Transfusion Audit Research Articles

Reducing blood transfusion in dialysis unit

REDUCING BLOOD TRANSFUSION IN DIALYSIS UNIT Ruth Yang, John Cunningham, John Connolly & Colley Crawford London UK Blood transfusions are generally detrimental to dialysis patients and should be avoided when possible (Daugirdas J 1994). The risks for patients, including: ABO incompatibility; anaphylactic reaction; transmission of virus infection such as hepatitis B,C or HIV; jeopardy of a prospect for renal transplantation. The dialysis unit has 110 patients. In 2002, 386 blood transfusion units were used. In 2003,we introduced a blood transfusion recording system aiming to monitor and reduce blood transfusion for the dialysis patients. It includes: 1) Introduction of Blood Transfusion Request form filled by doctors. It indicates the reason to prescribe. 2) Introduction of Blood Transfusion Record form filled by nurse for each transfusion. It includes date, patients name, HB, blood units and name of the doctor who prescribes. 3) Introduction of Blood Transfusion Folder. Both forms above are kept in it. The Anaemia co-ordinator produces an on going monthly audit of blood transfusion according to the data. A monthly anaemia review meeting is held between the nephrologists consultants, dialysis unit registrar and anaemia coordinator by using 1) a chart of all dialysis patients’ current Epo dose, monthly HB, MCV, HCT, reticulocyte count, fe, IBS, ferritin and CRP; 2) a trend record of HB and Epo dose for every patient on a monthly basis; 3) a chart with a graph indicating continuing Hb results according to the UK Renal Association, European Best Practice Guide and K/DOQI standards; 4) a chart with a graph indicating a correlation between average HB, average Epo dosage and blood transfusion each month. The result appeared encouraging. Blood transfusion has reduced by 62% in two yeas. Time Blood Transfusion units % 0 0 1 4 8 3 2 0 0 2 % 8 5 5 2 2 3 0 0 2 % 8 3 6 4 1 4 0 0 2 2005 140 36%

Clinical audit of the use of fresh‐frozen plasma and platelets in a tertiary teaching hospital and the impact of a new transfusion request form

To carry out an audit of the appropriateness of fresh-frozen plasma (FFP) and platelets (Plt) transfusion with reference to the Australian National Health and Medical Research Council/Australian Society of Blood Transfusion Clinical Practice Guidelines, and to assess the impact of a self-educating transfusion request form. A prospective review of the clinical indications and laboratory data in all transfusion episodes of FFP and Plt occurring in a tertiary teaching hospital in South Australia in two 2-month periods of the years 2002 and 2003. Reversal of warfarin has emerged as the major indication to transfuse FFP (34%). More than 72% FFP and 88% Plt were prescribed in an appropriate manner, and the majority were monitored adequately. The transfusion request form further improved the appropriate uses and was met with a satisfactory compliance. Further grounds for improvement are in FFP usage by the haematology unit and in cardiac bypass surgery, and Plt by surgical units. Clinical transfusion audit helps to identify current pattern of usage and areas of improvement. A self-educating transfusion specific request form is also beneficial.

A Prospective Audit of Blood Loss and Blood Transfusion in Patients Undergoing Coronary Artery Bypass Grafting After Clopidogrel and Aspirin Therapy

A Prospective Audit of Blood Loss and Blood Transfusion in Patients Undergoing Coronary Artery Bypass Grafting After Clopidogrel and Aspirin Therapy

Guidelines for Transfusion: A Way to Decrease Transfusion

SUMMARYTransfusion practice must be audited to comply with regulatory and quality standards. The Joint Commission on the Accreditation of Healthcare Organizations requires evaluation of transfusion practice as a part of continuous quality improvement. Transfusion guidelines are written by each institution, usually by a blood utilization committee, and then reviewed by the committee, which is composed of transfusion medicine and peer members. These guidelines should contain criteria that would make a transfusion easily justified without further investigation. In addition, they should include clinical criteria that render transfusion appropriate, even if the proscribed triggers are not met. Guidelines serve as a means of evaluating transfusion practice, not as transfusion indications.In addition to concerns about transfusion transmitted disease, there are also growing numbers of reports of increased morbidity and mortality due to transfusion itself, which is known to mediate inflammatory cytokines. With new safety measures, regulatory requirements and changes in demographics, there are less eligible donors, resulting in concerns over the adequacy of the blood supply.With the long potential life span of pediatric patients, preventing adverse transfusion outcomes that could have long‐term consequences is important. There are a variety of pharmacologic agents and new technologies available to decrease the need for blood products, reducing risks from transfusion, while preserving the supply of banked blood. Transfusion guidelines are an integral component of any program to help an institution evaluate how well it adheres to acceptable, safe practice. There are many publications written by expert consensus panels that set down adult transfusion audit guidelines and a few that specifically address pediatric guidelines. Unfortunately, there is a paucity of evidence‐based data in the pediatric transfusion literature. This paper will look at data to support the use of conservative transfusion practice and then discuss the creation of guidelines and how they can help, in a comprehensive program, to decrease or even abrogate the use of blood products. Where specific data for pediatric transfusion exists, it will be presented.

Computerized quality assurance of decisions to transfuse blood components to critically ill patients.

In critically ill patients optimal transfusion therapy for most clinical settings has not been determined. The objective of this study was to evaluate the impact of a computerized audit on transfusion decisions of red blood cells (RBC), fresh frozen plasma (FFP), and platelets among critically ill patients. Two hundred and ninety consecutive patients admitted to nine-bed medical-surgical intensive care unit at a university hospital were included in this prospective study. Prior to the study, the criteria for transfusions of RBCs, FFP and platelets were established. Phase I, the first 3-month period served as a control period. During phase II the fulfilment of these criteria was prospectively monitored by an audit software belonging to the computerized blood request program. If the predefined transfusion criteria were not met the audit software was automatically activated. The last 3-month period, phase III, was to assess if possible effects on transfusion decisions were permanent. The proportion of RBC transfusions administered according to predefined trigger during the study phases I, II, and III were 55.9%, 75.1% and 67.9%, respectively (P < 0.001). The proportion of FFP and platelet transfusions according to a predefined trigger did not differ statistically significantly between the study phases. Logistic multiple regression analysis revealed an independent effect of the audit phase on the decision to transfuse RBCs and FFP. The data suggests that a computerized prospective transfusion audit has impact on the realisation of predefined transfusion decisions.

Guidelines for assessing appropriateness of pediatric transfusion.

R ecent advances in donor screening, blood testing before transfusion, and modifications made to collected components, with irradiation as an example, make the blood supply safer than ever before. Nonetheless, blood components should only be transfused when risks and benefits have been carefully weighed.1-5 Particular consideration is required when transfusing preterm infants, the most heavily transfused patient group in the tertiary care setting, with the greatest potential for longevity.6-9 Recent data have demonstrated that transfusion practices vary tremendously, particularly in preterm infants.10 Establishing criteria for appropriate transfusion practice is important to ensure that clear-cut benefits are derived from the administration of this sometimes limited resource. In addition, the Joint Commission for the Accreditation of Health Care Organizations requires review of the appropriateness of all transfusions to correct transfusion practices that deviate from standard practice and that the use of blood and blood components be reviewed on a continuing basis, as part of a required performance-improvement function.11 Review for under-transfusion should also be considered. This paper has been written to help transfusion services and transfusion committees have a starting point to establish their own audit guidelines. References are included for each institution to evaluate as they embark upon this process. Transfusion medicine specialists who are not well versed in the special needs of neonates, as well as generalists who direct the transfusion service but lack specific expertise, can use this document and its references to initiate guideline development. These guidelines, representing the opinions of the authors and incorporating evidence-based data where it exists, have been designed to facilitate uniform transfusion practice whenever possible. Elements of transfusion practice, which should also be reviewed, include the documentation of informed consent as well as completion of transfusion records.11,12 Transfusion practice guidelines should not serve as medical indications for transfusion, nor can they be all inclusive. The appropriateness for most of these transfusion guidelines has been demonstrated in published reports. It should be pointed out that neonatal transfusion medicine is an evolving discipline. Because of the fragile clinical status of these small patients, it is difficult to design randomized controlled trials with enough statistical power to produce ironclad data. A great majority of the papers written about neonatal transfusion are practice oriented and derived by consensus. Therefore, adapting published literature to be used when creating transfusion audit guidelines for neonates should be done on an individualized basis.13-15 In certain selected clinical situations, transfusion events that deviate from the proposed guidelines may be considered appropriate. Scientific data, as well as a review of the patient’s chart, can be helpful in evaluating the appropriateness of transfusion events that deviate from guidelines.16,17 Physicians should clearly document, in writing, the indication for each transfusion administered and perform an assessment of the efficacy of the transfusion (e.g., relief of symptoms of anemia, cessation of bleeding). Parental informed consent, a process that includes delineating risks, benefits, and alternatives to transfusion, must be obtained in accordance with all applicable local, state, and national regulatory requirements. ObABBREVIATIONS: DIC = disseminated intravascular coagulation; ECMO = extracorporeal membrane oxygenation; ITP = idiopathic thrombocytopenic purpura; PCC = prothrombin complex concentrates; TA-GVHD = transfusion-associated GVHD; UCB = umbilical cord blood; WB = whole blood.

Audit of red cell transfusion.

Audit of red cell transfusion.

An audit of perioperative blood transfusion in a British teaching hospital

European Society of Anaesthesiologists; 8th Annual Meeting with the Austrian International Congress; Vienna, Austria, 1-4 April 2000

Audit in transfusion practice.

Given the growing concern for the safety, cost and adequacy of blood supply, there is an increasing need for appropriate blood product utilization. Despite a number of consensus guidelines for the transfusion of allogeneic blood products, inappropriate blood transfusion continues. We discuss the quality assurance process for improvement in transfusion therapy including audit of blood transfusion. Audits identify areas of problems in transfusion practice which can be corrected by education of doctors, formulation of practice guidelines and algorithms. To improve the effectiveness of the audit programmes, the frequency of audits has to be maintained and there should be continual reinforcement of policies.

The Transfusion Audit as a Tool to Improve Transfusion Practice: a Critical Appraisal

Transfusion audits have a long history and they are required by many regulatory agencies. These audits have been touted as effective in reducing unnecessary transfusions as evidenced by many published articles on the subject. Most of these studies, however, have one or more flaws in their design including the use of historical controls, disregard of the Hawthorne effect, use of multiple interventions, and publication bias. Studies differ in the baseline rate of inappropriate transfusions and have different methods of measuring these rates. There is also little data on how long the effect of implementing a transfusion audit system may last. Transfusion audits appear most successful when there is a high baseline rate of inappropriate transfusions and interventions other than the audit itself are performed. Individual institutions should critically evaluate whether or not their current system of transfusion audits is useful.

The Transfusion Audit as an Educational Tool

Audits of transfusion used as educational tools can improve transfusion practices. Effective audits must first identify problem(s) in transfusion practice and must then include as educational target, the attending physician. Educational methods that have been shown to he effective include: (1) meeting briefly one-on-one with physicians, (2) teaching at scheduled conferences, (3) making daily clinical rounds on patients who receive transfusion, (4) concurrent review of orders for transfusion prior to issue of the blood product and (5) installing algorithms and guidelines in the operating room. Transfusion practices improved with these educational audit methods.

Guidelines for Auditing Pediatric Blood Transfusion Practices

Although transfusion of blood products is an essential and potentially life-saving measure, not all blood transfusions are beneficial to patients. The associated risks, particularly transfusion-transmitted viral illnesses, such as hepatitis and acquired immunodeficiency syndrome, require that careful consideration be given before a decision is made to transfuse any blood product. Many institutions have established a local committee to monitor transfusion practices and audit such practices regularly. To assist in this task, the Pediatric Hemotherapy Committee of the American Association of Blood Banks has developed guidelines for the conduct of pediatric blood transfusion audits. These guidelines, summarized herein, cover transfusion of red blood cells, platelets, white blood cells, fresh-frozen plasma, albumin, and clotting concentrates. The use of cytomegalovirus low-risk and irradiated blood products is also discussed. Throughout the report, special attention is given to the transfusion needs of newborn infants.

Blood Component Transfusion Audit: A Comprehensive Microcomputer Program

Blood usage review is an essential aspect of hospital quality assurance. As part of a system for reviewing transfusion practices, the American Red Cross/New Jersey Blood Services has developed a series of microcomputer programs called the Blood Component Transfusion Audit. The programs use transfusion data collected on a standardized form to produce reports of utilization and analyses of transfusion practices, including the extent to which transfusions are justified by established criteria.

Automatic special case consultations in transfusion medicine

In the past, consultations in immunohematology were usually delivered only when there was a blood or component shortage, or when the time required for compatibility testing was prolonged due to the presence of a difficult recipient antibody problem. More recently, transfusion medicine physicians have increased their role as clinical consultants concerned about the appropriate indications for blood transfusion. This communication presents a way to begin a sound program of clinical transfusion medicine consultation. The program can fit with community-wide teaching efforts, community or hospital transfusion audits, and specific physician education programs. Automatic or unsolicited consultations appear to have been both accepted well and beneficial in large hospitals and in communities where they have been provided for more than 7 years.