Changes In Transfusion Practice Research Articles

Transfusion Camp Rwanda 2023: A train-the-trainer workshop establishing locally driven leadership in knowledge translation and sustainability in transfusion medicine education.

Blood transfusion is performed daily in hospitals. Gaps exist between transfusion guidelines and day-to-day clinical care. These gaps are prevalent in resource-limited settings due to scarce continuing medical education. Transfusion Camp Rwanda aims to bridge this gap by (1) delivering context-appropriate up-to-date education, (2) teaching participants how to independently deliver a case-based curriculum and (3) identifying strategies to promote change in transfusion practice in Rwanda. In May 2023, a multidisciplinary team from Canada and Rwanda carried out a Transfusion Camp train-the-trainer workshop for clinicians from all five provinces in Rwanda. Participants attended in-person lectures, seminars and workshop group discussions on the implementation of the Rwanda National Directives on Rational Use of Blood and Blood Components. Course feedback was based on the Kirkpatrick Model of Training and Evaluation. Fifty-one physicians and laboratory technicians participated in the course. Confidence in caring for patients based on transfusion guidelines was self-rated as 'excellent' by 23% of participants before and 77% after, while 84% reported they planned to teach Transfusion Camp to others and 100% responded that they will apply course content to clinical practice. Workshop groups recommended strategies to improve transfusion medicine practice in Rwanda in four domains: Communication, Institutional Approval, Practice Audits and Education. Transfusion medicine education in Rwanda using a train-the-trainer approach was well-received by participants and allowed for a more detailed understanding of the local medical and educational environment. These observations can inform the further expansion of the Transfusion Camp Rwanda project.

O-negative blood shortage management in a university hospital: Impact of transfusing RhD-positive red blood cells to RhD-negative patients.

Shortages of O-negative red blood cells are becoming increasingly common, forcing hospitals' blood transfusion services to find solutions to conserve this blood group for patients who need it most. The present study aimed to retrospectively evaluate the practice of transfusing selected RhD-negative patients with RhD-positive red blood cells and to assess the impact of this measure on patients and blood transfusion service management. Transfusion data of 1199 RhD-negative patients hospitalised at Cliniques Universitaires Saint-Luc between 2019 and 2022 were analysed. For patients who received RhD-positive red blood cells, age, gender, reason for hospital admission, indication for transfusion, and immunohematology analyses were recorded. These data enabled an assessment of transfusion practices over the years, characterisation of patients who received RhD-mismatched transfusions, determination of the alloimmunisation rate, and calculation of the total number of RhD-negative red blood cells saved. During the study period, 141 RhD-negative patients received 604 RhD-positive red blood cells. A change in transfusion practices was observed over the years, with a greater proportion of RhD-negative patients being transfused with RhD-positive red blood cells in 2022 (28%) compared to 2019 (2%). The overall alloimmunisation rate was at least 20%, and 416 red blood cells were saved without any consequences. Patients undergoing cardiovascular surgery received the highest number of RhD-positive red blood cells. The transfusion of selected RhD-negative patients with RhD-positive red blood cells is a low-risk practice that helps conserve RhD-negative red blood cells. However, there is a minimum 20% risk of alloimmunisation, which could have clinical and transfusion-related consequences in the future.

Changes in transfusion practice in Scotland between June 2013 and December 2019.

Reed, Matthew J.a,b,c; on behalf of the Scottish Transfusion and Laboratory Support in Trauma Code Red Audit Group Author Information

The Implementation of Patient Blood Management in a Tertiary Hospital: a 9-Year Retrospective Study of Blood Transfusion Practice.

To analyze the changes in clinical transfusion practice and explore the exact benefits after the implementation of patient blood management (PBM). The retrospective study included transfusion practice data from West China Hospital of Sichuan University during the years 2009 - 2018. The data of surgical patients in 2010 were taken as the baseline (pre-PBM), and the data of surgical patients from 2012 to 2018 (post-PBM) were compared with the baseline. Outcome measures were the change in transfusion practice, patient outcomes, and economic benefits pre/post-PBM. Compared with pre-PBM, the rapid growth of clinical red blood cell (RBC) consumption was curbed, the total units of red blood cells (RBCs) transfused was 65,322 units pre-PBM and was 51,880.5 units in 2011. The transfusion rate per 1,000 surgical patients post-PBM was lower, and the mean units of intraoperative transfusion and surgery transfusion represented a 50% reduction. According to the product-acquisition cost, PBM had saved 46.58 million Renminbi (RMB) in 2012 - 2018. The proportion of ambulatory surgery and interventional surgery increased, the proportion of Hb transfusion trigger was significantly lower than that in 2010, and the average length of stay (ALOS) was improved. Properly implementing a PBM program had the potential to reduce unnecessary transfusions and the related risks and costs.

Clinical audits – A quality improvement tool in transfusion medicine

A clinical audit is a quality improvement process that seeks to improve services and outcomes through a systematic review of care against explicit criteria. It is now a recognized tool for improving clinical quality of care. However, in transfusion medicine, they have been utilized in a limited manner. This review intends to discuss the methodology of carrying out a clinical audit systematically. Clinical audit is not research and focuses on the improvement of ordinary and routine practices. Various methodologies for selecting and prioritizing a good audit topic can be employed. Based on the Donabedian model, process-based audits from donor selection to the actual bedside transfusion could be audited to bring in improvement. Likewise, transfusion processes can be audited based on the dimensions of quality in the context of timeliness, effectiveness, and appropriateness. Prioritization of a topic can be done through a quality impact assessment. The objectives help quantify the aim of the audit, while the standards include criteria that are quantified against targets, based on the current evidence for the best possible care. A snapshot sample (20–50 cases) is sufficient to carry out a clinical audit. Where targets are not met, root-cause analysis and quality improvement tools guide the implementation of changes in transfusion practices. To ensure that change is implemented and internalized, it is necessary to have the entire team and the management on board; communication with all stakeholders is key. Re-audit, after the change has been internalized, is an essential part of all clinical audits. Meticulously planning and proper implementation ensure improvement of the care that transfused patients receive.

Pediatric liver transplantation in Australia and New Zealand: The case for a collaborative anesthetic database.

Liver transplantation is conducted with strict oversight of organizational structure and clinical practice. However, specific regulations pertaining to the delivery of anesthetic services are lacking and consideration of departmental structure and mechanisms for quality control must occur at a local level. Busy centers collect and process sufficient data to guide this process but those with low case loads may not generate enough data for useful analysis. In Australia and New Zealand, pediatric liver transplants are performed at only four locations. As these operations are not equally distributed geographically or temporally there are periods of low activity at some centers. As anesthesia affects patient outcome, quality assurance activities are important in this setting. Provide a global overview of the structure and function of liver transplantation networks. Identify issues related to provision of pediatric anesthetic services with specific reference to Australasia. Examine anesthetic data from a single pediatric center to illustrate benefits and limitations of such activity. Pediatric liver transplant centers from Australia and New Zealand were surveyed to determine the organizational and logistical issues related to a liver transplant service. An audit of 15years of liver transplants from a single center was conducted for benchmarking purposes and to identify changes in anesthetic practice over time. Pediatric liver transplants performed in Queensland from January 2005 to December 2019 were reviewed. Changes in transfusion practice reflected international trends. Morbidity and mortality were comparable to international data. Important complications such as hepatic artery and portal vein thrombosis were uncommon and did not generate enough data for further analysis. Combining the anesthetic liver transplant data from all sites in a single registry would expand data collection and generate broadly applicable findings. We propose the establishment of an Australasian pediatric anesthetic liver transplant database.

Changes in Transfusion Practice in Children and Adolescents over Time

Introduction: In recent years, resource-saving handling of allogeneic blood products and a reduction of transfusion rates in adults has been observed. However, comparable published national data for transfusion practices in pediatric patients are currently not available. In this study, the transfusion rates for children and adolescents were analyzed based on data from the Federal Statistical Office of Germany during the past 2 decades. Methods: Data were queried via the database of the Federal Statistical Office (Destasis). The period covered was from 2005 to 2018, and those in the sample group were children and adolescents aged 0–17 years receiving inpatient care. Operation and procedure codes (OPS) for transfusions, procedures, or interventions with increased transfusion risk were queried and evaluated in detail. Results: In Germany, 0.9% of the children and adolescents treated in hospital received a transfusion in 2018. A reduction in transfusion rates from 1.02% (2005) to 0.9% (2018) was observed for the total collective of children and adolescents receiving inpatient care. Increases in transfusion rates were recorded for 1- to 4- (1.41–1.45%) and 5- to 10-year-olds (1.24–1.33%). Children under 1 year of age were most frequently transfused (in 2018, 40.2% of the children were cared for in hospital). Transfusion-associated procedures such as chemotherapy or machine ventilation and respiratory support for newborns and infants are on the rise. Conclusion: Transfusion rates are declining in children and adolescents, but the reasons for increases in transfusion rates in other groups are unclear. Prospective studies to evaluate transfusion rates and triggers in children are urgently needed.

Restrictive Transfusion Practice in Adults Receiving Venovenous Extracorporeal Membrane Oxygenation: A Single-Center Experience

Objectives:Restrictive transfusion policies have been adopted in critical care, although these have not included patients receiving extracorporeal membrane oxygenation. We aimed to assess survival outcomes, adverse events related to RBC transfusion, and cost implications following a change from a “liberal” to a “restrictive” RBC transfusion practice in patients receiving extracorporeal membrane oxygenation.Design:Retrospective observational study.Setting:Single high-volume tertiary critical care department at a university hospital.Patients:Patients 16 years old or greater receiving venovenous extracorporeal membrane oxygenation between 2011 and 2017 for more than 24 hours.Interventions:None.Measurements and Main Results:Clinical diagnoses, complications, outcomes, median hemoglobin, and hematocrit levels were obtained from patients’ electronic records. All laboratory results for hemoglobin and hematocrit were included. RBC transfusions were obtained from prescription charts. We included 402 patients: 99 during a “liberal” transfusion practice (2011–2014)—when the target hemoglobin level was greater than 100 g/L; and 303 treated during a “restrictive” transfusion practice (2014–2017) when the target hemoglobin level was greater than 80 g/L. We found that survival outcomes did not change following the implementation of a “restrictive” transfusion policy. There was also a decrease in the extracorporeal blood flow rates with restrictive transfusion of 0.5 L/min. Nonsurvivors of venovenous extracorporeal membrane oxygenation had higher usage of RBC units following a change in transfusion practice. The restrictive strategy allowed a cost saving of £454 per patient.Conclusions:These results suggest that the adoption of a more restrictive approach to RBC transfusion during venovenous extracorporeal membrane oxygenation is more cost-effective and associated with similar survival outcomes, than when compared with a more liberal approach.

Trends in Iron Overload over Past Two Decades: Results from the Natural History of Iron Burden Study with the SQUID Biosusceptometer

Established in 2002, the Iron Overload Program in Oakland relies on a biosusceptometer (Ferritometer®, model 5700, Tristan Technologies, San Diego, USA) utilizing low temperature SQUID technology to quantify liver iron concentration (LIC). The procedure is non-invasive and patients as young as 2 years can be been measured without sedation. The measurement and analysis are rapid (30 - 45 min) and the results have been validated against biopsy. Over 3500 measurements have been performed on 1055 patients at risk of iron overload. Longitudinal data were acquired under the natural history of iron burden by non-invasive measurement techniques study since November 2002. Patients were referred for liver iron assessment at intervals determined by their providers. Seventy-one patients had ≥10 measurements, 34 had ≥15 measurements, and 7 had ≥20 measurements. Over the course of the study, the average age at enrollment fell from 23 +/- 17 years (range 2 - 88 years) to 18 +/- 15 years (2 - 73 years). There was an increase in the proportion of patients with non-transfusion dependent thalassemia and those with iron overload from red cell transfusions associated with chemotherapy or stem cell transplantation. In comparison to the first five years (2003 - 2008) in the most recent five years (2014 - 2018) chelation has shifted from deferoxamine to deferasirox and there has been an increase in the simultaneous use of two chelators. We observed an overall decrease in mean LIC from 2400 to 1800 micrograms Fe/g liver wet weight (14.4 to 10.8 mg/g liver dry weight). Ferritin to LIC ratios were 0.46 in non-transfused thalassemia, 0.85 in intermittently transfused (< 7 mL/Kg/month), and 1.10 in transfusion-dependent (≥7 mL/Kg/month). A subgroup analysis of longitudinal data in transfusion-dependent thalassemia with multiple measurements was conducted. The mean (±s.d.) LIC decreased by 42% from 15.8 ± 10.2 at the first measurement to 9.2 ± 9.7 mg/g at the last visit. At the same time, mean ferritin decreased from 2629 to 2115 ng/mL, a change of 20%. In this group of patients ferritin levels now overestimate LIC by a significant amount (Figure). This reflects either a change in transfusion practices or the type of chelation. These results show a positive impact of oral chelators and combined chelation regimens leading to a significant improvement in iron overload in thalassemia. The development of organ complications from iron toxicity is expected to decrease, but there is a risk of over-chelation if ferritin is the sole measure of iron status. Liver biosusceptometry has been a valuable method to assess diverse conditions associated with iron overload and to monitor chelation treatment in patients across all ages. Figure Disclosures Lal: Novartis: Research Funding; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding; Terumo Corporation: Research Funding; Insight Magnetics: Research Funding; bluebird bio: Research Funding; Protagonist Therapeutics: Membership on an entity's Board of Directors or advisory committees, Research Funding; La Jolla Pharmaceutical Company: Research Funding. Vichinsky:Pfizer: Research Funding; Global Blood Therapeutics: Consultancy; Agios: Research Funding.

Long-Term Outcomes Among Patients Discharged From the Hospital With Moderate Anemia: A Retrospective Cohort Study.

Randomized clinical trial findings support decreased red blood cell (RBC) transfusion and short-term tolerance of in-hospital anemia. However, long-term outcomes related to changes in transfusion practice have not been described. To describe the prevalence of anemia at and after hospital discharge and associated morbidity and mortality events. Retrospective cohort study. Integrated health care delivery system with 21 hospitals serving 4 million members. 445371 surviving adults who had 801261 hospitalizations between January 2010 and December 2014. Hemoglobin levels and RBC transfusion, rehospitalization, and mortality events within 6 months of hospital discharge. Generalized estimating equations were used to examine trends over time, accounting for correlated observations and patient-level covariates. From 2010 to 2014, the prevalence of moderate anemia (hemoglobin levels between 7 and 10 g/dL) at hospital discharge increased from 20% to 25% (P < 0.001) and RBC transfusion declined by 28% (39.8 to 28.5 RBC units per 1000 patients; P < 0.001). The proportion of patients whose moderate anemia had resolved within 6 months of hospital discharge decreased from 42% to 34% (P < 0.001), and RBC transfusion and rehospitalization within 6 months of hospital discharge decreased from 19% to 17% and 37% to 33%, respectively (P < 0.001 for both). During this period, the adjusted 6-month mortality rate decreased from 16.1% to 15.6% (P= 0.004) in patients with moderate anemia, in parallel with that of all others. Possible unmeasured confounding. Anemia after hospitalization increased in parallel with decreased RBC transfusion. This increase was not accompanied by a rise in subsequent RBC use, rehospitalization, or mortality within 6 months of hospital discharge. Longitudinal analyses support the safety of practice recommendations to limit RBC transfusion and tolerate anemia during and after hospitalization. National Heart, Lung, and Blood Institute.

Transfusion practices in geriatric short stay unit before and after the French national health authority guidelines of 2014.

Retrospective descriptive study in two geriatric short stay units, including patients aged 80 years-old or over, transfused in 2012 and 2015. 103 patients were included. More than 30% patients had a chronic heart failure, and there was no significant difference on general characteristics between the groups in the two years. Compared to 2012, the transfused population in 2015 was more fragile with a higher Charlson comorbidity index (p=0.005). The main symptoms of anemia bad tolerance were cardiovascular symptoms. The average pre-transfusion hemoglobin concentration was 7.9 g/dL in 2015, 8 g/dL in 2012 (p=0.63). By 2015, 72.3% transfusions respected the hemoglobin thresholds recommended in guidelines, compared to 50% in 2012 (p=0.023). Transfusion thresholds in our study were lower than those recommended; 13 adverse reactions were identified, 12 of them were heart failure. There was no significant difference in transfusion benefit between the two years. This study helped describe profile of elderly transfused patients, their geriatric characteristics and the transfusion data, without showing any changes in transfusion practices following the guidelines, despite a more fragile population in 2015. It seems difficult, because of the diversity in the geriatric population, to have a single threshold of hemoglobin recommended, only non-specific symptoms of intolerance and to consider only the cardiovascular comorbidities to decide whether or not to provide a transfusion.

Sa1011 - Changes in Transfusion Practices in Patients with Upper GI Bleeding, 2012-2015

Sa1011 - Changes in Transfusion Practices in Patients with Upper GI Bleeding, 2012-2015

Historical time trends in red blood cell usage in the Netherlands

Background: While the number of hospitalized patients in Dutch hospitals has increased since 1997, the demand for red blood cell units (RBCs) has simultaneously decreased. This implies a dramatic change in transfusion practice toward fewer blood transfusions on average per patient.Objectives: In order to explain the RBC reduction, different patient groups (surgical, medical, obstetrical, and specific age groups) were studied retrospectively in relation to RBC use. In addition, the use of combinations of RBCs, fresh frozen plasma, and platelets during a transfusion episode was examined for trends over time.Materials and methods: Data from the PROTON database, containing information on all transfusions in twelve Dutch hospitals in the period 1996–2005, including corresponding patient data (age, diagnosis, treatment, and hospitalizations) and blood unit data (type, amount, and date) were analyzed.Results: The proportion of RBCs used for surgical patients declined from 50% in 1996 to 40% in 2005, whereas medical use increased from 47% to 58% (the remaining 2%–3% went to obstetrical patients). Changes were more marked in the higher age groups. Also, a trend was observed toward the use of only one or two RBCs during a transfusion episode rather than three or more. Among surgical patients who received blood, the use of combinations of blood units, as compared to RBCs only, increased from 32% to 39%.Conclusion: The results suggest a more restrictive transfusion policy for surgical patients as well as an increase in medical indications for transfusion. This fits well with the current focus on more cost-effective transfusion policies. Keywords: red blood cell usage, combinations of blood units, trends in blood use, medical and surgical patients

Decreasing the critical value of hemoglobin required for physician notification reduces the rate of blood transfusions.

Red blood cell transfusions have been cited as one of the most overused therapeutic interventions in the USA. Excessively aggressive transfusion practices may be driven by mandatory physician notification of critical hemoglobin values that do not generally require transfusion. We examined the effect of decreasing the critical value of hemoglobin from 8 to 7 g/dL at our institution. Along with this change, mandatory provider notification for readings between 7 and 8 g/dL was rescinded. Transfusion rates were compared retrospectively during paired 5-month periods for patients presenting in three key hemoglobin ranges (6.00–6.99, 7.00–7.99, and 8.00–8.99 g/dL). A change in transfusion practices was hypothesized in the 7–8 g/dL range, which was no longer labeled critical and for which mandated physician calls were rescinded. Transfusion rates showed a statistically significant 8% decrease (P≤0.0001) during the 5-month period post change in our transfusion practices. This decrease in the 7.00–7.99 g/dL range was significantly greater than the 2% decrease observed in either the 6–6.99 g/dL (P=0.0017) or 8–8.99 g/dL (P≤0.0001) range. Cost savings of up to $700,000/year were extrapolated from our results showing 491 fewer units of red blood cells transfused during the 5-month post change. These cost savings do not take into account the additional impact of complications associated with blood transfusions.

Perioperative bleeding in patients undergoing liver transplantation.

Liver transplantation (LT) remains one of the most challenging surgical procedures. For many years uncontrolled bleeding and catastrophic haemorrhages were one of the major causes of perioperative mortality and morbidity. During the past fifty years or so, significant progress in surgical techniques and perioperative management has led to a marked change in transfusion practice over time, where up to 79.6% of LTs in experienced transplant centers are performed without any blood product transfusion. Despite this, perioperative bleeding and transfusion requirements remain potent predictors of patient's mortality, as well as postoperative complications and graft survival. The major impact of blood product transfusion on LT recipient outcomes implies that all patients on waiting lists should be carefully screened for the presence of risk factors of perioperative bleeding. Although multiple predictors of transfusion requirements during LT have been identified, no predictive model validated across centers has been constructed. The most suitable strategies to reduce intraoperative blood loss in this group should be employed on a case-to-case basis. This paper aims to summarize the most up-to-date evidence in the management of haemostasis in LT recipients.

Transfusion History and Risk of Non-Hodgkin Lymphoma (NHL): an Interlymph Pooled Analysis

Background. A recent meta-analysis of 9 case-control and 5 cohort studies reported a positive association of transfusion history with risk of NHL (RR=1.20; 95% CI 1.07-1.35), which was only evident in cohort (RR=1.25) and not case-control (RR=1.05) studies (Castillo et al., Blood 2010;116:2897-2907). Risk was similar in men and women, and for transfusions before or after 1992. In subset analyses, elevated risk was only apparent for chronic lymphocytic leukemia (CLL) and not diffuse large B-Cell lymphoma (DLBCL) or follicular lymphoma, but power was low. To further investigate these findings, particularly from studies conducted after 1990, better assess confounding, and address heterogeneity by NHL subtypes, we conducted an individual-level, pooled analysis of 13 case-control studies in the InterLymph Consortium (including 11 studies conducted after 1990; 8 studies were not included in the published meta-analysis).Methods. There were a total of 10,805 cases and 14,026 controls with transfusion data from 13 studies conducted in Europe, North America, and Australia. Transfusion history and other risk factors were self-reported in interviewer-administered or self-administered questionnaires. All risk factor data were harmonized centrally, and cases were grouped into NHL subtypes according to the WHO classification using guidelines from the InterLymph Pathology Working Group. Odds ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression, adjusted for age, sex, and study center.Results. The median age at diagnosis was 60 years for cases (range, 18-97) and 59 years for controls (range, 16-97). The overall prevalence of a history of any transfusion in controls was 15.5%, was higher in women (18.6%) than men (13.0%), and increased with age, but was not associated with race/ethnicity (Asian, Black, Hispanic, White, other) or geographic region after adjusting for age and sex. Among whites, history of any transfusion was inversely associated with NHL risk among men (OR=0.74; 95% CI 0.65-0.83) but not women (OR=0.92; 95% CI 0.83-1.03); there were no significant results for other race/ethnicity groups, and ORs were highly variable and imprecise due to small sample sizes. Thus analyses were restricted to white men, where there was no trend with the number of transfusions, time since first transfusion, age at first transfusion, or decade of first transfusion. Further adjustment for socioeconomic status, body mass index, smoking, alcohol use or hepatitis C virus (HCV) seropositivity did not alter these results. The associations were stronger in hospital-based (OR=0.56; 95% CI 0.45-0.70) than population-based (OR=0.84; 95% CI 0.72-0.98) studies, and were stronger in studies from Southern Europe (OR=0.53; 95% CI 0.36-0.79) than northern Europe (OR=0.67; 95% CI 0.53-0.83) or North America (OR=0.82; 95% CI 0.70-0.98). For NHL subtypes, statistically significant inverse associations were observed for follicular lymphoma (OR=0.70; 95% CI 0.56-0.88), DLBCL (OR=0.72; 95% CI 0.59-0.87), and CLL/SLL (OR=0.67; 95% CI 0.52-0.87), whereas weaker and non-statistically significant associations were observed for mantle cell (OR=0.81; 95% CI 0.54-1.23), marginal zone (OR=0.78; 95% CI 0.54-1.15), lymphoplasmacytic (OR=0.82; 95% CI 0.47-1.42) and peripheral T-cell (OR=0.83; 95% CI 0.49-1.40) lymphomas.Conclusion. Contrary to earlier results, transfusion history was inversely associated with risk of NHL and the common subtypes of follicular lymphoma, DLBCL and CLL/SLL among white men, whereas associations were null among white women and other racial/ethnic groups. These results were not explained by confounding by lifestyle factors or HCV seropositivity, era of first transfusion, hospital versus population-based study design, or geographic location. Despite dramatic changes in transfusion practice over the past 40 years, results were similar for decade of first transfusion, suggesting secular trends are a less likely explanation. Our results are unexpected and bias cannot be ruled out. Further studies, particularly cohort studies, are needed to clarify the role of transfusion history in NHL risk. DisclosuresNo relevant conflicts of interest to declare.

The Example of the UK SHOT Haemovigilance System

SHOT (Serious Hazards of Transfusion scheme) is the UK’s National confidential haemovigilance system, and was set up in 1996. It is an independent, confidential, professionally led haemovigilance scheme. Initially the reporting was voluntary but now required by several professional bodies. SHOT publishes annual reports with recommendations and circulates to all relevant organizations including the 4 UK Blood services, Departments of Health in England, Wales, Scotland and Northern Ireland, all relevant professional bodies and reporting hospitals. Over the 17 years of reporting, the evidence gathered has prompted changes in transfusion practice from the selection and management of donors to changes in hospital practice, better education and training. Acute transfusion reactions and transfusion-associated circulatory overload carry the highest risk for morbidity and death. Greatest risk to patients remain errors in the process at the point of blood sampling, in the laboratory and at bedside administration. SHOT’s objectives are to use findings to improve standards of hospital transfusion practice, to educate users on transfusion hazards and prevention, to aid production of clinical guidelines in blood transfusion and to inform national policy on transfusion safety. MHRA is the UK competent authority to which serious adverse reactions and events have to be reported annually. Overall the most common adverse incidents are caused by errors, resulting in the transfusion of an incorrect component or one that does not meet the specific requirements of the patient (e.g. not irradiated or not appropriately antigen matched). TACO (transfusion associated circulatory overload) accounts for most deaths and major morbidity reported to SHOT but is overall underreported. Transfusions are not always given appropriately. This may be due to wrong haemoglobin results, failure to assess patients appropriately, or avoidable use of emergency O RhD negative units because of poor communication or planning. Review of cases of haemolytic transfusion reactions (HTR) shows that they are observed mainly in Sickle Cell Disease patients. HTR are associated with major morbidity (10/16 cases in sickle cell patients over 3 years) and death (a child in 2010). SCD patients are at particular risk of alloimmunization and this can be reduced by red cell phenotyping prior to the first transfusion followed by routine matching for at least the Rh and Kell groups. SHOT output data led over the time to the development of strategies to improve transfusion safety such as the implementation of guidelines for improving practice, implementation of the National Comparative Audit of Blood Transfusion programme, the publication of the Better blood transfusion initiatives and the establishment of The UK transfusion laboratory collaborative.

The success of our patient blood management program depended on an institution‐wide change in transfusion practices

Patient blood management (PBM) programs seek to optimize the utilization of blood components. Since our institution's program started, the annual number of red blood cell (RBC) units transfused has decreased by 27% overall. We collected data for 6 months in 2007 (pre-PBM) compared with the same months in 2011 (post-PBM) to determine which changes in practice decreased RBC utilization. Indications for transfusion of nonsurgical patients were collected from the electronic medical records, while surgical indications were assigned to the admitting physician's specialty. Pre-PBM, we transfused 19,888 RBC units for a mean of 0.96 units per patient discharged, compared with 14,472 post-PBM, for a mean of 0.55 units per discharge. This represents a 43% reduction in RBC units transfused per patient discharged. While transfusion episodes decreased only slightly from 9519 to 9261, the success can be explained by the overall reduction in mean number of units per transfusion from 2 to 1.5 (p < 0.0001). Pre-PBM, 22 and 48% of patients received 1 or 2 units of RBCs per transfusion episode, respectively, while in 2011, the percentages were 51 and 33%, respectively (p < 0.0001). The mean number of RBC units per transfusion decreased significantly for approximately 50% of the indications. Our success was achieved through hospital-wide physician buy-in toward a restrictive transfusion approach. We hope to encourage others to consider PBM for improved patient outcomes and blood conservation.

Discontinuing washed red cell transfusions in thalassaemia patients

<h3>Aim</h3> To assess if thalassaemia patients previously transfused with washed red cells (WRC) can effectively be transitioned to leucodepleted RBC (LDRC) with leucodepletion standard and RBC plasma content low. <h3>Methods</h3> An audit was conducted from June 2009 at POWH of 20 thalassaemia patients previously receiving WRC before and after changing to LDRCs. Transfusion reactions, RBC requirement and Hb pre-transfusion were documented for six episodes around the introduction of LDRC. NSW Blood Service WRC supply data before and after this change in policy at POWH is reported. <h3>Results</h3> Reactions were only noted in a small number of patients transitioned to LDRC. In most cases reactions did not require reins-tituting WRC. In 2/20 patients WRC use was reinstituted. Changes in RBC requirement and haemoglobin levels were not apparent. In the 2008-2009 financial year, a total of 2708 washed units were supplied in NSW and following the wider adoption of this policy, 811 washed units were supplied in the 2012-2013 financial year. <h3>Discussion</h3> Thalassaemia patients on WRC can be successfully transitioned to leucodepleted RBC. The transition appears safe and the subsequent rate of reactions appears low. This change in transfusion practice may save costs and also simplify the logistics of regular blood transfusion in this patient group.

Changes in transfusion practice over time in the PICU.

Recent randomized clinical trials have shown the efficacy of a restrictive transfusion strategy in critically ill children. The impact of these trials on pediatric transfusion practice is unknown. Additionally, long-term trends in pediatric transfusion practice in the ICU have not been described. We assessed transfusion practice over time, including the effect of clinical trial publication. Single-center, retrospective observational study. A 10-bed PICU in an urban academic medical center. Critically ill, nonbleeding children between the ages of 3 days and 14 years old, admitted to the University of Maryland Medical Center PICU between January 1, 1998, and December 31, 2009, excluding those with congenital heart disease, hemolytic anemia, and hemoglobinopathies. None. During the time period studied, 5,327 patients met inclusion criteria. Of these, 335 received at least one RBC transfusion while in the PICU. The overall proportion transfused declined from 10.5% in 1998 to 6.8% in 2009 (p = 0.007). Adjusted for acuity, the likelihood of transfusion decreased by calendar year of admission. In transfused patients, the pretransfusion hemoglobin level declined, from 10.5 g/dL to 9.3 g/dL, though these changes failed to meet statistical significance (p = 0.09). Neonatal age, respiratory failure, shock, multiple organ dysfunction syndrome, and acidosis were associated with an increased likelihood of transfusion in both univariate and multivariable models. The overall proportion of patients transfused between 1998 and 2009 decreased significantly. The magnitude of the decrease varied over time, and no additional change in transfusion practice occurred after the publication of a major pediatric clinical trial in 2007. Greater illness acuity and younger patient age were associated with an increased likelihood of transfusion.