilia Society, 2017). ovium (joint lining), cartilage and sur-
The reduced frequency of infusions and Given as a liquid, tablet or mouthwash, it rounding tendons and tissues, leading to
increased levels of factor can decrease the is often used with clotting factor or desm- arthritic pain and reduced joint movement
treatment burden (Khair et al, 2019). Bleeds opressin. and strength (Nacca et al, 2017).
can also be controlled more quickly, often Older people with haemophilia are likely
requiring only a single infusion. “[In] the contaminated to have joint damage, due to limited access

Emicizumab blood scandal around 5,000 to treatment when they were young, and
often require orthopaedic surgery. Prophy-
Emicizumab is a non-factor replacement people with haemophilia laxis and prompt treatment of bleeds means
therapy used for haemophilia A. It is injected and other blood disorders children often now reach skeletal maturity
subcutaneously to prevent or reduce
bleeding episodes, but is not used to treat
in the UK were infected with well-preserved joint function,
although most people with severe haemo-
bleeding (Bit.ly/HaemophiliaNonFactor). with contaminated blood philia still experience joint problems at
The first commercially available product products” some stage. Hanley et al’s (2017) best-prac-
in a new generation of bypassing agents, it tice guidance for managing acute joint
is a monoclonal antibody that works by Complications bleeds and chronic synovitis was published
bridging activated factor IX and X to Haemophilia can have many short- and by the United Kingdom Haemophilia
restore the function of the missing acti- long-term complications; the main ones Centre Doctors’ Organisation.
vated factor VIII needed for effective blood are discussed below.
clotting (Bit.ly/NICEEmicizumab). Infection-related complications
Emicizumab is available in the UK for Inhibitors Improved blood-donor screening in man-
people with severe haemophilia A with The development of antibodies (inhibi- ufacturing plasma-derived products and
and without antibodies. It can revolu- tors) to clotting factor replacement thera- the switch to recombinant clotting factors
tionise care: treatment is a subcutaneous pies is the main complication of contem- has virtually eliminated the risk of transfu-
injection, given once weekly for the first porary care; it occurs in around 14% of sion-transmitted infections in the UK.
four weeks, and then weekly, fortnightly or people with haemophilia A and 2% of those However, there are still patients living
every four weeks in the maintenance phase with haemophilia B (Khair, 2019). Inhibi- with the long-term health effects of trans-
(Khair, 2019). As more people with haemo- tors prevent clotting factor from working, fusion-transmitted viruses and their treat-
philia survive into old age, emicizumab is mainly affecting people with severe hae- ments, and the psychological effect on the
also useful for treating people who mophilia A. families involved is only just being
struggle with repeated venous access or When they arise, inhibitors commonly acknowledged (Bit.ly/THSMHSupport).
who are no longer able to self-infuse, such develop during the first 50 treatment days,
as those in residential care homes who and usually in the first 20 days. This means Life-threatening complications
have congenital haemophilia. that, in people with severe haemophilia A, The most critical life-threatening compli-
In the UK, only a haemophilia compre- inhibitors generally appear in childhood, cations of haemophilia are:
hensive care centre can prescribe emici- while in those with mild-to-moderate ● Bleeding in the skull;
zumab and care is needed when co-infusing forms they tend to develop later in ● Haemorrhages in the soft tissue around
it with other treatments because of poten- life (Bit.ly/HaemophiliaBleeding). Periodic airways or other internal organs.
tial thrombotic side-effects (Khair, 2019). screening for inhibitors should be part of Spontaneous ICH occurs in up to 8% of
haemophilia care; patients also need people with haemophilia, and around 30%
Desmopressin screening before any surgical procedure, of those will die from it (Hegde et al, 2016).
Desmopressin stimulates the release of von including dental work.
Willebrand factor from endothelial cells by Treatment of inhibitors includes: Patient care
acting on the V2 receptor; it is used to: ● Attempting to eradicate the underlying All UK patients diagnosed with haemo-
● Control minor bleeding episodes in antibody by building up immune philia should be registered with a haemo-
people with milder forms of tolerance through regular exposure to philia comprehensive care centre that pro-
haemophilia; high doses of coagulation factor vides core multidisciplinary care from
● Help prevent bleeding associated with (immune tolerance induction); doctors, nurses, physiotherapists, psy-
minor operations, including dentistry ● Treating bleeding episodes with chosocial carers and coagulation labora-
(Haemophilia Society, 2017). infusions of bypassing agents factor tory staff, who liaise with non-haemo-
It is injected subcutaneously but can VIIa or activated prothrombin complex philia specialists – including dentists and
also be delivered intravenously or as a nasal concentrate (Khair, 2019); surgeons – when necessary. People with
spray. Side-effects include hyponatraemia ● Prophylaxis with emicizumab. haemophilia carry a bleeding disorder
(low sodium levels) and seizures; fluid information card and have all aspects of
retention can also occur, and patients are Joint and muscle damage their care coordinated by their specialist
asked to restrict fluids after treatment. Its Damage to muscles and joints caused by haemophilia team, even when care is
use is not recommended for children aged serious or repeated bleeding is a main delivered in other settings (Srivastava et
under two years (Khair, 2019). cause of morbidity in severe haemophilia, al, 2020).

Nursing Times [online] October 2021 / Vol 117 Issue 10 37 www.nursingtimes.net
 This article is open access
and can be freely distributed

Clinical Practice
Review

The nurse’s role diagnosis of haemophilia does not exclude Haemophilia Centre Doctors’ Organisation
(UKHCDO) guideline. Haemophilia; 23: 4, 511-520.
Clinical nurse specialists in haemophilia the possibility of non-accidental injury Hegde A et al (2016) Spontaneous intracerebral
practice at advanced levels have a pivotal and, if there is concern, usual child-pro- hemorrhage in hemophiliacs – a treatment
role in comprehensive care as part of the tection procedures should be followed. dilemma. International Journal of Surgery Case
Reports; 29: 17-19.
multidisciplinary team, including pro- Hirayama AB et al (2019) Prevalence of symptoms
moting evidence-based care, advocacy and
self-management skills for people with
“All UK patients diagnosed in hemophilia carriers in comparison with the
general population: a systematic review.
haemophilia (Khair et al, 2014). The with haemophilia should Hematology, Transfusion and Cell Therapy; 41: 4,
349-355.
changing role of the specialist nurse is dis- be registered with a Khair K (2021) The changing role of the specialist
cussed in detail by Khair (2021). haemophilia comprehensive haemophilia nurse. Nursing Times [online]; 117: 9,
50-52.
Nurses and other health professionals
should liaise with the specialist haemo- care centre that provides Khair K (2019) Management of haemophilia in
children. Paediatrics and Child Health; 29: 8,
philia team about all aspects of care for core multidisciplinary care” 334-338.
Khair K et al (2019) HOw patients view Extended
patients with haemophilia, regardless of half-life products: impressions from real-world
the care setting or how patients present. Moving forward experience (the HOPE study). Haemophilia; 25: 5,
The increase in modified factor products Current treatment with prophylactic 814-820.
Khair K et al (2014) A core competency framework
and alternative treatments means not all factor replacement in severe haemophilia for haemophilia nurses in the UK. The Journal of
patients are treated with standard clotting reduces the frequency of bleeding and Haemophilia Practice; 1: 1, 32-36.
Kruse-Jarres R et al (2017) Acquired haemophilia
factors (VIII and IX), and the patient’s spe- improves patients’ quality of life. Use of A: updated review of evidence and treatment
cialist haemophilia team can advise. modified factor products and alternative guidance. American Journal of Hemotology; 92: 7,
In haemophilia, bleeding is often treatment options is reducing the burden 695-705.
Makris M et al (2018) The definition, diagnosis and
internal, and nurses need to be able to rec- of treatment for some patients with hae- management of mild hemophilia A: communication
ognise the signs. In addition, it is impor- mophilia, and has the potential to improve from the SSC of the ISTH. Journal of Thrombosis
tant to be aware that older people with patient adherence and outcomes, although and Haemostasis; 16: 12, 2530-2533.
Nacca CR et al (2017) Hemophilic arthropathy.
mild-to-moderate haemophilia may not some challenges remain (Nogami and Orthopedics; 40: 6, e940-e946.
bleed often enough to develop the skills to Shima, 2019). Nogami K, Shima M (2019) New therapies using
self-treat at home, or may be reluctant to Like emicizumab, which disrupts coag- nonfactor products for patients with hemophilia
and inhibitors. Blood; 133: 5, 399-406.
learn; this means they might present more ulation, there are other molecules in early Reed J (2021) Contaminated blood inquiry: the
often at hospital with bleeds than people clinical trials that may impact on future school where dozens of pupils died. bbc.co.uk,
who have severe haemophilia. haemophilia care. Although these are, so 21 June.
Srivastava A et al (2020) WFH Guidelines for the
Patients with haemophilia who are on far, only in trials in adults, they show some Management of Hemophilia, 3rd edition.
surgical wards will need infusions to pre- promise for other subcutaneous treatment. Haemophilia.; 26 Suppl 6: 1-158.
vent potentially life-threatening bleeds. Gene therapy may provide another Zanon E, Pasca S (2019) Intracranial haemorrhage
in children and adults with haemophilia A and B: a
Pain management is also more complex – alternative. This works by delivering the literature review of the last 20 years. Blood
non-steroid anti-inflammatory drugs gene to make the missing factor, although Transfusion; 17: 5, 378-384.
cannot be used because they make the person will still be a carrier of the
bleeding worse. Nurses caring for patients mutated gene (Bit.ly/HaemophiliaGene).
with haemophilia must refer to the spe- Clinical trials for gene therapy in severe
Are you making the
cialist haemophilia team. haemophilia have been extremely suc-
most of Nursing Times?
Toddlers and young children pre- cessful, and one company has applied to
Nursing Times subscribers have
senting with problems in weight-bearing the European Medicines Agency and US unlimited online access to:
joints can be in severe pain; if a child is dis- Food and Drug Administration for licen-
tressed, screaming and unwilling to use sure for routine clinical use. All this adds ● Over 6,000 double-blind peer
the affected limb, nurses should not up to a brighter outlook for people with reviewed articles, published since
2000
attempt to pull it straight to demonstrate haemophilia; however, those who live for
mobility. Any child with haemophilia pre- longer with the disease will present with ● Clinical zones collating content
senting at the emergency department with new and different challenges and it will be relevant to over 60 clinical specialties
and nursing role
a head injury should be fast-tracked and important to understand how to manage
not go through the usual triage. haemophilia in frail, older people with sig- ● Print-friendly PDFs to download
Children who have severe haemophilia nificant comorbidities. NT ● An innovations hub offering inspiration
may need a central venous access device for service improvements
for prophylactic infusions; this can pose References ● User-friendly online learning on key
Butler RB (2012) Introduction to Bleeding
an infection risk and care may fall under nursing topics
Disorders. National Haemophilia Foundation.
that of the community paediatric team. A Darby SC et al (1995) Mortality before and after ● Self-assessments for selected articles,
history of bruising and bleeds in children HIV infection in the complete UK population of providing bite-size CPD
haemophiliacs. UK Haemophilia Centre Directors’
who have not been diagnosed with haemo- ● Journal club support for selected
Organisation. Nature; 377: 6544, 79-82.
philia – particularly when there is no The Haemophilia Society (2018) Initial Diagnosis: articles, providing participatory CPD
family history – can raise safeguarding Understanding the Experience. THS. ● A personal online portfolio to store
issues; this is a main source of stress for The Haemophilia Society (2017) Understanding revalidation and CPD evidence
Haemophilia. THS.
parents when their child is first diagnosed Hanley J et al (2017) Guidelines for the Go to nursingtimes.net to take
(The Haemophilia Society, 2018). However, management of acute joint bleeds and chronic advantage of these invaluable resources
it is also important to be aware that a synovitis in haemophilia: a United Kingdom

Nursing Times [online] October 2021 / Vol 117 Issue 10 38 www.nursingtimes.net