ISTH-SSC Bleeding Assessment Tool (ISTH-SCC BAT)
Evaluates bleeding symptoms in patients with inherited bleeding disorders.
Provided by
EVAL FoundationInstructions
Recommended for use in patients with a suspected inherited bleeding disorder.
Only symptoms and treatment BEFORE and AT diagnosis should be considered.
Patient details
Who created it:
The ISTH/SSC Joint VWF and Perinatal/Pediatric Hemostasis Subcommittees Working Group — led by Rodeghiero, Tosetto, Abshire, Arnold, Coller, James, Neunert, and Lillicrap. The group formed at the 53rd SSC Annual Meeting in Geneva (2007) and met regularly afterward, first convening in Toronto in January 2008. Additional contributors came from a Menorrhagia Working Group under the Women's Issues SSC.
What it is:
A standardized questionnaire and companion scoring system (the "Bleeding Score," or BS) designed to structure and quantify a patient's bleeding history — covering everything from epistaxis and bruising to surgical bleeding, menorrhagia, postpartum hemorrhage, and CNS bleeds. It's meant for use in both children and adults with suspected inherited bleeding disorders.
Why they made it:
Existing bleeding assessment tools had two main gaps: they lacked pediatric-specific symptoms, and they overweighted symptom severity while ignoring frequency. The working group wanted a single, standardized tool that could be validated consistently across studies, rather than having researchers each use their own ad hoc questionnaires.
How it works:
A physician or trained health professional administers the questionnaire, asking about symptoms and treatments occurring before or at diagnosis only.
For each of 14 symptom categories, specific "minimal criteria" define what counts as clinically significant (vs. trivial) — e.g., epistaxis only counts if it lasts 10+ minutes, happens 5+ times/year, or isn't explained by an obvious cause.
Each category is then scored 0–4 based on severity of intervention needed (nothing → consultation only → medical treatment → transfusion/surgery), using the detailed scoring grid (see the section Configuration).
The individual category scores sum into an overall Bleeding Score, intended to help discriminate real bleeding disorders from normal variation, and to standardize reporting across future validation studies.
Configuration
There are are 14 possible questions or bleeding assessment domains that are assessed based on gender and age.
Adult Male (≥18 years): All questions (below) except questions #9 (Menorrhagia), #10 (Post Partum Hemorrhage) & #14 (Other bleeding).
Adult Female (≥18 years): All questions (below) except question #14.
Female Child (<18 years): All questions (below).
Male Child (<18 years): All questions (below) except questions #9 (Menorrhagia), & #10 (Post Partum Hemorrhage).
Symptoms | Points | |
| No/trivial | 0 |
>5 /year or >10 minutes | 1 | |
Consultation only* | 2 | |
Packing, cauterization, or antifibrinolytic agents | 3 | |
Blood transfusion, replacement therapy, or desmopressin | 4 | |
| No/trivial | 0 |
≥5 bruises (>1 cm) in exposed areas | 1 | |
Consultation only* | 2 | |
Extensive | 3 | |
Spontaneous hematoma requiring blood transfusion | 4 | |
| No/trivial | 0 |
>5 /year or >10 minutes | 1 | |
Consultation only* | 2 | |
Surgical hemostasis | 3 | |
Blood transfusion, replacement therapy, or desmopressin | 4 | |
| No/trivial | 0 |
Present | 1 | |
Consultation only* | 2 | |
Surgical hemostasis or antifibrinolytic required | 3 | |
Blood transfusion, replacement therapy, or desmopressin | 4 | |
| No/trivial | 0 |
Present (not associated with ulcer, portal hypertension, hemorrhoids, angiodysplasia) | 1 | |
Consultation only* | 2 | |
Surgical hemostasis or antifibrinolytic required | 3 | |
Blood transfusion, replacement therapy, or desmopressin | 4 | |
| No/trivial | 0 |
Present (macroscopic) | 1 | |
Consultation only* | 2 | |
Surgical hemostasis or iron therapy | 3 | |
Blood transfusion, replacement therapy, or desmopressin | 4 | |
| No/trivial or none done | 0 |
Reported in ≤25% of all procedures, no intervention** | 1 | |
Reported in >25% of all procedures, no intervention** | 2 | |
Resuturing or packing | 3 | |
Blood transfusion, replacement therapy, or desmopressin | 4 | |
| No/trivial or none done | 0 |
Reported in ≤25% of all procedures, no intervention** | 1 | |
Reported in >25% of all procedures, no intervention** | 2 | |
Surgical hemostasis or antifibrinolytic | 3 | |
Blood transfusion, replacement therapy, or desmopressin | 4 | |
| No/trivial | 0 |
Consultation only*, changing pads more frequently than every 2 hours, clot and flooding, or PBAC score>100*** | 1 | |
Time off work/school >2 /year, requiring antifibrinolytics, or hormonal/iron therapy | 2 | |
Requiring combined treatment with antifibrinolytics and hormonal therapy or menorrhagia present since menarche and >12 months | 3 | |
Acute menorrhagia requiring hospital admission and emergency treatment, requiring blood transfusion/replacement therapy/desmopressin, requiring dilatation & curettage/endometrial ablation, or hysterectomy | 4 | |
| No/trivial or no deliveries | 0 |
Consultation only*, use of oxytocin, or lochia >6 weeks | 1 | |
Iron therapy or antifibrinolytics | 2 | |
requiring blood transfusion, replacement therapy, desmopressin, or requiring examination under anesthesia and/or the use of uterine balloon/package to tamponade the uterus | 3 | |
Any procedure requiring critical care or surgical intervention | 4 | |
| Never | 0 |
Post trauma or no therapy | 1 | |
Spontaneous or no therapy | 2 | |
Spontaneous or traumatic, requiring desmopressin or replacement therapy | 3 | |
Spontaneous or traumatic, requiring surgical intervention or blood transfusion | 4 | |
| Never | 0 |
Post trauma or no therapy | 1 | |
Spontaneous or no therapy | 2 | |
Spontaneous or traumatic, requiring desmopressin or replacement therapy | 3 | |
Spontaneous or traumatic, requiring surgical intervention or blood transfusion | 4 | |
| Never | 0 |
Subdural or any intervention | 3 | |
Intracerebral or any intervention | 4 | |
| No/trivial | 0 |
Present | 1 | |
Consultation only* | 2 | |
Surgical hemostasis or antifibrinolytics | 3 | |
Blood transfusion, replacement therapy, or desmopressin | 4 |
Note: The difference between 0 and 1 is important. A score of 1 means that the symptom is judged as present in the patient’s history by the interviewer but does not qualify for a score 2 or more.
* Consultation only: the patient sought medical evaluation and was either referred to a specialist or offered detailed laboratory investigation.
** E.g., 1 extraction/surgery resulting in bleeding (100%): the score to be assigned is 2; 2 extractions/surgeries, 1 resulting in bleeding (50%): the score to be assigned is 2; 3 extractions/surgeries, 1 resulting in bleeding (33%): the score to be assigned is 2; 4 extractions/surgeries, 1 resulting in bleeding (25%): the score to be assigned is 1.
*** If already available at the time of collection.
Results & Interpretation
ISTH-SSC BAT Score | Interpretation | |
Adult males (≥18 years) | 0-3 | Typical |
≥4 | Atypical | |
Adult females (≥18 years) | 0-5 | Typical |
≥6 | Atypical | |
Children (<18 years) both male and female | 0-2 | Typical |
≥3 | Atypical |
Low scores are associated with a low likelihood of a bleeding disorder, and additional evaluation may not be warranted.
Elevated scores indicate an increased risk of bleeding; Consider further diagnostic evaluation for an underlying inherited bleeding disorder as appropriate (e.g., laboratory studies, specialty consultation).
Results are not diagnostic but play a part of a comprehensive evaluation in conjunction with clinical judgment and specialty consultation.
All questions & possible results
Patient details
Sex
Select one option:
- Male
- Female
Age (years)
A number between 0 and 120 (whole numbers).
Bleeding domains
Only symptoms and treatment BEFORE and AT diagnosis should be considered.
Epistaxis
*Consultation only: the patient sought medical evaluation and was either referred to a specialist or offered detailed laboratory investigation.
Select one option:
- No or trivial
- > 5 episodes/year or lasting > 10 minutes
- Consultation only*
- Packing, cauterization or antifibrinolytic agents
- Blood transfusion, replacement therapy or desmopressin
Cutaneous
*Consultation only: the patient sought medical evaluation and was either referred to a specialist or offered detailed laboratory investigation.
Select one option:
- No or trivial
- 5 or more bruises (more than 1 cm) in exposed areas
- Consultation only*
- Extensive
- Spontaneous hematoma requiring blood transfusion
Bleeding from minor wounds
*Consultation only: the patient sought medical evaluation and was either referred to a specialist or offered detailed laboratory investigation.
Select one option:
- No or trivial
- > 5 episodes/year or lasting > 10 minutes
- Consultation only*
- Surgical hemostasis
- Blood transfusion, replacement therapy or desmopressin
Oral cavity
*Consultation only: the patient sought medical evaluation and was either referred to a specialist or offered detailed laboratory investigation.
Select one option:
- No/trivial
- Present
- Consultation only*
- Surgical hemostasis or antifibrinolytic required
- Blood transfusion, replacement therapy or desmopressin
Gastrointestinal bleeding
*Consultation only: the patient sought medical evaluation and was either referred to a specialist or offered detailed laboratory investigation.
Select one option:
- No/trivial
- Present (NOT associated with ulcer, portal hypertension, hemorrhoids or angiodysplasia)
- Consultation only*
- Surgical hemostasis or antifibrinolytic required
- Blood transfusion, replacement therapy or desmopressin
Hematuria
*Consultation only: the patient sought medical evaluation and was either referred to a specialist or offered detailed laboratory investigation.
Select one option:
- No/trivial
- Present (macroscopic)
- Consultation only*
- Surgical hemostasis or iron therapy
- Blood transfusion, replacement therapy or desmopressin
Tooth extraction
* Examples:
1 extraction/surgery resulting in bleeding (100%): the score to be assigned is 2;
2 extractions/surgeries, 1 resulting in bleeding (50%): the score to be assigned is 2;
3 extractions/surgeries, 1 resulting in bleeding (33%): the score to be assigned is 2;
4 extractions/surgeries, 1 resulting in bleeding (25%): the score to be assigned is 1.
Select one option:
- No/trivial or none done (0 pts)
- Reported in ≤25% of all procedures, no intervention* (1 pt
- Reported in >25% of all procedures, no intervention* (2 pts)
- Resuturing or packing (3 pts)
- Blood transfusion, replacement therapy or desmopressin (4 pts)
Surgery
* Examples:
1 extraction/surgery resulting in bleeding (100%): the score to be assigned is 2;
2 extractions/surgeries, 1 resulting in bleeding (50%): the score to be assigned is 2;
3 extractions/surgeries, 1 resulting in bleeding (33%): the score to be assigned is 2;
4 extractions/surgeries, 1 resulting in bleeding (25%): the score to be assigned is 1.
Select one option:
- No/trivial or none done (0 pts)
- Reported in ≤25% of all procedures, no intervention* (1 pt)
- Reported in >25% of all procedures, no intervention* (2 pts)
- Surgical hemostasis or antifibrinolytic (3 pts)
- Blood transfusion, replacement therapy or desmopressin (4 pts)
Menorrhagia
*Consultation only: the patient sought medical evaluation and was either referred to a specialist or offered detailed laboratory investigation.
∔ If already available at the time of collection.
Select one option:
- No/trivial
- Consultation only*, changing pads more frequently than every 2 hours, clot and flooding, OR PBAC score >100∔
- Time off work/school >2/year, requiring antifibrinolytics, or hormonal/iron therapy
- Requiring combined treatment with antifibrinolytics and hormonal therapy, OR menorrhagia present since menarche and > 12 months
- Acute menorrhagain requiring hospital admission and emergency treatment, requiring blood transfusion/replacement therapy/desmopressin, requiring dilatation and curettage/endometrial ablation or hysterectomy
Post-partum hemorrhage
*Consultation only: the patient sought medical evaluation and was either referred to a specialist or offered detailed laboratory investigation.
Select one option:
- No/trivial or no deliveries
- Consultation only*, use of oxytocin, or lochia > 6 weeks
- Iron therapy or antifibrinolytics
- Requiring blood transfusion, replacement therapy, desmopressin, OR requiring examination under anesthesia and/or use of a uterine balloon/package to tamponade the uterus
- Any procedure requiring critical care or surgical intervention
Muscle hematomas
Select one option:
- Never
- Post trauma, no therapy
- Spontaneous, no therapy
- Spontaneous or traumatic, requiring desmopressin or replacement therapy
- Spontaneous or traumatic, requiring surgical intervention or blood transfusion
Hemarthrosis
Select one option:
- Never
- Post trauma or no therapy
- Spontaneous or no therapy
- Spontaneous or traumatic, requiring desmopressin or replacement therapy
- Spontaneous or traumatic, requiring surgical intervention or blood transfusion
Central nervous system bleeding
Select one option:
- Never
- Subdural, any intervention
- Intracerebral or any intervention
Other bleeding∔
∔Umbilical stump bleeding, cephalohematoma, cheek hematoma caused by sucking during breast/bottle feeding, conjunctival hemorrhage or excessive bleeding following circumcision/venipuncture
*Consultation only: the patient sought medical evaluation and was either referred to a specialist or offered detailed laboratory investigation.
Select one option:
- No/trivial
- Present
- Consultation only*
- Surgical hemostasis or antifibrinolytic
- Blood transfusion, replacement therapy or desmopressin
Possible results
Typical Bleeding — ISTH-BAT bleeding score - Adult Male
The total bleeding score is 0-3 points.
Low scores are associated with a low likelihood of a bleeding disorder, and additional evaluation may not be warranted.
Elevated scores indicate an increased risk of bleeding; Consider further diagnostic evaluation for an underlying inherited bleeding disorder as appropriate (e.g., laboratory studies, specialty consultation).
Results are not diagnostic but play a part of a comprehensive evaluation in conjunction with clinical judgment and specialty consultation.
Atypical Bleeding — ISTH-BAT bleeding score - Adult Female
The total bleeding score is ≥6 points.
Low scores are associated with a low likelihood of a bleeding disorder, and additional evaluation may not be warranted.
Elevated scores indicate an increased risk of bleeding; Consider further diagnostic evaluation for an underlying inherited bleeding disorder as appropriate (e.g., laboratory studies, specialty consultation).
Results are not diagnostic but play a part of a comprehensive evaluation in conjunction with clinical judgment and specialty consultation.
Typical Bleeding — ISTH-BAT bleeding score - Adult Female
The total bleeding score is 0-5 points.
Low scores are associated with a low likelihood of a bleeding disorder, and additional evaluation may not be warranted.
Elevated scores indicate an increased risk of bleeding; Consider further diagnostic evaluation for an underlying inherited bleeding disorder as appropriate (e.g., laboratory studies, specialty consultation).
Results are not diagnostic but play a part of a comprehensive evaluation in conjunction with clinical judgment and specialty consultation.
Atypical Bleeding — ISTH-BAT bleeding score - Children Female (<18 years)
The total bleeding score is ≥3 points.
Low scores are associated with a low likelihood of a bleeding disorder, and additional evaluation may not be warranted.
Elevated scores indicate an increased risk of bleeding; Consider further diagnostic evaluation for an underlying inherited bleeding disorder as appropriate (e.g., laboratory studies, specialty consultation).
Results are not diagnostic but play a part of a comprehensive evaluation in conjunction with clinical judgment and specialty consultation.
Typical Bleeding — ISTH-BAT bleeding score - Children Female (<18 years)
The total bleeding score is 0-2 points.
Low scores are associated with a low likelihood of a bleeding disorder, and additional evaluation may not be warranted.
Elevated scores indicate an increased risk of bleeding; Consider further diagnostic evaluation for an underlying inherited bleeding disorder as appropriate (e.g., laboratory studies, specialty consultation).
Results are not diagnostic but play a part of a comprehensive evaluation in conjunction with clinical judgment and specialty consultation.
Atypical Bleeding — ISTH-BAT bleeding score - Children Male (<18 years)
The total bleeding score is ≥3 points.
Low scores are associated with a low likelihood of a bleeding disorder, and additional evaluation may not be warranted.
Elevated scores indicate an increased risk of bleeding; Consider further diagnostic evaluation for an underlying inherited bleeding disorder as appropriate (e.g., laboratory studies, specialty consultation).
Results are not diagnostic but play a part of a comprehensive evaluation in conjunction with clinical judgment and specialty consultation.
Typical Bleeding — ISTH-BAT bleeding score - Children Male (<18 years)
The total bleeding score is 0-2 points.
Low scores are associated with a low likelihood of a bleeding disorder, and additional evaluation may not be warranted.
Elevated scores indicate an increased risk of bleeding; Consider further diagnostic evaluation for an underlying inherited bleeding disorder as appropriate (e.g., laboratory studies, specialty consultation).
Results are not diagnostic but play a part of a comprehensive evaluation in conjunction with clinical judgment and specialty consultation.
Atypical Bleeding — ISTH-BAT bleeding score - Adult Male
The total bleeding score is ≥4 points.
Low scores are associated with a low likelihood of a bleeding disorder, and additional evaluation may not be warranted.
Elevated scores indicate an increased risk of bleeding; Consider further diagnostic evaluation for an underlying inherited bleeding disorder as appropriate (e.g., laboratory studies, specialty consultation).
Results are not diagnostic but play a part of a comprehensive evaluation in conjunction with clinical judgment and specialty consultation.
Citation
Rodeghiero F, Tosetto A, Abshire T, et al. ISTH/SSC bleeding assessment tool: a standardized questionnaire and a proposal for a new bleeding score for inherited bleeding disorders. J Thromb Haemost. 2010;8(9):2063-2065.
Literature
- ISTH/SSC bleeding assessment tool: a standardized questionnaire and a proposal for a new bleeding score for inherited bleeding disorders Journal of Thrombosis and Haemostasis, 8, 2063-2065 — Rodeghiero F, Tosetto A, Abshire T, et al.
- Normal range of bleeding scores for the ISTH-BAT: adult and pediatric data from the merging project. Haemophilia. 2014 Nov;20(6):831-5. doi: 10.1111/hae.12503. Epub 2014 Sep 6. PMID: 25196510; PMCID: PMC4251588. — Elbatarny M, Mollah S, Grabell J, Bae S, Deforest M, Tuttle A, Hopman W, Clark DS, Mauer AC, Bowman M, Riddel J, Christopherson PA, Montgomery RR; Zimmerman Program Investigators; Rand ML, Coller B, James PD.
- Application of the ISTH bleeding score in hemophilia. Transfus Apher Sci. 2018 Aug;57(4):556-560. doi: 10.1016/j.transci.2018.06.003. Epub 2018 Jun 15. PMID: 29921547. — Borhany M, Fatima N, Abid M, Shamsi T, Othman M.
- Validation of the ISTH/SSC bleeding assessment tool for inherited platelet disorders: A communication from the Platelet Physiology SSC Journal of Thrombosis and Haemostasis, 18, 732-739 Export — Gresele P, Orsini S, Noris P et al
