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Mitra B, Talarico CS, Olaussen A, Anderson D, Meadley B. Blood lactate after pre-hospital blood transfusion for major trauma by helicopter emergency medical services. Vox Sang 2024; 119:460-466. [PMID: 38357735 DOI: 10.1111/vox.13598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/16/2024] [Accepted: 01/29/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND AND OBJECTIVES The appropriate use of blood components is essential for ethical use of a precious, donated product. The aim of this study was to report in-hospital red blood cell (RBC) transfusion after pre-hospital transfusion by helicopter emergency medical service paramedics. A secondary aim was to assess the potential for venous blood lactate to predict ongoing transfusion. MATERIALS AND METHODS All patients who received RBC in air ambulance were transported to a single adult major trauma centre, had venous blood lactate measured on arrival and did not die before ability to transfuse RBC were included. The association of venous blood lactate with ongoing RBC transfusion was assessed using multi-variable logistic regression analysis and reported using adjusted odds ratios (aOR). The discriminative ability of venous blood lactate was assessed using area under receiver operating characteristics curve (AUROC). RESULTS From 1 January 2016 to 15 May 2019, there were 165 eligible patients, and 128 patients were included. In-hospital transfusion occurred in 97 (75.8%) of patients. Blood lactate was associated with ongoing RBC transfusion (aOR: 2.00; 95% confidence interval [CI]: 1.36-2.94). Blood lactate provided acceptable discriminative ability for ongoing transfusion (AUROC: 0.78; 95% CI: 0.70-0.86). CONCLUSIONS After excluding patients with early deaths, a quarter of those who had prehospital RBC transfusion had no further transfusion in hospital. Venous blood lactate appears to provide value in identifying such patients. Lactate levels after pre-hospital transfusion could be used as a biomarker for transfusion requirement after trauma.
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Affiliation(s)
- Biswadev Mitra
- Alfred Health Emergency Service, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Carly S Talarico
- Alfred Health Emergency Service, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alexander Olaussen
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - David Anderson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - Ben Meadley
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
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Wu J, Yang H, Yu D, Yang X. Blood-derived product therapies for SARS-CoV-2 infection and long COVID. MedComm (Beijing) 2023; 4:e426. [PMID: 38020714 PMCID: PMC10651828 DOI: 10.1002/mco2.426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/15/2023] [Accepted: 10/25/2023] [Indexed: 12/01/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is capable of large-scale transmission and has caused the coronavirus disease 2019 (COVID-19) pandemic. Patients with COVID-19 may experience persistent long-term health issues, known as long COVID. Both acute SARS-CoV-2 infection and long COVID have resulted in persistent negative impacts on global public health. The effective application and development of blood-derived products are important strategies to combat the serious damage caused by COVID-19. Since the emergence of COVID-19, various blood-derived products that target or do not target SARS-CoV-2 have been investigated for therapeutic applications. SARS-CoV-2-targeting blood-derived products, including COVID-19 convalescent plasma, COVID-19 hyperimmune globulin, and recombinant anti-SARS-CoV-2 neutralizing immunoglobulin G, are virus-targeting and can provide immediate control of viral infection in the short term. Non-SARS-CoV-2-targeting blood-derived products, including intravenous immunoglobulin and human serum albumin exhibit anti-inflammatory, immunomodulatory, antioxidant, and anticoagulatory properties. Rational use of these products can be beneficial to patients with SARS-CoV-2 infection or long COVID. With evidence accumulated since the pandemic began, we here summarize the progress of blood-derived product therapies for COVID-19, discuss the effective methods and scenarios regarding these therapies, and provide guidance and suggestions for clinical treatment.
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Affiliation(s)
- Junzheng Wu
- Chengdu Rongsheng Pharmaceuticals Co., Ltd.ChengduChina
| | | | - Ding Yu
- Chengdu Rongsheng Pharmaceuticals Co., Ltd.ChengduChina
- Beijing Tiantan Biological Products Co., Ltd.BeijingChina
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Daichman S, Ostrovsky D, Dreiher J, Pikovsky O. Does training make a difference? Proficiency training in transfusion guidelines and its effect on red blood cell administration. Transfusion 2022; 62:1121-1127. [PMID: 35362566 PMCID: PMC9322411 DOI: 10.1111/trf.16866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/09/2022] [Accepted: 03/09/2022] [Indexed: 01/28/2023]
Abstract
Background Packed red blood cell (RBC) transfusion is a very common and frequently lifesaving therapeutic intervention, but a liberal transfusion policy may be associated with inferior patient outcomes. Various guidelines have been proposed to reduce the rate of unnecessary RBC transfusions. However, physicians' proficiency in such guidelines and the effect of training on RBC administration remain unknown. Methods We performed a questionnaire‐based assessment of physicians' knowledge of the guidelines in a tertiary hospital in Israel, followed by an analysis of RBC administration six months before and six months after training was delivered. Results The level of proficiency was higher among Israeli university graduates (Odds Ratio [OR] 2.59, p‐value = 0.02), internists (OR 2.8, p‐value = 0.02), and physicians beyond the step‐one residency exam (OR 3.08, p‐value = 0.02). There was no significant effect of training on the rates of RBC administration (incidence rate ratio [IRR] = 0.96 [CI 95% 0.81–1.14], p‐value = 0.655). Conclusion Educational intervention alone is an ineffective means of reducing the rates of RBC administration. A more complex approach is required to prevent unnecessary RBC transfusions.
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Affiliation(s)
- Svetlana Daichman
- Department for Industrial Management, Sami Shamoon College of Engineering, Beer Sheva, Israel
| | - Daniel Ostrovsky
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Jacob Dreiher
- Division of Health in the Community, Ben-Gurion University of the Negev, Beer-Sheva, Israel.,Department of Management, Soroka University Medical Center, Beer Sheva, Israel
| | - Oleg Pikovsky
- Transfusion Medicine and Apheresis Institute, Soroka University Medical Center, Beer Sheva, Israel
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Seyhanli A, Ozkan YC, Bengi G, Alacacioglu I, Ozsan GH, Demirkan F. Evaluation of using fresh frozen plasma for patients with cirrhosis at a tertiary healthcare center in Turkey: Strict transfusion policies are essential. Transfus Apher Sci 2021; 60:103247. [PMID: 34462217 DOI: 10.1016/j.transci.2021.103247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 10/20/2022]
Abstract
AIM Management of blood transfusions is a critical issue, especially in cirrhotic patients, because of the absence of national policies in many countries. Fresh frozen plasma (FFP) is a common blood component misused excessively in various clinical situations and cirrhosis patients without any scientific rationale. We evaluated the FFP transfusions in patients with cirrhosis at our tertiary care hospital. MATERIAL AND METHOD The cases with cirrhosis diagnosed between 2014 and 2020 were selected using the hospital database. The appropriateness of FFP transfusion was determined based on the Practice Guidance by the American Association for the Study of Liver Diseases and Italian guidelines. RESULT Two hundred and six liver cirrhosis patients were identified who received FFP transfusion. The median age was 63 (22-94). Of the 206 patients, 79 (38.3 %) were female, and 127 (61.7 %) were men. The most common causes of liver cirrhosis were alcohol (27.7 %). 45.6 % of the patients were in Child-Pugh Class C. We found 62.1 % of FFP replacements were inappropriately used. Most inappropriate use of FFP (22.8 %, n = 47) occurred to correct prolonged INR in the absence of bleeding. CONCLUSION To avoid inappropriate usage of FFP, regular utilization reviews and formal education programs can be helpful. Our clinic has planned to arrange educational programs for physicians to use blood products appropriately and minimize transfusion-related side effects.
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Affiliation(s)
- Ahmet Seyhanli
- Department of Hematology, Sivas Numune Hospital, Sivas, Turkey.
| | - Yazgulu Cansu Ozkan
- Department of Internal Medicine, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey.
| | - Goksel Bengi
- Department of Gastroenterology and Hepatology, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey.
| | - Inci Alacacioglu
- Department of Hematology, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey.
| | - Güner Hayri Ozsan
- Department of Hematology, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey.
| | - Fatih Demirkan
- Department of Hematology, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey.
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Seeking Strategies to Optimize Blood Utilization: The Preliminary Experience with Implementing a Patient Blood Management Program in a Greek Tertiary Hospital. J Clin Med 2021; 10:jcm10102141. [PMID: 34063464 PMCID: PMC8157216 DOI: 10.3390/jcm10102141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/03/2021] [Accepted: 05/14/2021] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES Our aim was to assess blood utilization after implementation of a patient blood management (PBM) program in a Greek tertiary hospital. METHODS An electronic transfusion request form and a prospective audit of transfusion practice were implemented. After the one-year implementation period, a retrospective review was performed to assess transfusion practice in medical patients. RESULTS Pre-PBM, a total of 9478 RBC units were transfused (mean: 1.75 units per patient) compared with 9289 transfused units (mean: 1.57 units per patient) post-PBM. Regarding the post-PBM period, the mean hemoglobin (Hb) level of the 3099 medical patients without comorbidities transfused was 7.19 ± 0.79 gr/dL. Among them, 2065 (66.6%) had Hb levels >7.0 gr/dL, while 167 (5.3%) had Hb levels >8.0 gr/dL. In addition, 331 (25.3%) of the transfused patients with comorbidities had Hb >8.0 gr/dL. The Hb transfusion thresholds significantly differed across the clinics (p < 0.001), while 21.8% of all medical non-bleeding patients received more than one RBC unit transfusion. CONCLUSION A poor adherence with the restrictive transfusion threshold of 7.0 gr/dL was observed. The adoption of a less strict threshold might be a temporary step to allow physicians to become familiar with the program and be informed on the safety and advantages of the restrictive transfusion strategy.
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Feyisa T, Tesfaye Kiya G, Maleko WA. Assessment of recipients' characteristics, transfusion appropriateness, and utilization pattern of blood and blood products in Jimma Medical Center, Jimma, Ethiopia. PLoS One 2021; 16:e0250623. [PMID: 33901253 PMCID: PMC8075257 DOI: 10.1371/journal.pone.0250623] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/10/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND As blood transfusion remains life-saving and is being frequently prescribed, a greater number of its practice is unnecessary or inappropriate. This important clinical intervention is reported as one of the five overused medical treatments, with gross over-ordering and whole blood transfusions as the sole component being common in developing countries. Study of recipient's demographics, clinical conditions, appropriate blood utilization, and continuous clinical audits for quality assurance and service improvement plan are important factors to this practice. This study was designed to assess the recipient's characteristics, blood type distributions, appropriateness of blood transfusion, and utilization practice of the big medical center. METHODS Institution based cross-sectional study was conducted from February 1 to June 30, 2018. Data were collected using a structured data collection format prepared for this study. All transfusion prescriptions were followed from requisition up to completion. Patient's age, sex, requesting departments, hemodynamics, number and component of units requested and issued, and units transfused were collected. Transfusion appropriateness was assessed by a criterion-based method while blood utilization was calculated. RESULTS A total of 545 units of blood for 425 patients were cross-matched of the 809 units of total blood prescribed. The mean and median age of transfused individuals was found to be 27.47 ±15.28 years and 26 years respectively, and 65.4% females most in reproductive age groups. O and A Rhesus-positive blood types were the two major blood groups observed. Overall 82.1% of transfusions were appropriate; while only 27.8% of patients received appropriate components as 96.5% of individuals received a whole blood transfusion. Significant blood utilization was recorded with a C/T ratio of 1.05, TP% of 100%, and TI of 1.23. CONCLUSION Much of the transfusion recipients were relatively young aged and females, most in the reproductive age group. Although whole blood was used as a sole component, significant blood transfusion utilization and appropriateness were recorded; while appropriate component transfusion was recorded to be significantly low. Local transfusion guidelines and appropriate component preparation and utilization are required to improve the sub-optimal blood component transfusion practice.
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Affiliation(s)
- Tufa Feyisa
- Hematology Laboratory Unit of Jimma Medical Center, Jimma University, Jimma, Ethiopia
| | - Girum Tesfaye Kiya
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
| | - Wondimagegn Adissu Maleko
- School of Medical Laboratory Sciences, Jimma University, Jimma, Ethiopia
- Clinical Trial Unit, Jimma University, Jimma, Ethiopia
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Hill-Strathy M, Pinkerton PH, Thompson TA, Wendt A, Collins A, Cohen R, BComm WO, Cameron T, Lin Y, Lau W, Lieberman L, Callum J. Evaluating the appropriateness of platelet transfusions compared with evidence-based platelet guidelines: An audit of platelet transfusions at 57 hospitals. Transfusion 2020; 61:57-71. [PMID: 33078852 DOI: 10.1111/trf.16134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/27/2020] [Accepted: 08/27/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Platelet transfusions are used to prevent or control bleeding in patients with thrombocytopenia or platelet dysfunction. The pretransfusion platelet count threshold has been studied extensively in multiple patient settings yielding high-quality evidence that has been summarized in several comprehensive evidence-based platelet guidelines. STUDY DESIGN AND METHODS A prospective 12-week audit of consecutive platelet transfusions using validated and evidence-based adjudication criteria was conducted. Patient demographic, laboratory, and transfusion details were collected with an electronic audit tool. Each order was adjudicated either electronically or independently by two transfusion medicine physicians. The aim was to determine platelet transfusion appropriateness and common scenarios with deviations from guidelines. RESULTS Fifty-seven (38%) of 150 hospitals provided data on 1903 platelet orders, representing 90% of platelet usage in the region during the time period. Overall, 702 of 1693 adult (41.5%) and 133 of 210 pediatric orders (63.3%) were deemed inappropriate. The most common inappropriate platelet order was for prophylaxis in the absence of bleeding or planned procedure in patients with hypoproliferative thrombocytopenia and a platelet count over 10 x 109 /L (53% of inappropriate orders in adults and 45% in pediatrics). Platelet transfusions ordered with either a preprinted transfusion order set (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.44-2.73) or technologist prospective screening (OR, 1.40; 95% CI, 1.10-1.78) were more likely to be appropriate. CONCLUSION There is a discrepancy between clinical practice and evidence-based platelet guidelines. Broad educational and system changes will be needed to align platelet transfusion practice with guideline recommendations.
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Affiliation(s)
- MaryJane Hill-Strathy
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,University of St Andrews, Fife, UK
| | - Peter H Pinkerton
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Troy A Thompson
- Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada
| | - Alison Wendt
- Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada
| | - Allison Collins
- Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada
| | - Robert Cohen
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Wendy Owens BComm
- Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada
| | - Tracy Cameron
- Ontario Regional Blood Coordinating Network, Ontario, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine, University Health Network, Toronto, Ontario, Canada
| | - Wendy Lau
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Pediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine, University Health Network, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine, University Health Network, Toronto, Ontario, Canada
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8
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Pandey P, Setya D, Mirza SM, Singh MK. Prospective audit of blood transfusion request forms and continuing medical education to optimise compliance of clinicians in a hospital setting. Transfus Med 2020; 31:16-23. [PMID: 33000508 DOI: 10.1111/tme.12722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The aim of this study was to analyse blood requisition forms sent by clinicians in a tertiary care hospital to the transfusion service to ascertain their completeness and correctness. A secondary objective was to study the effect of continuing medical education (CME) in a hospital setting on clinician's behaviour regarding the importance of details that ought to be mentioned on blood requisition forms. BACKGROUND Transfusion audits are useful tools in the evaluation and education of those requesting blood components. METHODS/MATERIALS This was a prospective, observational study conducted in the department of Transfusion Medicine at a tertiary-level healthcare centre from June 2019 to December 2019. The study was divided into two phases: pre-CME (P1) and post-CME (P2). In both phases, an audit for assessing completeness and correctness of blood requisition forms, which were divided into four sections, was performed. A scoring system was devised to compare both phases. RESULTS In the P1 phase, 45.77% of the blood requisition form entries were complete and correct; 23.45% of incomplete entries were generated by emergency and trauma. In the P2 phase, 76.75% of the blood requisition form entries were complete and correct; 35.09% of the incomplete entries were generated by obstetrics and gynaecology. Complete and correct entries increased from 45.7% (P1) to 76.75% (P2). Scores of P1 were found to be lower than scores of P2 for all four sections. Cumulative mean score for P1 (20687) was found to be significantly lower than the mean score for P2 (30870). CONCLUSION Audit and CME regarding different aspects of transfusion medicine practices play a major role in the improvement of transfusion practices in hospitals.
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Affiliation(s)
- Prashant Pandey
- Department of Transfusion Medicine, Jaypee Hospital, Noida, India
| | - Divya Setya
- Department of Transfusion Medicine, Jaypee Hospital, Noida, India
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9
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Jaime-Pérez JC, García-Salas G, Áncer-Rodríguez J, Gómez-Almaguer D. Audit of red blood cell transfusion in patients with acute leukemia at a tertiary care university hospital. Transfusion 2020; 60:724-730. [PMID: 32056229 DOI: 10.1111/trf.15700] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 01/17/2020] [Accepted: 01/20/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Red blood cell (RBC) transfusion support is essential in patients with acute leukemia (AL). A restrictive RBC transfusion approach is assumed to be safe for most individuals with AL. The aim of this audit was to assess RBC transfusion appropriateness in AL patients at an academic center. STUDY DESIGN AND METHODS RBC transfusions in acute lymphoblastic leukemia and acute myeloid leukemia patients of all ages between January 1, 2013, and March 31, 2019, were analyzed for adherence to evidence-based criteria. Transfusion appropriateness was compared among ordering specialties, patient locations, and hematologic diagnoses. Pretransfusion hemoglobin was compared between categories. Overtransfusion rates were also analyzed. Descriptive statistics and categorical and numerical tests were employed to determine statistical significance. RESULTS A total of 510 RBC transfusions were received by 133 AL patients in the departments of internal medicine, hematology, and pediatrics. Overall, 84.5% were appropriate according to established criteria. Internal medicine was the ordering department with the highest rate of appropriateness (88.1%). The outpatient clinic was the location with the highest adherence (85.9%), whereas the intensive care unit had the lowest (70%; p = 0.03). The reasons for most appropriate and inappropriate transfusions were asymptomatic anemia with a hemoglobin below (60.6%) or above (69.6%) 7 g/dL in patients without cardiac disease, respectively. Overtransfusion was present in 22% of episodes. CONCLUSION RBC transfusion in AL patients reflected good adherence to guidelines. However, continuing education in transfusion medicine and prospective chart auditing are needed to improve adherence to established guidelines.
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Affiliation(s)
- José Carlos Jaime-Pérez
- Department of Hematology, Facultad de Medicina y Hospital Universitario Dr. Jose Eleuterio Gonzalez, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Gerardo García-Salas
- Department of Hematology, Facultad de Medicina y Hospital Universitario Dr. Jose Eleuterio Gonzalez, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - Jesús Áncer-Rodríguez
- Department of Pathology, Facultad de Medicina, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
| | - David Gómez-Almaguer
- Department of Hematology, Facultad de Medicina y Hospital Universitario Dr. Jose Eleuterio Gonzalez, Universidad Autonoma de Nuevo Leon, Monterrey, Mexico
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Yangdon T, Getshen M, Tashi L. A retrospective analysis of blood requisition versus utilization practices at national blood bank, jigme dorji wangchuck national referral hospital, Thimphu, Bhutan. GLOBAL JOURNAL OF TRANSFUSION MEDICINE 2020. [DOI: 10.4103/gjtm.gjtm_70_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Steffen KM, Bateman ST, Valentine SL, Small S, Spinella PC, Doctor A. Implementation of the Recommendations for RBC Transfusions for Critically Ill Children From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S170-S176. [PMID: 30161073 PMCID: PMC6124312 DOI: 10.1097/pcc.0000000000001592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To provide context for the implementation of the Pediatric Critical Care Transfusion and Anemia Expertise Initiative recommendations for RBC transfusions including a review of prior research related to implementation of transfusion guidelines, efforts to facilitate implementation through Transfusion and Anemia Expertise Initiative, and to provide a framework for recommendation implementation. DESIGN Review of existing clinical literature and description of a comprehensive approach to implementation based on Implementation Science principles. RESULTS The Transfusion and Anemia Expertise Initiative recommendations on RBC transfusions are based on clinical evidence and aim to limit unnecessary and potentially harmful transfusions. Prior efforts to use transfusion guidelines include use of provider education, local guidelines, visual aids, prospective and retrospective audit and feedback as well as computerized decision support tools; however, no single approach has been identified as optimal for implementation in pediatric critical care settings. Evidence around provider beliefs and transfusion decision-making point to the need for additional provider education, emphasizing the importance of limiting transfusions, and the development of recommendations, such as the Transfusion and Anemia Expertise Initiative guidelines, that can be applied to specific clinical conditions. CONCLUSIONS The Transfusion and Anemia Expertise Initiative guidelines will be broadly disseminated; however, coordinated implementation efforts will be required to impact practice. An approach that encourages involvement of a wide range of multiprofessional stakeholders, formal agreement on the implemented guidelines, selection of strategies that are practical and feasible, and active monitoring of clinical practice and outcomes throughout implementation is recommended. A formal second stage Transfusion and Anemia Expertise Initiative - Continuous Assessment of Blood-use is proposed to enhance implementation of the recommendations, follow uptake and impact on practice and patient outcomes, and ensure integration of new clinical evidence into the existing guideline as it is developed.
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Affiliation(s)
- Katherine M Steffen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, CA
| | - Scot T Bateman
- Division of Pediatric Critical Care, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Stacey L Valentine
- Division of Pediatric Critical Care, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Sara Small
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Philip C Spinella
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Allan Doctor
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis, MO
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12
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Patidar GK, Kaur D. Audit and education: Role in safe transfusion practice. Asian J Transfus Sci 2018; 12:141-145. [PMID: 30692799 PMCID: PMC6327772 DOI: 10.4103/ajts.ajts_135_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 06/08/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Auditing and education are the tools for improvement in the transfusion practices. Clinicians are not providing patient's demographic data and medical history to the blood bank that required transfusion. This missing information in blood request forms can lead to transfusion reactions to the patient. So we planned to analyse the blood request forms received at our blood bank and the impact of educational program for the clinicians. METHODS A total of 6894 blood request forms were received from the month of July 2014 to December 2014 at a blood bank in Amritsar, India. We evaluated for completeness of the blood request form in parameter columns like second identification (CR No. or Father/Husband Name), diagnosis, pre transfusion hematological parameters, quality and quantity of blood component required, history of previous transfusion and adverse transfusion reaction, urgency of transfusion, medical officer name and signature, phlebotomist name and signature etc. A series of CMEs on "Safe Transfusion Practices" were organized for clinicians and hospital staff from 1st August 2014 and improvement in clinicians' behavior was analysed. RESULTS A total of 60.83% requests were not filled completely during the study period. Of these 91.42% were in the month of July, which decreased to 48.76% in the month of December 2014 with a total improvement of 42.66%. Incomplete second identification (91.03%) and history of previous transfusion and adverse transfusion reactions (80.21%) were the commonest incomplete fields in the month of July 2014. In the month of December 2014, an improvement in incomplete second identification was observed (12.8%) however phlebotomist signature was still a major incomplete field (45.19%). A statistically significant (p value = 0.004, paired 't' test) improvement in completeness of forms was observed. SUMMARY Results of medical audit and using those as a basis for developing a highly targeted educational program, can improve the clinicians' approch towards transfusion practices.
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Affiliation(s)
- Gopal Kumar Patidar
- Department of Transfusion Medicine, Adlakha Medical Center, Amritsar, Punjab, India
| | - Daljit Kaur
- Department of Transfusion Medicine, Max Super-speciality Hospital, Shalimar Bagh, New Delhi, India
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Soril LJJ, Noseworthy TW, Dowsett LE, Memedovich K, Holitzki HM, Lorenzetti DL, Stelfox HT, Zygun DA, Clement FM. Behaviour modification interventions to optimise red blood cell transfusion practices: a systematic review and meta-analysis. BMJ Open 2018; 8:e019912. [PMID: 29776919 PMCID: PMC5961610 DOI: 10.1136/bmjopen-2017-019912] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To assess the impact of behaviour modification interventions to promote restrictive red blood cell (RBC) transfusion practices. DESIGN Systematic review and meta-analysis. SETTING, PARTICIPANTS, INTERVENTIONS Seven electronic databases were searched to January 2018. Published randomised controlled trials (RCTs) or non-randomised studies examining an intervention to modify healthcare providers' RBC transfusion practice in any healthcare setting were included. PRIMARY AND SECONDARY OUTCOMES The primary outcome was the proportion of patients transfused. Secondary outcomes included the proportion of inappropriate transfusions, RBC units transfused per patient, in-hospital mortality, length of stay (LOS), pretransfusion haemoglobin and healthcare costs. Meta-analysis was conducted using a random-effects model and meta-regression was performed in cases of heterogeneity. Publication bias was assessed by Begg's funnel plot. RESULTS Eighty-four low to moderate quality studies were included: 3 were RCTs and 81 were non-randomised studies. Thirty-one studies evaluated a single intervention, 44 examined a multimodal intervention. The comparator in all studies was standard of care or historical control. In 33 non-randomised studies, use of an intervention was associated with reduced odds of transfusion (OR 0.63 (95% CI 0.56 to 0.71)), odds of inappropriate transfusion (OR 0.46 (95% CI 0.36 to 0.59)), RBC units/patient weighted mean difference (WMD: -0.50 units (95% CI -0.85 to -0.16)), LOS (WMD: -1.14 days (95% CI -2.12 to -0.16)) and pretransfusion haemoglobin (-0.28 g/dL (95% CI -0.48 to -0.08)). There was no difference in odds of mortality (OR 0.90 (95% CI 0.80 to 1.02)). Protocol/algorithm and multimodal interventions were associated with the greatest decreases in the primary outcome. There was high heterogeneity among estimates and evidence for publication bias. CONCLUSIONS The literature examining the impact of interventions on RBC transfusions is extensive, although most studies are non-randomised. Despite this, pooled analysis of 33 studies revealed improvement in the primary outcome. Future work needs to shift from asking, 'does it work?' to 'what works best and at what cost?' PROSPERO REGISTRATION NUMBER CRD42015024757.
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Affiliation(s)
- Lesley J J Soril
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Thomas W Noseworthy
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Laura E Dowsett
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Katherine Memedovich
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Hannah M Holitzki
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Diane L Lorenzetti
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - David A Zygun
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, Alberta Health Services and Faculty of Medicine and Dentistry, University of Alberta, Calgary, Alberta, Canada
| | - Fiona M Clement
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
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14
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Lieberman L, Lin Y, Cserti-Gazdewich C, Yi QL, Pendergrast J, Lau W, Callum J. Utilization of frozen plasma, cryoprecipitate, and recombinant factor VIIa for children with hemostatic impairments: An audit of transfusion appropriateness. Pediatr Blood Cancer 2018; 65. [PMID: 29286568 DOI: 10.1002/pbc.26933] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 11/08/2017] [Accepted: 11/22/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Blood transfusions and fractionated products are not without risk and may lead to acute and long-term adverse events. The objective of this study was to evaluate the appropriateness of usage of frozen plasma (FP), cryoprecipitate (CRYO), and recombinant factor VIIa (rVIIa) in a pediatric setting. METHODS All orders for FP, CRYO, and rVIIa were prospectively audited over 6 weeks. Data collected included demographics, laboratory values, indication, and adverse reactions. The appropriateness of each order was independently evaluated using adjudication criteria rated by two hematologists. RESULTS Two hundred sixty-five products were ordered; 67% of the orders were issued to operating rooms or intensive care units. The most common indication for all products was cardiac surgery. FP was ordered as fluid replacement (15/215; 7%) to correct abnormal coagulation tests (23/215; 11%) and for patients with minor or no bleeding (111/242; 46%). FP was more likely to alter the international normalized ratio (INR) if the INR was over 2.0 (P < 0.0001). The rate of inappropriate products was judged as FP 19%, CRYO 21%, and rVIIa 91%. CONCLUSION FP, CRYO, and rVIIa are most commonly used in the operating room and intensive care units. FP was often used for fluid resuscitation and for patients with mild to no bleeding. FP was only effective in lowering the INR when the INR was over 2.0. Use of rVIIa was rarely ordered for an appropriate indication. Results of this study inform its readers where trials of pediatric transfusion should be performed to clarify how these products should be used in clinical practice.
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Affiliation(s)
- Lani Lieberman
- Department of Clinical Pathology, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Clinical Pathology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Christine Cserti-Gazdewich
- Department of Clinical Pathology, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Qi Long Yi
- Canadian Blood Services, Ottawa, Ontario, Canada
| | - Jacob Pendergrast
- Department of Clinical Pathology, University Health Network, Toronto, Ontario, Canada.,Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Wendy Lau
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Ontario, Canada.,Department of Clinical Pathology, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
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- Department of Clinical Pathology, University Health Network, Toronto, Ontario, Canada
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15
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Laki B, Taghizadeh-Ghehi M, Assarian M, Heidari K, Torkamandi H, Javadi MR, Gholami K. Effect of hospital-wide interventions to optimize albumin use in a tertiary hospital. J Clin Pharm Ther 2017; 42:704-709. [PMID: 28597926 DOI: 10.1111/jcpt.12566] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/02/2017] [Indexed: 12/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Albumin has been frequently used as a therapeutic agent based on previous recommendations that are mostly controversial. Considering limited evidence-based indications, common inappropriate albumin use in many hospitals necessitates prompt educational and regulatory interventions. We performed this study to assess the effect of a hospital-wide programme to optimize albumin use in a tertiary referral university-affiliated hospital. METHODS This study was conducted in three 45-day phases, separated by two sequential interventions: guideline implementation and albumin order-sheet consideration. We evaluated albumin use and assessed its appropriateness in each phase at baseline, after guideline implementation and after order-sheet consideration. RESULTS We recorded 100, 93 and 71 albumin orders for 100, 84 and 66 patients during the first, second and third phases, respectively. The adjusted number of albumin orders (used albumin vials) was 94.9 (1481.7 vials), 80.8 (1037.6 vials) and 66 (1219 vials) in the first, second and third phases of the study, respectively. Albumin orders with appropriate indication increased significantly over the three phases of the study (OR=1.5, P=.008). The frequency of inappropriate orders reduced significantly from the first phase to the third phase (58%-27%, P=.007). WHAT IS NEW AND CONCLUSION The pattern and amount of albumin use changed following guideline implementation and order-sheet consideration, and inappropriate albumin use was reduced in our hospital. There was still room for improvement, particularly for indications that were not included in the guideline. Hence, a more comprehensive guideline, frequent audit, feedback and interactive educational approaches might be necessary to achieve results that are of a greater magnitude.
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Affiliation(s)
- B Laki
- Clinical Pharmacy Department, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - M Taghizadeh-Ghehi
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - M Assarian
- Clinical Pharmacy Department, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - K Heidari
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - H Torkamandi
- Pharmaceutical Care Department, Dr. Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - M R Javadi
- Clinical Pharmacy Department, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - K Gholami
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
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16
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Colla CH, Mainor AJ, Hargreaves C, Sequist T, Morden N. Interventions Aimed at Reducing Use of Low-Value Health Services: A Systematic Review. Med Care Res Rev 2016; 74:507-550. [PMID: 27402662 DOI: 10.1177/1077558716656970] [Citation(s) in RCA: 208] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The effectiveness of different types of interventions to reduce low-value care has been insufficiently summarized to allow for translation to practice. This article systematically reviews the literature on the effectiveness of interventions to reduce low-value care and the quality of those studies. We found that multicomponent interventions addressing both patient and clinician roles in overuse have the greatest potential to reduce low-value care. Clinical decision support and performance feedback are promising strategies with a solid evidence base, and provider education yields changes by itself and when paired with other strategies. Further research is needed on the effectiveness of pay-for-performance, insurer restrictions, and risk-sharing contracts to reduce use of low-value care. While the literature reveals important evidence on strategies used to reduce low-value care, meaningful gaps persist. More experimentation, paired with rigorous evaluation and publication, is needed.
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Affiliation(s)
- Carrie H Colla
- 1 Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | | | - Thomas Sequist
- 2 Harvard Medical School, Boston, MA, USA.,3 Brigham and Women's Hospital, Boston, MA, USA.,4 Partners HealthCare, Boston, MA, USA
| | - Nancy Morden
- 1 Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,5 Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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17
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Appropriate use of red blood cell transfusion in emergency departments: a study in five emergency departments. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 15:199-206. [PMID: 27416566 DOI: 10.2450/2016.0324-15] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 04/04/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Transfusion of blood components continues to be an important therapeutic resource into the 21st century. Between 5 and 58% of transfusions carried out are estimated to be unnecessary. According to several studies, at least 20% of packed red blood cell transfusions (RBCT) are administered in hospital emergency departments (ED), but few data are available about the appropriateness of RBCT in this setting. This multicentre, cross-sectional observational study aims to assess the appropriateness of RBCT indications and transfused volumes in patients who attend ED. MATERIALS AND METHODS The study cohort is made up of consecutive consenting adult patients (≥18 years old) who received RBCT in ED over a 3-month period and for whom relevant clinical data were collected and analysed. RESULTS Data from 908 RBCT episodes (2±1 units per transfused patient) were analysed. RBCT was considered appropriate in 21.4% (n=195), with significant differences according to RBCT indication (p<0.001), hospital level (p<0.001) and prescribing physician (p=0.002). Pre-transfusion haemoglobin level (Hb) negatively correlated with RBCT appropriateness (r=-0.616; p<0.01). Only 72.4% of appropriate RBCT had a post-transfusion Hb assessment (n=516). Of these, 45% were considered to be over-transfused (n=232), with significant differences according to RBCT indication (p=0.012) and prescribing physician (p=0.047). Overall, 584/1,433 (41%) of evaluable RBC units were unnecessarily transfused. DISCUSSION The appropriateness of RBCT in ED is similar to other hospital departments, but the rate of over-transfusion was high. These data support the need for a reassessment after transfusion of each RBC unit before further units are prescribed. In view of these results, we recommend that physicians should be made more aware of the need to prescribe RBCT appropriately in order to reduce over-transfusion.
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18
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Bahadur S, Sethi N, Pahuja S, Pathak C, Jain M. Audit of pediatric transfusion practices in a tertiary care hospital. Indian J Pediatr 2015; 82:333-9. [PMID: 24794324 DOI: 10.1007/s12098-014-1370-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 02/03/2014] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Shalini Bahadur
- Department of Pathology and Blood Bank, Lady Hardinge Medical College, New Delhi, India
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19
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de Souza DA, Silva FGE, Costa PJMDS. Critical evaluation of justifications for the transfusion of red blood cells: the reality of a government emergency hospital. Rev Bras Hematol Hemoter 2013; 35:263-7. [PMID: 24106444 PMCID: PMC3789431 DOI: 10.5581/1516-8484.20130070] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 04/17/2013] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Blood products and derivatives are indispensable resources in medical therapies. However, it is important to note that the number of donations is far from ideal. Despite constant campaign efforts, a deficit of 1 million units is expected by 2030. OBJECTIVES To determine the adequacy of the indications for red blood cell transfusion in an emergency hospital in Alagoas. METHODS This was a cross-sectional observational study conducted at the Alagoas Blood Center. Of a total of 2936 red blood cell transfusion requests in 2009, 334 were randomized and compared with transfusion parameters described in the literature (primary variable). After analysis, the transfusion requests were categorized as adequate, inadequate or inconclusive. This last group included all red blood cell transfusion requests with insufficient clinical information, rendering their classification as adequate or inadequate impossible. The secondary variable involved the reasons for red blood cell transfusion. A 95% confidence interval was used in the statistical analysis. RESULTS Forty-seven (14.07%) requests were adequate and 30 (8.98%) were inadequate. Most of the requests were classified as inconclusive (76.94%). The main indications for transfusion were upper gastrointestinal bleeding (26.95%), anemia (46.71%), hypovolemia/hypovolemic shock (10.78%) and sepsis/septic shock (3.29%). CONCLUSION It was not possible to reach a conclusion on the adequacy of the indication for transfusion in most of the cases. Therefore, it is important to adopt a transfusion protocol, rigorously analyze blood bank requests, to provide awareness campaigns on the rational use of blood and to implement strategies to use blood products more effectively.
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Affiliation(s)
- Diego Agra de Souza
- Universidade Estadual de Ciências da Saúde de Alagoas - UNCISAL, Maceió, AL, Brazil
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20
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Pahuja S, Sethi N, Singh S, Sharma S, Jain M, Kushwaha S. Concurrent audit of fresh frozen plasma: experience of a tertiary care hospital. ACTA ACUST UNITED AC 2013; 17:306-10. [PMID: 22971538 DOI: 10.1179/1607845412y.0000000019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
UNLABELLED 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.
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Cheng DR, Bajraszewski C, Verma KP, Wolff AM. How appropriately is blood ordered in a rural hospital? Transfus Apher Sci 2013; 48:79-82. [DOI: 10.1016/j.transci.2012.06.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Accepted: 06/29/2012] [Indexed: 10/28/2022]
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Trichet M. [Computers to facilitate the quality of blood products orders]. Transfus Clin Biol 2012; 19:228-32. [PMID: 23039959 DOI: 10.1016/j.tracli.2012.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 07/06/2012] [Indexed: 10/27/2022]
Abstract
The decision to order component blood products is perhaps the most critical step in patient's transfusion safety. A variety of techniques used to bring about behavioural changes in the transfusion practices of physicians have been met with limited success. Computerized order entry (CPOE) and decision support systems have been demonstrated to improve the quality of orders in terms of legibility and completeness. In addition, CPOE systems have been shown to affect physician ordering behaviour and to reduce the percentage of inappropriate orders. However, CPOE systems with poorly interfaced designs can result in usability problems and finally in order errors. Evaluation of the system has to guide CPOE systems' evolutions to aid in patient safety.
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Affiliation(s)
- M Trichet
- Unité d'hémovigilance et de sécurité transfusionnelle, centre hospitalier départemental de la Vendée, les Oudairies, 85925 La Roche-sur-Yon cedex 9, France.
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Allden RLW, Sinha R, Roxby DJ, Ireland S, Hakendorf P, Robinson KL. Red alert - a new perspective on patterns of blood use in the South Australian public sector. AUST HEALTH REV 2011; 35:327-33. [PMID: 21871195 DOI: 10.1071/ah10957] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 12/13/2010] [Indexed: 11/23/2022]
Abstract
OBJECTIVES In 2006 South Australia had a red cell issue rate, measured as product issues per 1000 population, 22.4% higher than the national average. A pilot study was undertaken to investigate the disparity in issue rates between SA and the national average with a secondary aim of establishing information on SA red cell use. METHODS A linked electronic database was developed using clinical, epidemiological and red cell transfusion data within hospitals in the SA public sector. Aggregated red cell use across the SA public health sector was analysed by clinical variables such as Diagnosis Related Group (DRG), including specialty related groups (SRGs) and major diagnostic categories (MDCs). The DRGs that were associated with blood use were identified and applied to national hospital separations data in order to derive comparative blood utilisation rates for SA and Australia. RESULTS Although blood issue and usage by population measure showed a significant difference of 22.4 and 22.0% respectively between SA and Australia, when measured against weighted separations the differences reduced to 7.4 and 7.1% respectively. CONCLUSION This study showed the importance of analysing blood issues and utilisation on an activity adjusted basis rather than a raw per capita basis.
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Appropriateness of red blood cell use in orthopedic surgery and traumatology: analysis of transfusion practice. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2011. [DOI: 10.1007/s00590-011-0816-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Arnold DM, Lauzier F, Whittingham H, Zhou Q, Crowther MA, McDonald E, Cook DJ. A multifaceted strategy to reduce inappropriate use of frozen plasma transfusions in the intensive care unit. J Crit Care 2011; 26:636.e7-636.e13. [PMID: 21439762 DOI: 10.1016/j.jcrc.2011.02.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2010] [Revised: 02/09/2011] [Accepted: 02/13/2011] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this study is to determine the effect of a multifaceted behavior-change strategy on inappropriate use of frozen plasma (FP) transfusions in the intensive care unit (ICU). MATERIALS AND METHODS A prospective, time-series study was conducted in a 15-bed medical-surgical ICU in 3 phases: (1) baseline observation; (2) educational campaign, audit and feedback to prescribers, and implementation of an FP request form; and (3) FP request form only. Independently, in triplicate and blinded to study phase, appropriateness of each FP request was adjudicated based on published guidelines and clinical context. RESULTS Over the 15-month study period, 626 FP transfusions (210 FP requests) were administered to 88 patients. Inappropriate FP requests decreased slightly from phases I to III (60% vs 46%; P = .09), FP requests that were consistent with the guidelines did not change (23% vs 22%; P = .86), and FP requests that were appropriate for the ICU yet inconsistent with the guidelines increased (17% vs 32%; P = .04). Although uptake of the FP request form decreased in phase III, it was associated with fewer inappropriate transfusions. CONCLUSIONS The behavior-change strategy modestly improved appropriate use of FP transfusions in the ICU. Improving FP request form accuracy, completeness, and compliance may be required to achieve maximum effect and ensure sustainability.
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Affiliation(s)
- Donald M Arnold
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada L8N 3Z5.
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Crispin PJ, Burgess M, Crispin TM. Transfusion demand control strategies: potential efficacy of hospital and regional interventions. Transfus Apher Sci 2010; 43:341-345. [PMID: 21030310 DOI: 10.1016/j.transci.2010.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Contingency plans have been developed to direct appropriate responses to blood shortages. Planning requires an understanding of the potential savings of different conservation strategies. METHOD The Australian Capital Territory (ACT) Haemovigilance and ACT Pathology transfusion databases were reviewed from March to September 2003. All transfusion episodes were prioritised in accordance with the Australian National Blood Supply Contingency Plan. The number of red cell transfusions related to various indications, their appropriateness and acuity was determined. The potential reduction in red cell usage was modelled for potential red cell reduction interventions. RESULTS There were 2305 units of red cells captured during the timeframes of the audits. This accounted for an estimated 70% of all red cell transfusions in the ACT. After correcting for the number of red cells transfused at each hospital, red cells were prioritised as category 1 in 59%, 2 in 27% and 3 in 13%. The remainder had insufficient data for classification. Transfusion for elective surgery accounted for 14.7% of red cells used, with 9.0% rated category 3 under the contingency plan. There were 17.3% of red cells transfused for inappropriate indications, when reviewed against national guidelines. After excluding inappropriate transfusions, cancelling elective surgery could potentially save a further 5.5% and 4.3% of blood utilisation for category 3 and 2 patients, respectively. Significant differences were found between hospitals. CONCLUSION Targeting inappropriate transfusions by vetting particularly for inappropriate transfusions not only re-directs blood away from those unlikely to benefit, but is also more effective at preserving the red blood cells than other measures during times of supply limitation. Contingency planning needs to accommodate the variable case-mix in hospitals, allocate resources for transfusion medicine specialists to review every transfusion request and may be better coordinated at a jurisdictional level.
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Affiliation(s)
- Philip J Crispin
- Haematology Department, Canberra Hospital, Garran ACT, Australia; Australian National University Medical School, Acton ACT, Australia.
| | - Maria Burgess
- Department of the Chief Health Officer, ACT Health, Canberra, Australia
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Tavares M, DiQuattro P, Nolette N, Conti G, Sweeney J. Reduction in plasma transfusion after enforcement of transfusion guidelines (CME). Transfusion 2010; 51:754-61. [DOI: 10.1111/j.1537-2995.2010.02900.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Verlicchi F. Evaluation of clinical appropriateness of blood transfusion. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2010; 8:89-93. [PMID: 20383301 PMCID: PMC2851211 DOI: 10.2450/2009.0123-09] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/18/2009] [Accepted: 09/14/2009] [Indexed: 11/21/2022]
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Damiani G, Pinnarelli L, Sommella L, Farelli V, Mele L, Menichella G, Ricciardi W. Appropriateness of fresh-frozen plasma usage in hospital settings: a meta-analysis of the impact of organizational interventions. Transfusion 2010; 50:139-44. [DOI: 10.1111/j.1537-2995.2009.02371.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Francis JJ, Tinmouth A, Stanworth SJ, Grimshaw JM, Johnston M, Hyde C, Stockton C, Brehaut JC, Fergusson D, Eccles MP. Using theories of behaviour to understand transfusion prescribing in three clinical contexts in two countries: development work for an implementation trial. Implement Sci 2009; 4:70. [PMID: 19852832 PMCID: PMC2777847 DOI: 10.1186/1748-5908-4-70] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2009] [Accepted: 10/24/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Blood transfusion is an essential part of healthcare and can improve patient outcomes. However, like most therapies, it is also associated with significant clinical risks. In addition, there is some evidence of overuse. Understanding the potential barriers and enablers to reduced prescribing of blood products will facilitate the selection of intervention components likely to be effective, thereby reducing the number of costly trials evaluating different implementation strategies. Using a theoretical basis to understand behaviours targeted for change will contribute to a 'basic science' relating to determinants of professional behaviour and how these inform the selection of techniques for changing behaviour. However, it is not clear which theories of behaviour are relevant to clinicians' transfusing behaviour. The aim of this study is to use a theoretical domains framework to identify relevant theories, and to use these theories to identify factors that predict the decision to transfuse. METHODS The study involves two steps: interview study and questionnaire study. Using a previously identified framework, we will conduct semi-structured interviews with clinicians to elicit their views about which factors are associated with waiting and further monitoring the patient rather than transfusing red blood cells. Interviews will cover the following theoretical domains: knowledge; skills; social/professional role and identity; beliefs about capabilities; beliefs about consequences; motivation and goals; memory, attention, and decision processes; environmental context and resources; social influences; emotion; behavioural regulation; nature of the behaviour. The interviews will take place independently in Canada and the UK and involve two groups of physicians in each country (UK: adult and neonatal intensive care physicians; Canada: intensive care physicians and orthopaedic surgeons). We will: analyse interview transcript content to select relevant theoretical domains; use consensus processes to map these domains on to theories of behaviour; develop questionnaires based on these theories; and mail them to each group of physicians in the two countries. From our previous work, it is likely that the theories will include: theory of planned behaviour, social cognitive theory and the evidence-based strategy, implementation intention. The questionnaire data will measure predictor variables (theoretical constructs) and outcome variables (intention and clinical decision), and will be analysed using multiple regression analysis. We aim to achieve 150 respondents in each of the four groups for each postal survey.
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Affiliation(s)
- Jill J Francis
- Health Services Research Unit, University of Aberdeen, UK
| | - Alan Tinmouth
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute and Department of Medicine, University of Ottawa, Canada
- Canadian Blood Services, Ottawa, Canada
| | - Simon J Stanworth
- NHS Blood & Transplant, John Radcliffe Hospital, Headington, Oxford, UK
| | - Jeremy M Grimshaw
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute and Department of Medicine, University of Ottawa, Canada
| | | | - Chris Hyde
- NHS Blood & Transplant, John Radcliffe Hospital, Headington, Oxford, UK
| | - Charlotte Stockton
- Centre for Medical Statistics and Health Evaluation, University of Liverpool, UK
| | - Jamie C Brehaut
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute and Department of Epidemiology and Community Medicine, University of Ottawa, Canada
| | - Dean Fergusson
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute and Department of Medicine, University of Ottawa, Canada
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Audit of the clinical use of fresh-frozen plasma in Umbria: study design and results of the pilot phase. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2009; 6:211-9. [PMID: 19112736 DOI: 10.2450/2008.0042-07] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Fresh-frozen plasma (FFP) is unanimously recognised by international guidelines as the blood component of choice for the management of acute haemorrhage when accompanied by disorders of haemostasis, for disseminated intravascular coagulation in the presence of haemorrhage, for rare bleeding disorders when specific clotting factor concentrates are not available and for thrombotic thrombocytopenic purpura. The literature, however, reports a high percentage of inappropriate requests for FFP. This article presents the results of a pilot study of clinical auditing of the use of FFP in the Region of Umbria (Italy). METHODS This study was based on the examination of the requests for FFP made in April 2006 to four Immunotransfusion Services (ITS) in Umbria and of the clinical records of the patients receiving transfusions. The following indicators were identified and evaluated: completeness of the request, appropriateness of the indication and the dose, completeness of the records in the clinical charts, adverse events, in-hospital morbidity and mortality, efficacy of the treatment (evaluated by analysing the changes between pre- and post-transfusion coagulation test results) and, as an indicator of the process, the correspondence between data in the paper request form and in the computerised database. The data were extracted from the ITS databases, from the paper request forms and from the patients' clinical records. RESULTS Two hundred and twenty-one requests (615 units of FFP) for 109 patients and 92.8% of the related clinical records were examined. The patients were admitted in medical (22.9%), surgical (51.4%) and critical care units (25.7%). In 50.7% of the cases, the completeness of the data in the individual requests was good (65-80% of the fields filled in). The indication was appropriate in 31.5% of the requests evaluated (56.1% of the total), with no difference related to different requesters. The dosage was appropriate in 62.7% of the requests evaluated (62% of the total). A comparison of pre- and posttransfusion laboratory data showed a significant correction of pathological values (p=0.02) only for the International Normalised Ratio (INR). CONCLUSIONS Critical areas that should be targeted by interventions to improve plasma usage are those related to the appropriateness of the indication, the completeness of the data entered in the request forms and the data recorded in the clinical charts.
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The good use of plasma. A critical analysis of five international guidelines. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2008; 6:18-24. [PMID: 18661920 DOI: 10.2450/2008.0041-07] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND The clinical use of fresh-frozen plasma (FFP) is progressively increasing both nationally and internationally, despite the fact that many studies have shown the weaknesses of the indications for its use. Guidelines on the good use of plasma have, therefore, been adopted in various countries. The aim of the present study was to analyse some of the existing guidelines on the good use of plasma, applying a scientifically validated method, as a preliminary step in the implementation of Regional guidelines. METHODS Abibliographic search (1990-2006) was conducted in databases, websites, and the archives of scientific societies. Relevant articles were recovered in full. The selected guidelines were evaluated using theAGREE instrument, which assesses the completeness and structural quality of the guidelines and, in some aspects, the contents of the recommendations. The project, co-ordinated by the Regional Centre for Co-ordination and Compensation (CRCC) and carried out by four Services of Immunohaematology and Transfusion (SIT) in Umbria, was funded by the Region of Umbria and approved by the four health care institutions involved. RESULTS The bibliographic search yielded 3067 abstracts of which 239 were considered relevant. The analysis of these led to the recovery of 11 guidelines, among which five were selected: those from the British Committee for Standards in Haematology, theAgence Française de Securité Sanitaire de Produits de Sante, the Canadian Members of the Expert Working Group, the American Society of Anesthesiologists Task Force on Blood Component Therapy and the National Health and Medical Research Council (NHMRC)/Australasian Society of Blood Transfusion. CONCLUSIONS None of the guidelines analysed obtained a score higher than 50% in all the domains of the AGREE score. There was no evidence of a tendency to improvement over time in the guidelines analysed. Objective evaluation of the guidelines analysed could provide the starting point for the subsequent production of similar documents.
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Jackson GN, Snowden CA, Indrikovs AJ. A Prospective Audit Program to Determine Blood Component Transfusion Appropriateness at a Large University Hospital: A 5-Year Experience. Transfus Med Rev 2008; 22:154-61. [DOI: 10.1016/j.tmrv.2007.12.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Tinmouth A. Reducing the amount of blood transfused by changing clinicians' transfusion practices. Transfusion 2007; 47:132S-136S; discussion 155S-156S. [PMID: 17651336 DOI: 10.1111/j.1537-2995.2007.01369.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Alan Tinmouth
- Ottawa Hospital and Ottawa Health Research Institute, Ottawa, Ontario, Canada
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Tuscan study on the appropriateness of fresh-frozen plasma transfusion (TuSAPlaT). BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2007; 5:75-84. [PMID: 19204757 DOI: 10.2450/2007.0015-07] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/24/2007] [Accepted: 06/04/2007] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The considerable increase in the consumption of fresh-frozen plasma (FFP) recorded in 2002 in the Region of Tuscany made it necessary to check the appropriateness of the use of this blood component in all transfusion facilities in the Tuscan network. MATERIALS AND METHODS From July 1, 2003 to December 31, 2005, the Regional Blood Transfusion Coordinating Centre carried out an audit on the clinical use of FFP in the 40 structures included in the Tuscan transfusion network. The study had two complementary parts: a review of guidelines on the use of FFP and the involvement of Hospital Transfusion Committees in evaluating the outcome of the audit and in the consequent local policy decisions and in educating clinicians. RESULTS The data from all 40 of the regional transfusion structures were analysed. The audit, which was initially retrospective, gradually became prospective. The percentage clinical use of FFP decreased, compared to 2002, in each of the 3 years of the study: a) 2003: - 8.92%; b) 2004: - 2.11%; c) 2005: -1.97%. The inappropriate requests for plasma decreased from 27% to 22.7% of the total. It was possible to classify the inappropriate requests for plasma on the basis of homogeneous, regionally defined criteria. The most frequent inappropriate indication (60.7% of the total) was the use of plasma in the case of haemorrhage in patients with a normal PT and/or PTT or unavailable results. Each hospital revised its own guidelines between 2004 and 2005 and the Hospital Transfusion Committees set up appropriate educational and behavioural interventions. CONCLUSIONS The capacity of transfusion facilities to make data on the use of blood components available systematically and continuously is an essential feature of clinical governance; systematic clinical auditing increases the level of appropriate behaviours in the transfusion sector, contemporaneously contributing to self-sufficiency in transfusion products, and may direct research towards those clinical settings at greatest risk of inappropriate use of transfusion therapy with FFP.
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Bampton PA, Sandford JJ, Young GP. Achieving long-term compliance with colonoscopic surveillance guidelines for patients at increased risk of colorectal cancer in Australia. Int J Clin Pract 2007; 61:510-3. [PMID: 17313621 DOI: 10.1111/j.1742-1241.2006.01158.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We have previously demonstrated that we could improve colonoscopic surveillance practice for patients at increased risk of colorectal cancer by the adoption of guidelines, facilitated by a nurse co-ordinator. This study was to determine whether we could sustain this improvement over a longer period (4 years). All colonoscopic surveillance decisions made by the co-ordinated colorectal screening programme of our hospital between 2000 and April 2004 were reviewed. Reasons for variance were recorded, and surveillance decisions made in the last 4 months of the study time were compared with decisions made 4 years previously, both before and after the introduction of the co-ordinated programme. Between 2000 and 2004, 1794 surveillance decisions were made with variance occurring in 100. In the last 4 months of the period of study, 98% of decisions matched guidelines, suggesting that the improvement made following the adoption of the guidelines (45-96% p < 0.05) could be maintained. Reasons for variance from guidelines included a belief that the particular clinical scenario was not covered in the guidelines, disagreement with the guidelines or patient anxiety. Adherence to evidence based medicine guidelines for colonoscopy surveillance can be maintained over time at a high level. A number of clinical scenarios are not covered adequately by the existing guidelines and continue to generate disagreement amongst clinicians.
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Affiliation(s)
- P A Bampton
- Department of Gastroenterology and Hepatology, Flinders Medical Centre, Bedford Park, SA 504269, Australia.
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Brand C, Landgren F, Hutchinson A, Jones C, Macgregor L, Campbell D. Clinical practice guidelines: barriers to durability after effective early implementation. Intern Med J 2005; 35:162-9. [PMID: 15737136 DOI: 10.1111/j.1445-5994.2004.00763.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Clinical practice guidelines in general (General-CPG) may reduce variation in clinician performance and improve patient outcomes. Short-term evaluation is now routine, but demonstration of early successful implementation does not necessarily ensure longer-term effectiveness. AIM To assess adherence to chronic obstructive pulmonary disease (COPD)-CPG recommendations at the Royal Melbourne Hospital (RMH), 2 years after successful implementation. To identify barriers to sustained success of General-CPG. METHODS A multi-faceted evaluation was performed to document: (i) current adherence to COPD management recommendations (medical record audit); (ii) awareness of attitudes towards and barriers for the use of COPD-CPG and General-CPG (staff survey, focus groups and key informant interviews) and (iii) access to and quality of available General-CPG (internet review and random sample General-CPG evaluation. RESULTS Adherence to COPD-CPG recommendations was highly variable. Adherence was higher in the Emergency Department than the general wards and for specific therapeutic recommendations. It was lower for non-pharmacological therapy and for recommendations relating to processes of care. Most health professionals were in favour of General-CPG. Barriers to use of General-CPG were in keeping with previous literature reports. Organizational issues including high levels of staff turnover and lack of integration of General-CPG into hospital quality frameworks were highlighted as major barriers. Hospital intranet access and presentation of General-CPG identified lack of consistency in terminology and presentation. CONCLUSION Short-term effectiveness of COPD-CPG implementation did not ensure sustained success. Departmental organizational behaviours and organizational system barriers are major factors influencing durability.
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Affiliation(s)
- C Brand
- Clinical Epidemiology & Health Service Evaluation Unit, The Royal Melbourne Hospital, Parkville, Victoria, Australia.
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Hui CH, Williams I, Davis K. 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. Intern Med J 2005; 35:283-8. [PMID: 15845110 DOI: 10.1111/j.1445-5994.2005.00803.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM 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. METHODS 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. RESULTS 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. CONCLUSION Clinical transfusion audit helps to identify current pattern of usage and areas of improvement. A self-educating transfusion specific request form is also beneficial.
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Affiliation(s)
- C-H Hui
- Transfusion Medicine Unit, Royal Adelaide Hospital Campus, Institute of Medical and Veterinary Science, Adelaide, South Australia, Australia.
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Petäjä J, Andersson S, Syrjälä M. A simple automatized audit system for following and managing practices of platelet and plasma transfusions in a neonatal intensive care unit. Transfus Med 2004; 14:281-8. [PMID: 15285724 DOI: 10.1111/j.0958-7578.2004.00515.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
During neonatal intensive care, blood components are often used in clinical situations where both their efficacy and safety lack solid justification. A practical system to continuously analyse actual transfusion practices is a prerequisite for improvements of quality in transfusion therapy. We hypothesized that such a system would reveal inappropriate variations in clinical decision making and offer a means for staff education and quality improvement and assurance. The study consisted of three 120-152-day periods (P I, P II and P III) between January 2000 and October 2001 and involved 543 new patient admissions (141 patients with birth weight < 1501 g) and 6227 days of patient care at a single tertiary level NICU. P I was a control with no intervention, P II was after technically introducing the computer system and, the last period, P III was after presenting and discussing the results of P I and P II at a staff meeting. Upon an order of platelet or fresh frozen plasma (FFP) unit from the blood bank, a computer-based audit system compared the last platelet count or prothrombin time [expressed as percentage of normal clotting activity, prothrombin time (PT-%)] to predefined criteria. In the case of exceeding the preset thresholds, the system required additional information and recorded the pretransfusion laboratory values for later analysis. Thirty-two per cent of platelet transfusions were given with pretransfusion platelet count >49 x 10(9) L(-1), and 60% of these transfusions (19% of all platelet transfusions) could not be clinically justified in retrospective chart review. There was no significant change in this practice from P II to P III. FFP transfusions were given with significantly different pretransfusion PT-% values during P II and P III. The proportions of FFP transfusions with pretransfusion PT-% > 49% were 7.8% and 0.9% during P II and P III, respectively (P < 0.0001). In chart review, none of the FFP transfusions with pretransfusion PT-% > 49% could be justified by clinical grounds. Inappropriate transfusions of both platelets and plasma remain a significant challenge for quality assurance of neonatal intensive care. Automated recording of pretransfusion platelet count and prothrombin time reliably identified the poorly justified transfusions and thus offered a practical resource-saving tool for quality assurance of transfusion in the NICU. A significant shift towards more appropriate use of plasma was demonstrated after implementation of the audit system.
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Affiliation(s)
- J Petäjä
- Hospital for Children and Adolescents, Helsinki University Central Hospital, Helsinki, Finland.
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Schofield WN, Rubin GL, Dean MG. Appropriateness of platelet, fresh frozen plasma and cryoprecipitate transfusion in New South Wales public hospitals. Med J Aust 2003; 178:117-21. [PMID: 12558482 DOI: 10.5694/j.1326-5377.2003.tb05101.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2002] [Accepted: 10/31/2002] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To estimate the appropriateness of transfusions of platelets, fresh frozen plasma (FFP) and cryoprecipitate using National Health and Medical Research Council and Australasian Society for Blood Transfusion guidelines (NHMRC/ASBT 2002). DESIGN AND SETTING Three separate retrospective surveys of medical records from 1 January to 31 August 2000 (1147 transfused patients) from 14 hospitals selected randomly from all public hospitals that use these blood products in New South Wales: five tertiary referral, five major metropolitan, and four major rural (base) hospitals. MAIN OUTCOME MEASURES Proportion of potentially inappropriate transfusions. RESULTS 33% (136/414) of platelet, 37% (248/669) of FFP and 62% (37/60) of cryoprecipitate transfusions were assessed as inappropriate. By hospital type, 29% (75/259) of platelet transfusions were inappropriate at tertiary referral hospitals, 51% (40/78) at major urban hospitals, and 27% (21/79) at major rural hospitals. For FFP, 36% (112/313), 37% (80/216) and 39% (55/140) were inappropriate for referral, urban and rural hospitals, respectively. Cryoprecipitate was used almost exclusively at tertiary referral hospitals. CONCLUSIONS In terms of the NHMRC/ASBT guidelines on use of blood products, there is considerable inappropriate transfusion of platelets, FFP and cryoprecipitate in NSW public hospitals.
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Affiliation(s)
- William N Schofield
- Department of Public Health and Community Medicine, University of Sydney at Westmead Hospital, Main Admin. Block, Westmead Hospital, Hawkesbury Road, Westmead, NSW 2145.
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Wilson K, MacDougall L, Fergusson D, Graham I, Tinmouth A, Hébert PC. The effectiveness of interventions to reduce physician's levels of inappropriate transfusion: what can be learned from a systematic review of the literature. Transfusion 2002; 42:1224-9. [PMID: 12430683 DOI: 10.1046/j.1537-2995.2002.00185.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Kumanan Wilson
- Department of Medicine, University of Toronto, Ontario, Canada.
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Abstract
BACKGROUND Limited blood supplies necessitate the rational use of blood products. The aim of the present study was to provide a basis for audits of red cell usage in surgery by benchmarking common practice. Application of the data to the construction of a maximum surgical blood order schedule may be relevant for centres that perform a serological crossmatch or who collect autologous units. METHODS Data on surgical procedures identified by Commonwealth Medical Benefits Schedule item numbers, were collected retrospectively from theatre and blood bank records at the Royal Melbourne and Melbourne Private hospitals from May 1997 to April 1998. The percentage of procedures for which red cells were transfused, and the mean, median and range of units transfused for procedures with >/= 30% transfusion likelihood were identified. RESULTS Over 12 months, 266 surgical procedure codes were itemized >/= 10 times each, contributing 12 300 data entries. Only 38 procedures demonstrated an incidence of transfusion of at least 30%. Most frequently transfused procedures included spinal fusion, total hip replacement, mandible/maxilla resection, prostatectomy and bladder excision. CONCLUSION The number of common surgical procedures in which there is a 30% or greater likelihood that red cell transfusions will be given is limited. This benchmarking of common red cell usage is a first step in the process of determination of transfusion appropriateness.
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Affiliation(s)
- Ellen L Maxwell
- Department of Diagnostic Haematology, Royal Melbourne Hospital, Parkville, Victoria, Australia.
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Rubin GL, Schofield WN, Dean MG, Shakeshaft AP. Appropriateness of red blood cell transfusions in major urban hospitals and effectiveness of an intervention. Med J Aust 2001; 175:354-8. [PMID: 11700811 DOI: 10.5694/j.1326-5377.2001.tb143617.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To assess the appropriateness of red blood cell (RBC) transfusions and the effectiveness of an intervention to reduce inappropriate RBC transfusions. DESIGN Medical record audit by hospital staff using a data form, before and after randomly allocated interventions (letter only or letter+visit). Criteria for assessing appropriateness of RBC transfusions were based on a systematic literature review. SETTING Ten major urban hospitals in Sydney, New South Wales, in 1998 and 1999. SUBJECTS Medical records of up to 120 patients at each hospital (n=1117). INTERVENTIONS Letter-only (5 hospitals)--results of first audit at the hospital mailed to chief executive officer of that hospital; letter+visit (5 hospitals) results of first audit at the hospital presented by the research team to a meeting of that hospital's staff, and then mailed to the chief executive officer. MAIN OUTCOME MEASURE Proportion of RBC transfusions assessed as inappropriate. RESULTS At first audit, 35% of RBC transfusions were assessed as inappropriate. Small reductions in inappropriate transfusions were found at the second audit, but the change was significant only for the hospitals receiving the letter-only intervention. About 5% of patients received a single RBC unit; 40% of single-unit transfusions were inappropriate. More RBC transfusions were inappropriate in surgical patients than in those treated by other specialties. CONCLUSIONS About a third of RBC transfusions were assessed as inappropriate. The interventions had only a small effect on transfusion appropriateness.
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Affiliation(s)
- G L Rubin
- Department of Public Health and Community Medicine, University of Sydney at Westmead, NSW.
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McGrath KM, Hancock L, Foster KM. Compliance with clinical guidelines for blood transfusion practice: how can changes be maintained? Med J Aust 2001; 174:435. [PMID: 11386585 DOI: 10.5694/j.1326-5377.2001.tb143367.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Tobin SN, Campbell DA, Boyce NW. Durability of response to a targeted intervention to modify clinician transfusion practices in a major teaching hospital. Med J Aust 2001; 174:445-8. [PMID: 11386588 DOI: 10.5694/j.1326-5377.2001.tb143370.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine the durability of a successful intervention to modify clinician transfusion practices, and to compare current transfusion practices in the "intervention" hospital with those in a hospital with no intervention. DESIGN Prospective, descriptive study. SETTING Two major metropolitan teaching hospitals--Royal Melbourne Hospital and Western Hospital, Footscray. SUBJECTS Consecutive patient transfusion episodes for red cells, platelets and fresh frozen plasma (FFP). OUTCOME MEASURES Appropriateness of transfusion according to intervention guidelines; comparison of inappropriate transfusion rates before the intervention, immediately after the intervention and 3 years after the intervention. Comparison of inappropriate transfusion rates in intervention and non-intervention hospitals. RESULTS Inappropriate transfusion rates 3 years after the intervention were 20% for red cells, 27% for platelets, and 43% for FFP. These were significantly higher than equivalent rates reported immediately after the intervention. Inappropriate transfusion rates at the non-intervention hospital were comparable (26% for red cells, 36% for platelets and 52% for FFP). CONCLUSION Appropriate clinician transfusion practices have proven difficult to sustain 3 years after hospital guideline generation and promotion. A "gate-keeping" role by hospital blood bank staff proved impractical in the long term.
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Affiliation(s)
- S N Tobin
- Clinical Epidemiology and Health Service Evaluation Unit, NorthWestern Health Care Network, Melbourne, VIC
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Abstract
Physicians with interest or expertise in transfusion medicine must apply their clinical consultation and laboratory management skills to be accorded support for their activities. To establish credibility, efforts must initially be directed where patient benefit and financial gain can be documented. Focusing efforts on practice improvements and sharing the results of those efforts with physician colleagues and administrators can help ensure continued support. Transfusion medicine continues to play an important role in health care, particularly in an era of managed care and reduced resources. Investment in the activities of this discipline will pay off for patients, clinicians, and hospitals.
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Affiliation(s)
- J P AuBuchon
- Blood Bank and Transfusion Service, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA
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