Inappropriate Use Of Blood Research Articles

Evaluation of Blood Requisition Forms Submitted to Transfusion Medicine Department of a Tertiary Care Hospital in Dhaka, Bangladesh

Introduction: Blood requisition form (BRF) analysis is one of the most efficient and effective approaches to assess and monitor rational use of blood and its product. BRF is the first line of communication between the clinicians and transfusion medicine specialists which helps to recognize and evaluate inappropriate use of blood. This issue is frequently underrated by the clinicians which results in increased risk of inappropriate transfusion. The current study is aimed to examine the pattern of completion of blood requisition forms and to ensure safe blood transfusion. Materials and methods: This cross sectional prospective study was conducted from January 2020 to December 2021, at the Department of Transfusion Medicine, Sir Salimullah Medical College Mitford Hospital, Dhaka, Bangladesh. A total of 32,133 blood requisition forms that were submitted during the study period were compiled and reviewed anonymously. The data were analyzed using Microsoft Excel. Results: During the study period, a total of 32,133 Blood requisition forms were analyzed. Only 15.2% of these forms were duly completed. Rest of the forms had one or more important parameters left blank. The most common incomplete BRF items were the clinical history or differential diagnosis of the patient (52.66%), presumed date and time of transfusion (95.19%), previous transfusion history (95.9%), and referring doctor’s name and designation (88%). Blood requests were more for females (52.02%) than males (47.98%) during the period. Requisitions were more for adults (90%) than pediatric patients. Conclusion: The current study provides evidence that the rate of completion of BRFs is not satisfactory. The request forms evaluated were not covering acceptable demographic and clinical data of the patients. Both the Hospital Transfusion Committee (HTC) and the Department of Transfusion Medicine can help to improve and standardize transfusion practice by working together. Sir Salimullah Med Coll J 2022; 30: 142-147

Study of Utilization Pattern of Blood And Blood Components in Obstetrics at A Tertiary Care Hospital

Background: Blood transfusion is a life-saving procedure, but inappropriate use of blood and its components in obstetric emergencies, especially in cases of massive bleeding, increases the risk of morbidity and mortality. The aim of this study was to describe the determinants of blood and blood components in obstetrics in a tertiary care hospital with indications for transfusion for different components during the study. Subjects and Method: A Prospective Observational study was carried from May 2018 to December 2019 at Department of Obstetrics and Gynaecolog,T.N.M.C & B.Y.L.Nair Hospital Mumbai. The independent variables are sociodemographic characteristics, parity, mode of delivery, education, hospital level, while dependent variables are frequency of obstetric transfusion. Frequency of transfusion of blood and its components obtained from case file of patient. The other data were collected by questionnaire. Analysis of 366 Obstetric patients requiring blood transfusion in eighteen months period was done. Qualitative data were presented as frequency and percentages and analysed using the chi-square test. Results: During the whole study 366 of obstetric admission required transfusion of blood and its components. Severe anaemia during pregnancy/postpartum anaemia (51%) were the most common indications for blood product transfusions followed by Accidental Haemorrhage (30%), Caesarean section (10.38%) Genital tract trauma including uterine rupture (11%), Postpartum Haemorrhage’s (13%), Placenta previa (6.5%), Ectopic pregnancies (3.5%), Vesicular mole (3.27%), Retained placenta (3.27%) Ruptured uterus (1%), and Abortion (2.7%). Packed cells (47%) were the most common type of blood and blood products transfused followed by Fresh Frozen Plasma (41.86%). Conclusion: : In obstetric emergencies, correct diagnosis and management of emergencies, A pre- planned, multidisciplinary protocol yields excellent effects in the management. Keywords: blood transfusion, pregnancy, anaemia, obstetric emergencies Correspondence: Avinash N. Jadhao. Associate Professor, Department of Biochemistry Seth GSMC & KEMH Parel Mumbai 400012, India. Email: avinashjadhao@kem.edu. Phone no.91 7718971066.

Blood Transfusion in Obstetrics and Gynecology: A Retrospective Analysis in Government Naseerullah Babar Hospital Peshawar

OBJECTIVES: To evaluate the indications of blood transfusion in the Obstetrics and Gynecology Department of Government NaseerUllah Khan Babar Memorial Hospital. METHODOLOGY: This retrospective observational study was performed on indoor gynecology and obstetrics patients for the period of one year, a total of 100 patients were included in this study that received blood transfusion. Samples were collected by non-random convenience sampling after getting approval from the hospital ethical committee. Data was analyzed by using SPSS version 20. RESULTS: In this study a total of 100 patients who received blood transfusion were analyzed, out of 100 patients 78% of patients received transfusion due to obstetrical causes and 22% patients got transfused for gynecological causes. Most common blood group transfused was B+ and O+ and mean hemoglobin level at which patients received blood transfusion was 9.7g/dl. Blood components preparation can provide components to treat two to three patients from a single donor. The use of packed cell transfusion should be promoted instead of whole blood transfusion that is not even needed in most of the cases. CONCLUSION: Blood transfusion practice has been used aggressively in gynecology and obstetrics in some cases even without proper indications. There is a need to modify this practice by correcting anemia through drugs to avoid the inappropriate use of blood. Use of blood components should be encouraged.

A Review of Blood and Blood Products Requisition and Utilization in Post-neonatal Ward of a Tertiary Hospital in South Western Nigeria

Background: Blood and its products ordering is a common practice in paediatrics. The ready availability of blood and blood components has resulted in liberal use. Inappropriate use of blood and blood products exposes patients to the risk of transfusion transmissible diseases and allergic and haemolytic reactions.
 Objective: To assess blood and blood products requisition and utilization in a post-neonatal ward in a semi-urban tertiary hospital in Nigeria
 Methods: Retrospective analysis of medical records of all transfused post-neonatal patients during the study period from 1st July 2015 to¬ 31st December 2016 to calculate the cross-match to transfusion ratio, transfusion probability and transfusion index.
 Results: The units of blood cross-matched were 98 and 90 blood units transfused. The cross-match to transfusion ratio was 1.09 indicative of significant blood usage. The transfusion probability was 100% indicative of significant blood usage. The transfusion index was 1.10 indicative of significant blood utilization.
 Conclusion: Transfusion of blood and blood products in the post-neonatal ward of our setting meet the standard criteria for quality indicators for blood utilization.

Patient blood management and blood conservation – Complimentary concepts and solutions for blood establishments and clinical services in South Africa and beyond

Blood transfusions come with risks and high costs, and should be utilized only when clinically indicated. Decisions to transfuse are however not always well informed, and lack of clinician knowledge and education on good clinical transfusion practices contribute to the inappropriate use of blood. Low and middle-income countries in particular take much strain in their efforts to address blood safety challenges, demand-supply imbalances, high blood costs as well as high disease burdens, all of which impact blood usage and blood collections. Patient blood management (PBM), which is a patient-focused approach aimed at improving patient outcomes by preemptively diagnosing and correcting anaemia and limiting blood loss by cell salvage, coagulation optimization and other measures, has become a major approach to addressing many of the challenges mentioned. The associated decrease in the use of blood and blood products may be perceived as being in competition with blood conservation measures, which is the more traditional, but primarily product-focused approach. In this article, we hope to convey the message that PBM and blood conservation should not be seen as competing concepts, but rather complimentary strategies with the common goal of improving patient care. This offers opportunity to improve the culture of transfusion practices with relief to blood establishments and clinical services, not only in South Africa and LMICs, but everywhere. With the COVID-19 pandemic impacting blood supplies worldwide, this is an ideal time to call for educational interventions and awareness as an active strategy to improve transfusion practices, immediately and beyond.

Assessing the appropriateness of blood transfusion among injured patients at a Ghanaian tertiary hospital: Time for clarity on the use of a scarce resource.

Hemorrhage is an important cause of preventable injury-related death. Many low- and middle-income country (LMIC) patients do not have timely access to safe blood. We sought to determine the degree of appropriateness of blood transfusion among patients with injuries requiring surgical intervention at presentation to a tertiary hospital in Ghana. We performed a retrospective review of such patients presenting to Komfo Anokye Teaching Hospital (KATH), from January 2015 to December 2016. Patients' hemoglobin levels at presentation were determined as the first record of hemoglobin after presentation and their receipt of blood transfusion was determined by explicit documentation in the chart. We defined appropriate blood transfusion practice as patients receiving transfusion when hemoglobin was equal or below a threshold, or patients not being transfused when hemoglobin was above the threshold. We considered both restrictive (hemoglobin ≤7 g/dL) and liberal (hemoglobin ≤10 g/dL) transfusion thresholds. There were 1,408 patients who presented to KATH with injuries that met inclusion criteria. Two hundred and ninety two (292) patients were excluded because of missing hemoglobin information. Four hundred and fifty eight (458;41%) patients received blood transfusion. Transfused patients had a higher mean age (38 vs 35 years) and were less likely to be male (62% vs 71%). Transfused patients underwent more external fixation procedures (28% vs 19%), trauma amputations (5% vs 1%) and trauma laparotomies (3% vs 1%). At a restrictive transfusion threshold (hemoglobin ≤7 g/dL), 20% of patients who needed a transfusion did not receive one and 39% of patients who did not need a transfusion received one. At a liberal threshold (hemoglobin ≤10 g/dL), 33% of patients who needed a transfusion did not receive one and 30% of patients who did not need a transfusion received one. Blood transfusion practice was inappropriate in 31%-39% of all patients. Our data suggest that clearer guidelines for blood transfusion among emergency surgery patients are needed in Ghana and similar LMICs to avoid inappropriate use of blood as a scarce resource.

The scientific basis for patient blood management

Patient blood management is an increasingly used term to describe an evidence-based, multidisciplinary approach to optimising the care of patients who might need transfusion. It encompasses measures to avoid transfusion such as anaemia management without transfusion, cell salvage and the use of anti-fibrinolytic drugs to reduce bleeding as well as restrictive transfusion. It ensures that patients receive the optimal treatment, and that avoidable, inappropriate use of blood and blood components is reduced. This paper provides an overview of the scientific basis for patient blood management with a focus on the increasing evidence for restrictive rather than liberal transfusion practice and the use of electronic blood ordering and decision support to facilitate its implementation.

Making the right clinical decisions in component therapy

Rational clinical decision‐making is essential to guide appropriate transfusion practice. The use of evidence‐based guidelines needs a focused effort on various activities to promote implementation including training of all healthcare personnel involved, clinical audit and meaningful patient involvement. At present, there continues to be considerable inappropriate use of blood and components with variation in practice and targeted strategies are needed to improve practice supported by the use of information technology where available. There is a collective need to implement the principles of Patient Blood Management with an evidence‐based multidisciplinary approach to optimizing the care of all patients who might need transfusion with the timely use of alternatives wherever available.

Clinical use of blood and its components in tertiary health care center in northwestern India

Background: Blood transfusion is an indispensible part of modern-day health care and there is an increase in use of blood. National guidelines for use of blood and its components are often not followed in practice. Objective: To define the justified and appropriate use of blood and its components as a drug. Materials and Methods: We carried out cross-sectional study on patients requiring transfusion of blood and its components from January 2012 to June 2012. Tested blood (7048 units) and its components for 2742 patients were surveyed during a period of 6 months and the indications for usage and transfusion reactions associated with its usage were recorded. Result: Of the hospitalized patients, 11.82% received blood transfusion. A total of 7048 transfusions were performed in 2742 patients. Most of the blood transfusions were seen in age group of 18–50 years followed by ≤12 years. Blood transfusion was more common in males than in females, except in the age group of 13–17 years. Of the blood transfusions received, maximum were of packed red cell (47.15%) followed by those of whole blood (43.06%). Of 5154 components prepared, only 4353 were used. Single-unit blood transfusions were performed in 55.65% patients. Most common and rare blood groups were B+ and AB–, respectively. Maximum transfusions were performed among patients with anemia (877) followed by those with thalassemia (422) and those having bone fractures (306). Maximum transfusions were performed to children ward (765). Conclusion: This study reinforces the importance of justified and appropriate use of blood and its components in the clinical practice. Implementation of guidelines for use of various blood products may help in decreasing inappropriate use of blood and its components.

Teaching transfusion medicine: current situation and proposals for proper medical training.

The current curricula in medical schools and hospital residence worldwide lack exposure to blood transfusion medicine, and require the reformulation of academic programs. In many countries, training in blood transfusion is not currently offered to medical students or during residency. Clinical evidence indicates that blood transfusions occur more frequently than recommended, contributing to increased risk due to this procedure. Therefore, the rational use of blood and its components is essential, due to the frequent undesirable reactions, to the increasing demand of blood products and the cost of the process. Significant improvements in knowledge of and skills in transfusion medicine are needed by both students and residents. Improvements are needed in both background knowledge and the practical application of this knowledge to improve safety. Studies prove that hemovigilance has an impact on transfusion safety and helps to prevent the occurrence of transfusion-related adverse effects. To ensure that all these aspects of blood transfusion are being properly addressed, many countries have instituted hospital transfusion committees. From this perspective, the interventions performed during the formation of medical students and residents, even the simplest, have proven effective in the acquisition of knowledge and medical training, thereby leading to a reduction in inappropriate use of blood. Therefore, we would like to emphasize the importance of the exposure of medical students and residents to blood services and transfusion medicine in order for them to acquire adequate medical training, as well as to discuss some changes in the current medical curricula regarding transfusion medicine that we judge critical.

A retrospective clinical audit of blood transfusion requests in tertiary care hospital

Introduction: The inappropriate use of medical technology is a major factor in increased health care expenses and inappropriate use of blood is costly. There is a need for continuous audit of the use of products as therapy. Audits are useful tools in the education of those ordering blood components, potentially resulting in the reduction of inappropriate use of blood components. Aim: A retrospective clinical audit of blood transfusion requests in patients at a tertiary care hospital. Material and Methods: This retrospective clinical audit conducted at NKP salve institute of medical sciences and research center and lata mangeshkar hospital Nagpur for a period of 3 months from April 2013 to June 2013. A retrospective analysis of blood and its component requisitions in all patients from different clinical departments was reviewed regarding diagnosis, indication for transfusion, number of units requested and the speciality prescribing it. Reports of silent investigations like hemoglobin, platelet count, coagulogram was also recorded. Results: Out of 869 requisitions, 301 were for male patients and 568 were for female patients. Total number of blood components distribution request was 1188. 632 were for whole blood, 364 were for packed red cells, 182 were for FFP and 10 for platelet concentrate. Pre transfusion Hemoglobin was >8 gm/dl in 273 requests. Pre transfusion hemoglobin values were not available for 192. The urgency for transfusion was mentioned on 728, indication was mentioned on 804 and diagnosis was mentioned on 755 requisition forms. Multiple blood components requests were 97. The maximum request was from Department of Obstetrics and Gynaecology. Total blood components issues were 707. Out of which 329 whole blood, 194 packed red cells, 182 FFPs and platelet concentrate were 2. Total donors were 554. Conclusion: Clinical audits helps to reduce inappropriate use of blood and blood components, avoids blood transfusion reaction and avail the deprived patients.

Hospital‐based transfusion error tracking from 2005 to 2010: identifying the key errors threatening patient transfusion safety

This report provides a comprehensive analysis of transfusion errors occurring at a large teaching hospital and aims to determine key errors that are threatening transfusion safety, despite implementation of safety measures. Errors were prospectively identified from 2005 to 2010. Error data were coded on a secure online database called the Transfusion Error Surveillance System. Errors were defined as any deviation from established standard operating procedures. Errors were identified by clinical and laboratory staff. Denominator data for volume of activity were used to calculate rates. A total of 15,134 errors were reported with a median number of 215 errors per month (range, 85-334). Overall, 9083 (60%) errors occurred on the transfusion service and 6051 (40%) on the clinical services. In total, 23 errors resulted in patient harm: 21 of these errors occurred on the clinical services and two in the transfusion service. Of the 23 harm events, 21 involved inappropriate use of blood. Errors with no harm were 657 times more common than events that caused harm. The most common high-severity clinical errors were sample labeling (37.5%) and inappropriate ordering of blood (28.8%). The most common high-severity error in the transfusion service was sample accepted despite not meeting acceptance criteria (18.3%). The cost of product and component loss due to errors was $593,337. Errors occurred at every point in the transfusion process, with the greatest potential risk of patient harm resulting from inappropriate ordering of blood products and errors in sample labeling.

End‐to‐end electronic transfusion management in hospital practice

Background Errors occur at all stages of the hospital transfusion process and the resulting morbidity and mortality are well documented. Recent initiatives in the UK and elsewhere to reduce transfusion errors have focussed on implementing recommended manual procedures for good practice, but have only been partially effective.Aims Our approach was to ‘re‐engineer’ bedside and laboratory transfusion procedures.Materials and Methods We implemented barcode patient identification, bedside handheld computers and electronically controlled blood fridges to simplify transfusion procedures and improve practice.Results There was an improvement from 11.8% to 100% of staff following the process for correct pre‐transfusion bedside patient identification; no ABO incompatible red cell transfusions in 5 years; a reduction in wrong blood component transfused events from 1 in 27,523 to 1 in 67,935; reduced nursing (one nurse rather than 2 and half the time to administer blood) and laboratory workload; and more rapid delivery of urgently required red cell units to patients (from a median of 18 minutes to 45 seconds). The electronic system provided a simple mechanism for compliance with UK/EU regulatory requirements for the traceability of blood, and the documentation of transfusion and training. Feedback from both staff and patients was positive.Discussion The project was taken through pilot stages between 2001 and 2006 through to its full implementation across the acute hospitals in Oxfordshire in 2006/07. Our group wrote a national specification for the electronic transfusion process, but the implementation elsewhere in the UK has been slow. There is the potential to introduce an additional module into the electronic transfusion process to provide ‘decision support’ for doctors ordering blood to minimise inappropriate use of blood as part of a patient blood management programme, and use the same ‘end‐to‐end electronic’ approach for other clinical procedures such as drug administration.Conclusion The implementation of a hospital electronic transfusion management system was shown to provide improvement in transfusion practice and in the efficiency of the service.

Appropriate blood component usage

Blood transfusion (which includes FFP, platelets, cryoprecipitate and any other blood‐derived product) remains an important modality of treatment across all clinical disciplines. A blood transfusion is deemed appropriate when used in an evidence‐based fashion and where the effects of the transfusion are felt to outweigh any potential risks and complications that may arise from the transfusion. In certain cases, it may be the best treatment option available, for example plasma exchange in thrombotic thrombocytopenic purpura. However, blood transfusion can result in acute or delayed complications, as well as the risk of transmission of infectious agents. The inappropriate use of blood and blood products increases the risk of transfusion‐related complications and adverse events to recipients. It also contributes to shortages of blood products and the possibility of it not being available when required for other patients in an appropriate setting. It is therefore necessary to reduce the unnecessary transfusions through the appropriate clinical use of blood, avoiding unnecessary transfusions, and use of alternatives to transfusion.

Evaluation Of Blood Component Request And Ultrasound In Maiduguri North Eastern Nigeria

Background: Lives can be saved through blood and blood component transfusions. However, people still die or remain at risk of transfusion-transmissible infections due to poor donor recruitment and selection, use of poorly screened blood and inappropriate use of blood and blood components. Objectives: To evaluate the pattern of blood component request and utilisation in north eastern Nigeria. Setting: Department of Haematology and Blood Transfusion of the University of Maiduguri Teaching Hospital, Northeastern Nigeria. Results: A total of 1097 blood component was requested for transfusion. Out of these, 1066 were used and 31 were returned and later discarded due to contamination. The commonest prescribed blood type was whole blood (81.1%) Blood used was higher for obstetrics and gynaecological cases and least for paediatric surgical cases. The number of patients transfused with only one unit of blood constitutes 49.3%. The proportion of donor category was 47.3% for directed or family replacement, 39.7% for commercial or paid donors, 12.2% for predeposit autologous donors and only 0.8% for voluntary donors. Conclusion: This study has shown that family replacement and paid donors, which are associated with high prevalence of transfusion-transmissible infections, still provide most of the blood components used in this environment. Keywords: Blood component requests, Northeastern Nigeria., transfusion.Highland Medical Research Journal Vol. 5 (1) 2007 pp. 28-32

Perioperative Blood Transfusion

The use of donor (allogeneic) blood products has been vital to the development of modern surgical and anaesthetic practice. The National Blood Service supplies approximately 2.2 million units of blood products to hospitals each year. The risk of infections transmitted by blood products has caused major concern over the past twenty years. Blood transfusion today is safer than ever with regard to infective risk, but is still associated with many problems, which may adversely affect patient outcome. The prevalence of administrative errors leading to adverse patient outcome has been highlighted by haemovigilance systems such as the Serious Hazards of Transfusion (SHOT) reporting system and evidence for immunosuppression associated with transfusion has accumulated. The introduction of more sophisticated testing in order to improve the safety of donor blood has increased the cost of blood components. In addition, an increasingly elderly population and more ambitious surgery are projected to lead to an increased demand for blood products. This raises the possibility that future demand for donor blood may outstrip supply. It is for these reasons that there is a growing awareness of the need to use this valuable resource more sensibly. The aim of this review is to discuss the pivotal efficacy data and safety issues related to transfusion of red cell and haemostatic component therapies. By highlighting not only the evidence on which much of current practice is based, but also areas for concern regarding safety, the objective is to help the clinician understand the basis for strategies to minimize inappropriate use of blood and blood products. Donor blood is collected into an additive solution containing citrate that chelates calcium ions to prevent coagulation. The whole blood is now processed into various components, but typically red cell and platelet concentrates, frozen plasma and cryoprecipitate. The composition of these factors is outlined in Figure 1.

Future Directions in Utilization Review: The Role of Transfusion Algorithms

Transfusion practice guidelines and retrospective utilization review have been ineffective in curtailing the inappropriate use of blood and blood products, particularly in cardiac surgical patients. Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) are at increased risk for excessive perioperative blood loss requiring transfusion of blood products. Recent evaluations have focused on the use of point-of-care coagulation assays for patient-specific therapy. Blood component administration in patients with excessive post-CPB bleeding is generally empiric, in part related to the times required to perform of laboratory-based tests. Methods are now available for rapid, on-site assessment of coagulation assays to allow appropriate, targeted therapy for acquired hemostatic abnormalities. Recent studies indicate that a rapid evaluation of thrombocytopenia and coagulation factor deficiencies, coupled with transfusion algorithms, can facilitate the optimal administration of transfusion-based therapy in patients who exhibit excessive bleeding after CPB. The use of point-of-care assays and transfusion algorithms may provide an effective concurrent method of utilization review of blood products in the surgical setting.

Blood transfusion practices and blood-banking services in a Kenyan hospital

To identify ways to improve the operation of blood-screening programs and to decrease the inappropriate use of blood by evaluating blood-transfusion practices and blood-banking services in a Kenyan hospital. Prospective cohort. The study was conducted in a rural district hospital in western Kenya between September 1990 and July 1991. We collected data on all transfusion requests (blood donation, grouping, HIV screening) and blood recipients (age, sex, diagnosis, and for a 3-month period on the pediatric, maternity, and female wards, admission hemoglobin and outcome). During the 11-month study period, 799 patients received 927 transfusions: 67% were children < 15 years of age, 27% were adult women and 6% were adult men. Transfusions were often delayed due to reliance on patient-recruited donors. Patients who received blood donated on or after the date of request waited longer for transfusion (median, 3 days) than patients who received blood that had been banked and screened before the request (median, 1 day). Patient-recruited donors had a higher HIV-seropositivity rate than volunteer donors (13.4 and 4.6%, respectively; chi 2 test, P < 0.001). Overall, 47% of pediatric transfusions were classified as inappropriate: 23% did not meet the criteria of having hemoglobin < 5.0 g/dl and clinical evidence of respiratory distress, and 27% were transfused 2 or more days after requested. Among adults, 68% received one unit of blood or less. Improved laboratory services, reduction of unnecessary transfusions, and increased recruitment of volunteer donors are critical for improving the appropriate and timely use of blood and reducing transfusion-associated HIV transmission.