836 Audit of Neonatal Blood Transfusions

Abstract

Introduction: Blood transfusions are very common on a neonatal unit. Patients often need a large number of blood transfusions but each may be as little as 8mls. To reduce donor exposure and wastage of blood each standard unit is split into 6 parts or a Pedipack which may be all or partly allocated to 1 infant. Our guideline was developed in 2007 and a prospective audit showed good compliance with no unnecessary donor exposure, but wastage due to inappropriate allocation of a full pedipack. Aims: This was a retrospective re-audit of all babies who had received a blood transfusion to ensure continued compliance with the protocol and to monitor donor exposure and the wastage of blood units. Results: Babies received between 1 and 17 blood transfusions. For babies ≤28 weeks gestation who did not receive pedipacks as per protocol they were exposed to up to 6 unnecessary donors. For babies >28 weeks 15% were allocated an inappropriate full pedipack resulting in wastage. Conclusions: There was very poor adherence to the protocol resulting in unnecessary exposure to multiple donors and excessive wastage. This was felt to be due to poor compliance with the guideline, poor communication between the neonatal unit and blood bank staff and an increase in the need for blood transfusions resulting in a lack of availability of full pedipacks. Recommendations: To provide teaching sessions for all staff. To improve communication between the neonatal unit and blood transfusion. To re-audit to ensure that improvements have occurred.