Blood Requests Research Articles

Blood tests: One too many? Evaluating blood requesting guidance developed for acute patients admitted to trauma and orthopaedic units

In a recently published report from the Academy of Medical Royal Colleges, around 20% of clinical practice which encompasses blood science investigations is considered wasteful. Blood tests including liver function tests (LFTs), C-reactive protein (CRP), coagulation screens, and international normalising ratios (INR) are frequently requested for patients who undergo emergency hospital admission. The paucity of guidance available for blood requesting in acute trauma and orthopaedic admissions can lead to inappropriate requesting practices and over investigation.Acute admissions over a period of one month were audited retrospectively for the frequency and clinical indications of requests for LFTs, coagulation screens/INR, and CRP. The total number of blood tests requested for the duration of the patient's admission was recorded. Initial auditing of 216 admissions in January 2014 demonstrated a striking amount of over-investigation. Clinical guidelines were developed with multidisciplinary expert input and implemented within the department. Re-audit of 233 admissions was carried out in September 2014.Total no. of LFTs requested: January 895, September 336 (−62.5%); coagulation screens/INR requested: January 307, September 210 (−31.6%); CRPs requested: January 894, September 317 (−64.5%). No. of blood requests per patient: January (M=4.81, SD 4.75), September (M=3.60, SD=4.70). Approximate combined total cost of LFT, coagulation/INR, CRP in January £2674.14 and September £1236.19 (−£1437.95, −53.77%).A large decrease was observed in admission requesting and subsequent monitoring (p<0.01) following the implementation. This both significantly reduced cost and venepuncture rates.

Negative experiences and donor return: an examination of the role of asking for something different.

Negative donation experiences, including vasovagal reactions, deter donor retention. However, whether this deterrence effect varies as a function of whole blood (WB) donation history and requests to donate the same or a different product remains unclear. The responses of 894 eligible WB donors who had been approached to convert to plasmapheresis and 954 eligible first-time plasmapheresis donors who had been surveyed on their last donation experience and their intention to donate plasma were considered. This information was matched with individual vasovagal reaction records, deferral category, WB donation history, and subsequent donation behavioral data obtained from the blood collection agency. Path analysis indicated that the application of a deferral and an officially recorded vasovagal reaction decreased donors' intentions to continue plasmapheresis donation, but had no effect on WB donors' intentions to convert to plasmapheresis. Consistent with past findings, vasovagal reactions occurred more frequently with female and inexperienced donors. Experiencing vasovagal reactions and deferrals may not universally deter donors from continuing to donate. Rather, the offer to convert to another form of donation-in this instance, plasmapheresis-after experiencing a negative donation event while donating WB may be sufficient to eliminate the deterrence effect on retention.

Profile of Blood Transfusion Requests from Hospitals to Bandung Blood Transfusion Unit, Indonesian Red Cross in 2011

Background : Blood transfusion as a part health services should be provided under appropriate indications and in a safe manner. In Indonesia, blood collection is run by the Blood Transfusion Unit of Indonesian Red Cross, where the blood is screened, processed into blood components, and finally distributed to hospitals. The purpose of this study was to describe the profile of blood transfusion requests from hospitals that do not have blood bank facility to the Bandung Blood Transfusion Unit, Indonesian Red Cross. Methods : A descriptive study was carried out using secondary data from Bandung Blood Transfusion Unit Indonesian Red Cross (UTD PMI Bandung). All blood request forms from hospitals during 2011 were collected and analyzed. Variables in this study were the amount of blood units, blood components, blood type, and indications of blood transfusion. Results : The number of blood units requested by hospitals were 35,841 units. The most blood units requested was in August 2011. The blood component requested was the packed red cell (61.1%), whole blood (17.4%), thrombocyte concentrate (10.6%), and fresh frozen plasma (7%). The total percentage of O, A, B and AB blood types were 36.1%, 28.6%, 27.5%, and 7.9% respectively. The most frequent indication for transfusion was anemia (61.7%), followed by surgery and other causes of bleeding. Conclusions : The total blood units requested by hospitals vary each month. The most blood component requested is Packed Red Cell and the type of blood is O blood type. The most frequent indication is anemia. DOI : 10.15850/amj.v2n3.519

Implementing mass-scale red cell genotyping at a blood center.

When problems with compatibility beyond ABO and D arise, currently transfusion services search their inventories and perform time-consuming serologic testing to locate antigen-negative blood. These clinically important blood group antigens can be detected reliably by red cell genotyping, which is a technology whereby DNA-based techniques are used to evaluate gene polymorphisms that determine the expression of blood group antigens. We introduced mass-scale genotyping and measured availability of genotyped blood. All non-Caucasian donors qualified for genotyping along with donors who had a history of repeat donation. Mass-scale red cell genotyping, performed on an electronic interfaced open array platform, was implemented to screen blood donors for 32 single-nucleotide polymorphisms that predicted 42 blood group antigens. Genotype screening results were confirmed by phenotyping, when needed for antigen-negative transfusion, before release of the red blood cell (RBC) unit. Approximately 22,000 donors were red cell genotyped within 4 months and a total of 43,066 donors in 4 years. There were 463 discordances (0.52% of 89,596 genotypes with a phenotype). Among the 307 resolved discordances, approximate equal numbers represented historical serologic or genotyping discrepancies (n = 151 and n = 156, respectively). In the final year of the study, a mean of 29% of the daily inventory had a genotype. Red cell genotyping of blood donors using an electronic interface created a large and stable supply of RBC units with historical genotypes. The database served the needs of antigen-negative blood requests for a large regional blood center and allowed us to abandon screening by serology.

G548(P) Special requirements in blood transfusion – an audit of requesting errors

Context This Audit was conducted in a tertiary haematology/oncology unit to identify errors in red cell transfusion requests by unit nursing and medical staff. Problem When requesting blood it is important to consider whether the patient has any special transfusion requirements, most common being the need for CMV screened or irradiated blood products. It is important to request these for patients who require them and significant harm can be caused to patients if they don’t receive what they need (Figure 1). It is equally key to avoid wasting these resources; Irradiation reduces shelf life of blood, and over-requesting CMV negative blood reduces availability for those who need it. Incorrect use is currently picked up by blood bank staff, there is no safety net in place. Assessment of problem and analysis of its causes The list of red cells used for transfusion kept by bloodbank was audited, looking at who requested the transfusion and what special requirements they requested. This was compared against what each patient should have had requested, and discrepancies were identified. Initially 2 months of blood requests were audited and showed 3/37 and 7/57 errors. There has therefore been discussion amongst haematology and blood bank across the city regarding measures to reduce this and re-audit conducted. Intervention Three measures have been introduced: Alerts on the computer system for patients with special transfusion requirements A citywide guideline of which scenarios or patients warrant these requirements A form held by blood bank for each patient detailing their requirements, created at their first transfusion Study design This was an audit and had a prospective design Strategy for change The results were discussed in conjunction with other local haematology departments. The staff of the haematology/oncology unit were given access to the agreed guideline of which types of patients have special transfusion needs, trakcare alerts were implemented and blood bank agreed on forms that they would hold. These were in place for a year prior to reaudit. Following the results of re-audit, a presentation at a departmental meeting highlighted ongoing issues. Measurement of improvement Following the interventions the results were analysed simply to show percentage change pre- and post intervention. The results showed a large increase in the number of incorrectly requested transfusions from an average of 10% error per month to 38% per month. The majority of errors were due to over-requesting special requirements (30%), but there was also a significant amount of missed requirements (8%). The majority of errors were related to CMV requesting (69%). The alerts on the computer system relating to special requirements were also looked at. 25% of patients had alerts. 6 of these had alerts when, according to the guideline, they are not required and 4 who do have special requirements did not have an alert. Effects of changes There are still a high number of errors and this clearly is an ongoing problem with an impact on patient safety. On discussion several issues have been highlighted. Trakcare alerts have not been publicised to staff and there is limited knowledge of the intranet guideline, which is particularly relevant at night when the unit is covered by an on call team. Blood bank find the individual patient forms cumbersome and find it difficult to track down medical staff to fill them in. Lessons learnt This audit has shown that there are ongoing errors in this area. The interventions in place have not fully addressed this and further work is needed. Message for others This audit has identified a key patient safety issue. The misrequesting of blood can cause significant harm and the interventions tried so far have proved cumbersome. Further work is ongoing in this area.

The Evaluation of Blood Requests for Transfusion and It’s Utilization in Four Iranian Hospitals

The Evaluation of Blood Requests for Transfusion and It’s Utilization in Four Iranian Hospitals

Improving blood transfusion safety in a low-resource setting: an audit of 1,163 transfusion requests

Sub-Saharan Africa suffers from more acute life-threatening indications for blood transfusion compared with high-income countries [1]. The commonest 'systems failure' contributing to perioperative death in low-resource settings is the timely availability of correctly cross-matched blood products [2]. Often this is not the result of an absolute shortage of blood products, but failure in the chain of supply and distribution. We audited an early step in this chain, the quality of blood requests, at the University Teaching Hospital (UTH) in Lusaka, Zambia. UTH does not have a formal blood request form, and only the cancer diseases hospital (CDH) has a blood request form developed by the blood bank.

Investments in blood safety improve the availability of blood to underserved areas in a sub-Saharan African country.

Since 2004, several African countries, including Namibia, have received assistance from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). Gains have been documented in the safety and number of collected units in these countries, but the distribution of blood has not been described. Nine years of data on blood requests and issues from Namibia were stratified by region to describe temporal and spatial changes in the number and type of blood components issued to Namibian healthcare facilities nationally. Between 2004 and 2007 (early years of PEPFAR support) and 2008-2011 (peak years of PEPFAR support), the average number of red cell units issued annually increased by 23.5% in seven densely populated but less-developed regions in northern Namibia; by 30% in two regions with urban centres; and by 35.1% in four sparsely populated rural regions. Investments in blood safety and a policy decision to emphasize distribution of blood to underserved regions improved blood availability in remote rural areas and increased the proportion of units distributed as components. However, disparities persist in the distribution of blood between Namibia's urban and rural regions.

Poster Absracts

Background: Since 2004, several African countries, including Namibia, have received assistance from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). Aims: Gains have been documented in the safety and number of collected units in these countries, but the distribution of blood has not been described. Methods: Nine years of data on blood requests and issues from Namibia were stratified by region to describe temporal and spatial changes in the number and type of blood components issued to Namibian healthcare facilities nationally. Results: Between 2004-2007 (early years of PEPFAR support) and 2008-2011 (peak years of PEPFAR support), the average number of red cell units issued annually increased by 23.5% in seven densely populated but less developed regions in northern Namibia; by 30% in two regions with urban centers; and by 35.1% in four sparsely-populated rural regions. Summary/Conclusions: Investments in blood safety and a policy decision to emphasize distribution of blood to underserved regions improved blood availability in remote rural areas and increased the proportion of units distributed as components. However, disparities persist in the distribution of blood between Namibia's urban and rural regions.

G219(P) Improving the use of Phlebotomy Services in A Paediatric Inpatient setting

ContextA Children’s Hospital offers a twice daily phlebotomy service on the General Paediatric ward. At the start of this project, if the phlebotomists were unsuccessful in obtaining a blood sample,...

DAT positivity in blood donors: A perplexing scenario

A blood request was received for 70 year male patient suffering from Chronic Obstructive Pulmonary Disease with anemia. One unit was found incompatible in AHG phase. Patient's antibody screen, indirect antiglobulin test (IAT), direct antiglobulin test (DAT) and auto control was negative. DAT of donor unit was positive with anti IgG gel card and negative with C3d reagent along with positive auto control. Donor was 30 year male with no history of blood transfusion and medication and had no evidence of hemolysis. Donors with positive DAT should be deferred, notified and referred to physician but further studies are required.

Rationale for blood request: cross match versus group and screen

The journal is the official publication of the College of Surgeons of Sri Lanka. Its mission is to reach the highest standard of scientific surgical practice by dissemination of high quality scientific information and to foster and promote the growth of scientific surgery in Sri Lanka and in the region. The Sri Lanka Journal of Surgery publishes peer-reviewed leading articles, review articles, scientific articles, perspectives and case reports in the field of surgery and broadly related surgical sciences The journal adheres to the publication ethics as portrayed by the Committee on Publication Ethics (COPE) and is a member of this organisation. It is listed as an ICMJE journal which follow its recommendations (ICMJE recommendations) on Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals.

Pattern of blood transfusion request and utilization at a Nigerian University Teaching Hospital

Introduction: Provision of adequate safe blood is challenging in developing countries due to paucity of voluntary blood donors, poor facilities for storage and blood component preparation as well as inappropriate blood ordering and utilization. Appraisal of pattern of blood transfusion requests and utilization helps highlight shortcomings that could be addressed toward judicious use of blood. Aims: To determine the pattern of blood transfusion requests and utilization at a Nigerian Teaching Hospital. Materials and Methods: Blood request forms and cross-match worksheets at the blood bank of Usmanu Danfodiyo University Teaching Hospital (UDUTH) Sokoto were analyzed over a 3-month period. Number of blood units requested, cross-matched, or transfused and the cross-match to transfusion ratio (CTR) for clinical units were computed. Results: Of the 1703 units of blood requested for 986 patients, 94.42% (1608) were cross-matched but only 34.51% (555) were transfused giving a CTR of 2.90 for the hospital. The CTR for the various clinical units were: O and G - 3.40, Surgery - 3.11, Trauma center - 2.74, Emergency - 2.61, Medicine - 2.02, and Pediatrics - 1.97. Conclusions: The overall CTR of the hospital is high indicating suboptimal transfusion practice. Introducing transfusion guidelines and type and screen with abbreviated cross-match method can help toward apt requisition and utilization of blood thereby reducing wastages.

Improving the use of phlebotomy services in a paediatric inpatient setting.

The aim of this project was to improve the use of the current Paediatric Phlebotomy service. The main problem identified was the lack of a system to notify medical teams of unsuccessful blood requests. A phlebotomy process map was constructed to help analyse reasons why failure to notify occurred. Pre and post intervention audits were conducted using the number of unsuccessful blood requests notified as a baseline measurement. The initial intervention was modified based on feedback during the process. A 44% improvement in the number of unsuccessful blood requests notified and a potential cost savings of £6240 was demonstrated in the post-intervention audit. Further work is required as to whether these improvements can be increased, sustained and be cost effective.

Il controllo del sanguinamento nella protesi totale di ginocchio

Total knee arthroplasty is associated with high blood loss and high incidence of blood transfusion. In order to reduce the bleeding after total knee replacement, several strategies have been used simultaneously, including surgical and medical techniques, technological devices and drugs. The synergistic use of the available methods may be a good solution for reducing blood loss and requests for autologous blood transfusion.

Appropriate clinical use of blood in Uganda

The Uganda Blood Transfusion Services, in line with the requirements for the minimum health care package of Uganda, has made tremendous strides in improving the adequacy and quality on blood supply to hospitals and health center that administer blood. This is mainly due to the extensive technical and financial support to the procurement and processing components of the transfusion chain. Unfortunately these efforts have not been reciprocated at the in‐hospital setting. This is characterized by underdeveloped administrative structures catering for blood transfusion like lack of a hospital transfusion policy which has lead to paucity of instructive procedures, monitoring and evaluation as well as defined persons responsible for in‐hospital transfusion quality assurance. Additionally, documentation of what is to be or what has been done is still under‐developed.As a way of improvement, a step‐by‐step quality improvement strategy should be developed. First, a small working group of clinicians, laboratory technicians and administrators should be created to design the policy and strategies (blood transfusion plan) for clinical use of blood. Second, start creating Hospital Transfusion Committees with appropriate terms of reference. These should be supported by the hospital high authority. Third, design simple education materials for the three major in‐hospital transfusion processes and identified procedures, with their respective standard operating procedures (SOPs) and related outcome documents like a Blood Request Form (ordering, component selection and administration). Disseminate these materials through continuous professional trainings for in‐service staff and curriculum reviews for medical and paramedical schools. Fifth, embark on updating the National Transfusion Policy to embrace and support the development of National clinical standards and guidelines. These steps will be achieved when the concept of quality assurance is formally and philosophically incorporated into the structure and functioning of Uganda's health systems, consistently implemented, and supported by a culture of quality, as reflected in organizational values and policies that advocate quality of care.

Appropriateness of blood product transfusion in the Obstetrics and Gynaecology (O&amp;G) department of a tertiary hospital in West Africa

Misuse of blood by clinicians was suggested to explain blood shortage in sub-Saharan Africa although based on little evidence. This study evaluated whether routine halving (restricted) of blood requests was justified. On alternated days for 3 months in 2011-2012, restricted or full blood product supply [whole blood (WB), red cell concentrate (RCC)] was provided to the Obstetrics & Gynaecology department (O&G). Patient age, haemoglobin (Hb) level pre- and post-transfusion, clinical condition, blood products request and supply, transfused and returned, clinical outcome were collated. Five hundred and nineteen patients (249 restricted and 270 full supply) received 1001 blood products (94.6% WB, 6.4% RCC). Clinical conditions were severe peri-partum bleeding (72.4%) requiring emergency transfusion (82%) whilst 27.6% of total transfusion was for anaemia, 18% being moderate (8-10 g dL(-1) ). Pre-transfusion Hb level was <6 g dL(-1) in 36.7%, 6-8 g dL(-1) 29.1% and ≥ 8 g dL(-1) in 33.2% of cases. Fifty-five percent of the transfused blood was stored ≤ 1 week. Restricted supply triggered additional request (40%) compared to 10% in full supply mode. Whether with restricted or full supply, blood requests, supply and units transfused/patient were similar (restricted 2.3 and 2.1 unit patient(-1) and full 2.9 and 2.3 unit patient(-1) , respectively). Fatal clinical outcome was 3.1% evenly distributed between supply modes and transfusion reactions 0.8%. O&G clinicians order blood according to clinical need and transfuse 85% of the products supplied. Product supply did not significantly affect use although appropriateness of transfusion was difficult to assess.

Transfuse Neonates with Cord Blood-Derived Red Blood Cells: A Feasibility Study to Assess Allogeneic Cord Blood Unit Fractionation and Validation

AbstractAbstract 275Newborns are currently transfused with RBCs from adults, which mainly contain adult hemoglobin (HbA). HbA has a lower affinity for oxygen than fetal hemoglobin: therefore adult red cell transfusion could be responsible for increased oxygen increasing the risk of the “oxygen radicals disease of the newborn”. Autologous umbilical cord blood has been suggested as the only alternative source of blood for newborn transfusions. Previous studies, however, demonstrated that autologous cord blood transfusions in newborns are not sufficient to entirely cover the early neonatal blood requests. We reported the preliminary results of our study carried out to assess the feasibility of an allogeneic cord blood (ACB) transfusion program for prematures in terms of preparation and yield of valid ACB red blood cell (RBC) units. ACB units collected at the Cord Blood Bank but not suitable for processing and storage for allogeneic transplant cord blood were evaluated. Eligible criteria for cord blood collection were: more than 37 weeks of gestation, absence of mother’s infection or fever 24 hours before the delivery, no stain of the amniotic fluid. ACB units eligible for our study contained more than 60 mL of cord blood, with no clots or hemolysis. We prepared buffy coat–depleted ACB RC units by automated separation (Compomat G4®, Fresenius HemoCare, Germany) in a processing set (Compoflex®). Suspension in SAG-mannitol and post-storage filtration was performed to obtain a leukocyte-depleted red cell unit. Resuspended units were stored for fourteen days after manipulation (2–6°C). Cultures for bacterial contamination were performed immediately after manipulation and after 14 days; biochemical determination (LDH, glucose, lactate, potassium, chloride, sodium, pH and pO2) were performed the day of fractionation (=0) and after 7 and 14 days of storage. Biochemical data were also compared to the same parameters obtained from adult red blood cell concentrates. We collected 76 ACB units. Thirty-three were discharged for insufficient volume or clots. The median collection volume of the 43 remaining units was 92.3 (± 18.3) ml. After fractionation, 43 ACB RC units were obtained with a median volume of 31.2 (± 8.2) ml and a median hematocrit of 59 ± 2%. Microbial contamination was absent in all units after manipulation and after 14 days; viral tests carried out on mother’s blood at the time of cord blood collection were negative. Biochemical parameters maintained rather well up to 14 days of storage, but less resistant than adult red cells. Our data highlight that ACB is a promising source of RBC for transfusion in preterm infants. Besides the reduction of waste of not validated ACB units collected in the Cord Blood Bank, transfusional utilization of ACB RBC can overcome several problems of autologous cord blood transfusion: insufficient volumes is less frequent in ACB from term newborns and the incidence of clots, which is one of the more frequent cause of ineligibility of cord blood units, is substantially reduced when collection is performed by trained staff, in term neonates and using adequate blood shakers. Microbial contamination is prevented by adopting the strict eligibility criteria and the adequate aseptic collection technique adopted in the Cord Blood Bank. In conclusion, the preparation of transfusionally valid RCs from ACB is possible and convenient. Clinical studies are needed to evaluate the efficacy and safety of this new transfusion practice. Disclosures:No relevant conflicts of interest to declare.

The use of telemedicine in Italian Blood Banks: a nationwide survey.

Telemedicine is defined as the use of electronic information and communication technologies to provide health care between distant people. Many activities in transfusion medicine could benefit from the application of telemedicine. To map the spread of the use of telemedicine in transfusion medicine in Italy, the Italian Society of Transfusion Medicine and Immunohaematology (SIMTI) performed a nationwide survey: the results are presented in this paper. A survey, dealing with different aspects of the use of telemedicine, was performed by sending a questionnaire to 280 Italian Blood Centres. The survey was designed to evaluate the diffusion of telemedicine and the features of the systems, with special attention to the systems' safety and legal adequacy. One section of the questionnaire was designed to identify the features of the systems considered essential by the respondents. Out of 280 Blood Services contacted, 196 (70%) filled in at least one of the questions of the online questionnaire. Globally the use of some form of telemedicine was reported by 70% of the respondents. Telemedicine is used for remote validation of laboratory tests by 32% of the Centres that responded, for remote biological validation of blood units by 34% and for assignment of blood components by 29%. Less frequently, telemedicine is used to control electronic refrigerators, for electronic blood requests and for bed-side identification of patients. The use of telemedicine is widespread in Italian Blood Services. There appears to be some heterogeneity between structures with regards to the evaluation of the systems' safety and their legal adequacy. No telemedicine system should be introduced into practice until it has proven to have the same standards of safety as the corresponding "on site" activity.

Survey on blood ordering and utilisation patterns in elective urological surgery.

Blood transfusion is an important part of the medical care service. As there has not been a regional study about blood requests for operations, this study was done to assess blood ordering for various types of elective urological surgery. In a descriptive, retrospective, cross-sectional study, blood requests for all patients undergoing elective urological surgery in Razi Hospital (Rasht, Iran) during the first 6 months of 2010 were studied. The patients' data (age, sex, weight, type of surgery, haemoglobin level before and after surgery, number of units of blood cross-matched and number of units transfused in the operating theatre and in the 3 days after surgery) were collected from their clinical records. Patients with a history of coagulopathy or anticoagulant drug use were excluded. The cross-match to transfusion ratio (C/T ratio), transfusion index (TI) and transfusion probability (T%) were calculated. The level of statistical significance was set at P =0.05. Of the 435 patients studied, 327 (75.1%) were male and 108 (24.9%) were female. The mean age of patients was 51.74 ± 19.33 years. The mean number of units of blood requested for each operation was 2.8 ± 1.2, whereas the mean number transfused was 0.59 ± 0.24; the difference was statistically significant (P<0.05). The relationships between pre-operative haemoglobin concentration and both blood requested and blood used were also statistically significant (P =0.038 and P <0.001, respectively). Calculated for all the operations, the C/T ratio was 14.16, the TI was 0.11 and the T% was 8.85%. Overall, only 8.5% of the patients (n=37) need blood transfusion in the operating theatre and only 10.8% (n=47) required transfusion within the 72 hours after surgery. The amount of blood requested and cross-matched for elective urological surgery is much greater than the real level of consumption. An appropriate, standard blood order guideline would reduce costs and staff workload.