A prospective audit of transfusion requests in a tertiary care hospital for the use of fresh frozen plasma

Cryoprecipitate Utilization Patterns Observed With a Required Prospective Approval Process vs Electronic Dosing Guidance

OBJECTIVES

We evaluated the impact of electronic medical record (EMR)-guided pooled cryoprecipitate dosing vs our previous practice of requiring transfusion medicine (TM) resident approval for every cryoprecipitate transfusion.

METHODS

At our hospital, cryoprecipitate pooled from five donors is dosed for adult patients, while single-donor cryoprecipitate is dosed for pediatric patients (defined as patients <50 kg in weight). EMR-based dosing guidance replaced a previously required TM consultation when cryoprecipitate pools were ordered, but a consultation remained required for single-unit orders. Usage was defined as thawed cryoprecipitate; wastage was defined as cryoprecipitate that expired prior to transfusion.

RESULTS

In the 6 months prior to intervention, 178 ± 13 doses of pooled cryoprecipitate were used per month vs 187 ± 15 doses after the intervention (P = .68). Wastage of pooled cryoprecipitate increased from 7.7% ± 1.5% to 12.7% ± 1.4% (P = .038). There was no change in wastage of pediatric cryoprecipitate doses during the study period. These trends remained unchanged for a full year postimplementation.

CONCLUSIONS

Electronic dosing guidance resulted in similar cryoprecipitate usage as TM auditing. Increased wastage may result from reduced TM oversight. Product wastage should be balanced against the possibility that real-time audits could delay a lifesaving therapy.

Risk factors for inappropriate blood requisition among hospitals in Tanzania

BACKGROUND

Blood is a critical aspect of treatment in life saving situations, increasing demand. Blood requisition practices greatly effect sufficient supply in blood banks. This study aimed to determine the risk factors for inappropriate blood requisition in Tanzania.

METHODS

This was a cross sectional study using secondary data of 14,460 patients' blood requests from 42 transfusion hospitals. Primary data were obtained by using cluster-sampling design. Data were analysed using a two-level mixed-effects Poisson regression to determine fixed-effects of individual-level factors and hospital level factors associated with inappropriate blood requests. P-value <0.05 (2-tails) was considered statistically significant.

RESULTS

Inappropriate requisition was 28.8%. Factors significantly associated with inappropriate requisition were; reporting pulse rate and capillary refill decrease the risk (RR 0.74; 95% CI 0.64, 0.84) and (RR 0.73; 95% CI 0.63, 0.85) respectively and the following increased the risk; having surgery during hospital stay (RR 1.22; 95% CI 1.06, 1.4); being in general surgical ward (RR 3.3; 95% CI 2.7, 4.2), paediatric ward (RR 1.8; 95% CI 1.2, 2.7), obstetric ward (RR 2.5; 95% CI 2.0, 3.1), gynaecological ward (RR 2.1; 95% CI 1.5, 2.9), orthopaedics ward (RR 3.8; 95% CI 2.2, 6.7). Age of the patient, pallor and confirmation of pre-transfusion haemoglobin level were also significantly associated with inappropriate requisition. Majority of appropriate requisitions within the wards were marked in internal medicine (91.7%) and gynaecological wards (77.8%).

CONCLUSIONS

The proportion of inappropriate blood requests was high. Blood requisition was determined by clinical and laboratory findings and the ward patients were admitted to. Adherence to transfusion guidelines is recommended to assure the best use of limited blood supply.

Audit of pediatric transfusion practices in a tertiary care hospital

OBJECTIVE

To perform a retrospective audit of transfusion practices, in order to study the appropriate and inappropriate usage of different blood components in pediatric population.

METHODS

The present study, conducted over a period of 3 mo analyzed all the episodes of transfusions and divided them into appropriate and inappropriate according to the type of blood components, the requesting departments and the clinical indication of transfusion. Data was reviewed according to the British Committee for Standards in Hematology and American Association of Blood Bank guidelines.

RESULTS

A total of 2,145 units of hemocomponents were transfused to children, including 1,181 units of red cell concentrates, 566 units of platelet concentrates/platelet rich plasma, 118 units of whole blood and 280 units of fresh frozen plasma in 1,819 episodes. Appropriate usage of blood components was 59.65%. Whole blood was most appropriately transfused (82.9%). Appropriate indications outnumbered inappropriate requisitions in Department of Pediatric Medicine (70.38 %), Nursery (82.54 %) and Thalassemia day care centre (55.63%). Red cell concentrate was most appropriately indicated in anemias (73.14%) and inappropriately in cases of surgeries (53.6%). Platelets were used more appropriately in all clinical indications. Whole blood was transfused most appropriately (100%) in double venous exchange therapy. Most appropriate indication of fresh frozen plasma usage was coagulopathy (42.57%).

CONCLUSIONS

As the appropriate usage (59.65%) of blood components was low in the present study, regular auditing of transfusion practices from time to time is indicated. This not only helps guide their judicious use but also serves to evaluate and decrease their inappropriate usage.

An audit of fresh frozen plasma usage in a tertiary trauma care centre in north India

Fresh frozen plasma (FFP) transfusion is a crucial part of management of trauma patients. There is a paucity of literature about the audit of appropriateness of FFP use in trauma patients. To evaluate and analyze the appropriateness of FFP transfusion practices for trauma patients. Prospectively compiled blood bank records of FFP transfusion practices over a period of 4 months from Augusts'08 through Deember'08 were retrospectively analyzed for 207 patients. The number of FFP units used in all these trauma patients were evaluated a propos the cause of injury, departments, type of surgery, presence of coagulopathy, bleeding, massive transfusion, length of hospital stay and patient outcome. Trauma scores such as Glasgow coma score and injury severity score were also calculated to estimate the severity of injury. The appropriateness of FFP transfusion was assessed according to the guidelines drafted by the College of American Pathologists. FFP transfusion for patients experiencing active bleeding, micro vascular bleeding, coagulopathy and/or massive transfusion, was deemed appropriate. Patients receiving FFP were categorized and individually correlated with the outcome. The influences of other variables which affect patient outcome were excluded using stepwise multivariate logistic regression analysis. p value < 0.05 were considered to be statistically significant. A total of 207 trauma patients were included in the study, 183 (88.4 %) males and 24 (11.6 %) females. The FFP use among neurosurgery patients was 46.9 %, general surgery patients 40.6 % and orthopedics 12.6 %. Appropriate use of FFP was 49.5 % according to the CAP guidelines. Trauma patients who required FFP as a part of treatment were categorized as; Patients who had bleeding alone (n = 40), bleeding with coagulopathy (n = 16), and coagulopathy alone (n = 43), and further correlated with the outcome and were found statistically insignificant. The prevalence of appropriate use of FFP at trauma centre was 49.5 %. The FFP use by neurosurgery:orthopedics:general surgery was 5:1:4. The highest appropriate FFP use was by Neurosurgery department (50.5 %). Assessing the pattern of usage and rate of misuse of FFP units, allows us to establish required strategies to improve the state of affairs.

Concurrent audit of fresh frozen plasma: experience of a tertiary care hospital

Fresh frozen plasma (FFP) transfusion is among the highest risk of all blood component transfusions and also the most inappropriately used blood component. All these factors have impact on safety, economy, and work burden.

OBJECTIVE

To assess the utilization of FFP in a tertiary care hospital.

METHODS

Concurrent audit was conducted manually over the period of 4 months from April 2010 to July 2010. Patient's age, sex, clinical diagnosis, indication for FFP transfusion, and coagulation profile were noted. Data were analysed and episodes of transfusion were divided into appropriate and inappropriate. Requests were further classified according to the requesting department, clinical diagnosis, and coagulation profile.

RESULTS

A total of 1763 units of FFP were transfused to 560 patients in 877 episodes of requisition. Out of 877 episodes, about 686 (78.2%) requests were found to be inappropriate. Highest number of FFP requisitions was received from department of paediatrics and paediatric surgery (580 episodes). Most inappropriate requests were received from the department of orthopaedics (88.9%) and paediatrics (80.17%). The most common indication for FFP transfusion was surgical/traumatic bleeding/massive transfusion (40.9%) in which 68.5% requests were inappropriate. Out of 686 inappropriate episodes, the most common cause was in setting of normal or mildly altered coagulation profile irrespective of bleeding status of patient.

DISCUSSION

Inadvertent use of FFP is a major problem and guidelines are not strictly adhered to. Concurrent audit of FFP use needs to be done to make appropriate interventions to prevent misuse of this valuable commodity.

Whole blood and component use in resource poor settings

Data on blood collection, testing and component preparation has improved worldwide; however, there is limited information on blood utilization from the developing countries. Blood requirement in the Southeast Asia region is 15 million units against a collection of 9.3 million. There is huge diversity in the management of blood transfusion services, the voluntary blood collection (range 40-100%) and proportion of blood separated into components (10-95%). The major indications for transfusion are for emergency obstetric care, surgery, pediatric and trauma patients. The prevalence of thalassemia in this region is high and in India alone 2 million units of packed red cells are required for transfusion to these patients. The Blood Safety Program in India has developed as a component of the National Aids Control Program and has lead to infrastructure development, blood component separation facilities and formulation of a National Blood Policy. In order to facilitate emergency obstetric care nearer home, blood storage centers are being established at primary health care centers. Emerging infectious threats like dengue hemorrhagic fever necessitate platelet transfusion therapy. A few centers in India issue NAT screened blood. It is envisaged to establish a nationally co-ordinated transfusion service for cost-effective quality blood/components for appropriate clinical use.

Utilization of blood and components in a tertiary care hospital

PURPOSE

Blood transfusion is an important part of patient management. Indications for blood use must be clear in the mind of ordering clinicians, to avoid its misuse and also to avoid unnecessary exposure of the patient to donor blood antigens, adverse reactions and transfusion transmissible diseases.

METHODS

In a retrospective pilot study, details of whole blood and components transfused were noted and correlated with the patient's diagnosis and indications for transfusion, during 1 month.

RESULTS

The blood units supplied were 720. Whole blood was the most utilized product; followed by packed red blood cells. Supply of blood was maximum to the surgical wards. The patients of trauma followed by malignancy and surgery required whole blood mostly. Anemia was the most common indication for blood products.

CONCLUSIONS

Periodic review of blood component usage is very important to assess the blood utilization pattern in any hospital.