|Year : 2020 | Volume
| Issue : 1 | Page : 54-57
A retrospective analysis of blood requisition versus utilization practices at national blood bank, jigme dorji wangchuck national referral hospital, Thimphu, Bhutan
Tshering Yangdon, Mahrukh Getshen, Lobzang Tashi
Department of Pathology and Laboratory Medicine, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
|Date of Submission||04-Dec-2019|
|Date of Decision||01-Feb-2020|
|Date of Acceptance||20-Feb-2020|
|Date of Web Publication||17-Apr-2020|
Department of Pathology and Laboratory Medicine, Jigme Dorji Wangchuck National Referral Hospital, Thimphu
Source of Support: None, Conflict of Interest: None
Background and Objectives: Although National Guidelines on Clinical Use of Blood has been developed, it is a common practice to order blood based on the subjective anticipation of blood loss, instead of evidence-based requirement at National Referral Hospital, Thimphu. However, National Blood Bank follows the maximum surgical blood ordering schedule, thereby saving the resources and making blood available for emergency patients. Nonetheless, the need-based assessment is not conducted to determine the efficacy of the practice. This study aimed to assess the effectiveness of the current practice of following the national guidelines on maximum surgical ordering of blood by evaluating the blood requisition versus utilization practice. Materials and Methods: A hospital-based retrospective study was conducted at national blood bank over a 1-year period (January–December 2018). Demographic data, such as age and sex, and clinical wards with maximum transfusion done were recorded. Blood utilization indices were computed for cross-match-to-transfusion ratio (C:T, <2.5), transfusion index (TI, >0.5) and transfusion probability (%T, >30) to indicate significant blood usage. All data were processed and analyzed with software programs Microsoft Excel 2013 and GraphPad Prism (v 7.04). Results: Of 4012 blood units cross-matched, 3205 blood units were transfused to patients (C:T ratio 1). Majority (65.33%) of the patients were females and 34.66% were males. The overall TI was 1.49 and %T was 73.07%, implying significant blood usage. The maximum request for blood was made from gynecological and obstetrics ward, emergency, and daycare blood transfusion unit. Similarly, the patients transfused with the cross-matched units were also found to be highest for these wards. Conclusion: The study demonstrates that the current practice of maximum blood ordering schedule is effective in saving valuable time and resources. However, there is a need to sensitize the requesting physician on rational order for effective management of the blood inventory.
Keywords: Blood requisition, maximum surgical blood ordering, rationale order
|How to cite this article:|
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. Glob J Transfus Med 2020;5:54-7
|How to cite this URL:|
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. Glob J Transfus Med [serial online] 2020 [cited 2020 Aug 13];5:54-7. Available from: http://www.gjtmonline.com/text.asp?2020/5/1/54/282747
| Introduction|| |
Blood ordering by a physician often causes burden for blood bankers, especially in resource-limited setting. Maximal ordering of blood has been reported in several developing countries, based on subjective anticipation of blood loss instead of evidence-based requirement.
Type and cross-match are the routine protocol in Asian countries in contrast to electronic type and screen protocols followed in western countries. This may cause the unavailability of blood for the others, implying inappropriate distribution of blood units, inaccessibility for emergency patients with increased need for blood transfusion, increased cost of blood supply, and increased workload for the blood bank staff., The common factors associated with the request of blood transfusion may vary with differing opinions on hemoglobin threshold level below which patients require blood transfusion, differences in operative cases, and lack of proper transfusion protocols.
Blood request form (BRF) is a line of communication between the ordering physician and blood bank staff. A standard BRF comprises detailed patient data such as demographic information, clinical diagnosis, reason for transfusion, and physician name and signature among many others. The use of duly filled BRF could help in reducing unnecessary cross-matching of blood units. Unfortunately, details in BRF are often poorly documented, causing wastage in time following up with the physician by the blood bank staff.
At National Referral Hospital, maximum blood is ordered for patient anemic management which is often based on assumptions of blood loss. The lack of judicious use of blood and blood components with the limitation in maintaining the blood inventory often causes problem for the National Blood Bank. This results in requesting for replacement blood donors, thereby increasing the transfusion associated risk of transfusion transmissible infections.
The National Guidelines on Clinical Use of Blood developed in 2009 comprises maximum blood ordering schedule (MSBOS) and group and screen hold (GSH) protocol equation, which would lead to better utilization of blood. The MSBOS provides a list of guide to the expected blood usage for surgical procedures along with the number of blood units to be cross-matched preoperatively for each procedure,
The decision for GSH protocol is carried out based on percentage of blood usage as follows:
For the procedures in which blood usage calculated is <30% GSH is followed, whereas for >30%, the number of units kept cross matched is calculates as per the requirment stated in BRF by the ordering physician. However, the prescription practice is often not consistent with the recommended guidelines.
A number of indices are used to determine the efficiency of blood ordering and utilization system. The efficacy indices such as cross-match to transfusion ratio (C:T) ratio <2.5, transfusion index (TI) >0.5, and transfusion probability (%T) >30% provide appropriate requirement of blood and its utilization.,,,,
Despite a number of studies done elsewhere, there are no published accounts of assessment carried out at National Blood Bank (NBB), Thimphu. Therefore, the primary objective of this study was to evaluate the effectiveness of the current practice on MSBOS by analyzing the blood requisition and utilization practices.
| Methods|| |
A hospital-based retrospective study was conducted over a 1-year period (January–December 2018). Details of blood requisition and transfusion of cases were collected and reviewed. Patient's age, sex, number of units cross-matched and transfused, and number of patients cross-matched and transfused were noted. Demographic data, such as age and sex, and clinical wards with maximum transfusion done were recorded in frequency and percentages.
All data were processed and analyzed with the software programs Microsoft Excel 2013 (version 13) and GraphPad Prism version 7.04 for Windows, GraphPad Software, La Jolla, California, USA. Blood utilization indices were computed with the following equation:
- C:T ratio = Number of units cross-matched/number of units transfused
A ratio of 2.5 and below is considered indicative of significant blood usage.
- TI = Number of units transfused/number of patients cross-matched
A value of 0.5 or more was considered indicative of significant blood utilization.
- Transfusion probability (%T) = Number of patients transfused/number of patients cross-matched × 100.
A value of 30% and above was considered indicative of significant blood usage.
This was sought from the Research Ethics Board of Medicine, Ministry of Health, Bhutan. Confidentiality of the information was assured using patient reference number entered in the cross-matching register, and BRFs were received from the clinical wards. Ethical clearance was given vide letter (Ref. No. REBH/Approval/2018/032) dated July 27, 2018.
| Results|| |
In 2018, a total of 3900 blood units were collected, of which a total of 4012 blood units were cross-matched and 3205 were transfused to the patients. 897 (65.33%) were females and 476 (34.66%) were males. On different age category, the maximum requisition was made between the age group of 25 and 44 years for both male and female, respectively [Figure 1], followed by 45–65 age group patients.
Of 1373 BRFs received, a total of 1052 (76.6%) of BRF were completely filled. 321 (23.3%) of BRF was with incomplete details for diagnosis, age, sex, or the reason for transfusion not mentioned.
The overall C:T ratio was 1, TI was 1.49, and %T was 73.07%, respectively [Table 1]. Throughout the year, the C:T ratio remained the same, indicating significant blood usage. For TI, the maximum was achieved in December (1.75) and minimum in August (1.28), suggestive of significant blood utilization. The maximum %T was achieved in December (80.52) with minimum of 69.6% in May. However, the overall %T throughout the year indicated efficient blood usage. The maximum request for blood was made from gynecological and obstetrics followed by emergency department and outpatient blood transfusion ward [Table 2]. Similarly, the patients transfused with the cross-matched units were also highest for these wards.
| Discussion|| |
To reduce blood reservation and make it available, especially in resource-constrained settings, simple blood typing, screening, and hold protocol is used in different blood bank centers. In our setting, due to GSH protocol followed only at NBB, the blood is made available in inventory for use in emergency cases. However, there is a need to sensitize the physician to follow GSH protocol in order to reduce time spent by NBB to segregate BRF.
The completeness of the BRF can assist in determining MSBOS, reducing inaccessibility, and improving safe patient transfusion. Our figure revealed 76.6% of BRF being completely filled which are comparable to some extent with the studies from Nigeria (81.2%) and India (97%). The lack of proper documentation and completeness of the BRF has been reported in many researches, indicating unnecessary use of blood products., This could be improved with the appropriate documentation of BRF and rational prescription of blood by the physician.
One of the strategies to evaluate the efficiency of blood utilization is the determination of C:T ratio, which was first Boral and Henry in 1975. Ideally, this ratio should be 1.0, but a ratio of 2.5 and below was suggested to be indicative of efficient blood usage. Our study has reported an overall C:T ratio of 1.0 which is better when compared with studies from Pakistan (1.52), India (2.5), and Malaysia (5.0).
The TI is another indicator of effective blood utilization practices and a value of >0.5 is suggestive of effective blood usage. In the present study, the overall TI of 1.49 showed effective usage compared to other studies from Pakistan (0.65) and India (0.36), respectively.,
The transfusion probability (%T) value of >30% is indicative of appropriate transfusion which was first used in 1980. The overall %T in our study was 73.07% which is comparably higher than studies from Pakistan (65.38%) and India (59%), respectively.,
| Conclusion|| |
The current study demonstrates that GSH protocol for routine and surgeries is effective in saving valuable time and resources in developing countries. The overall values of C:T ratio, TI, and %T were acceptable to indicate significant blood usage. In vast majority of elective surgical procedures, routine cross-match and preparation are not necessary.
However, compliance to national guideline is practiced only at NBB. Therefore, sensitization of Clinicians is required for proper ordering of blood and also in appropriate filling up of BRF.
The medical graduates should also be adequately sensitized regarding clinical blood transfusion practice guideline and these should be incorporated in the teaching module for the health-care workers including Clinicians, nurses and Blood Bank staff involved in Blood transfusion process.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Belayneh T, Messele G, Abdissa Z, Tegene B. Blood requisition and utilization practice in surgical patients at university of gondar hospital, northwest ethiopia. Journal of blood transfusion 2013;2013:758910. Available from: https://doi.org/10.1155/2013/758910
Mangwana S, Bedi N, Yadav P, Chugh R. Optimization of blood transfusion services: Analysis of blood requisition and utilization practices in cardiac surgical patients in a tertiary care hospital, India. Glob J Transfus Med 2017;2:47-51. [Full text]
Soleimanha M, Haghighi M, Mirbolook A, Sedighinejad A, Mardani-Kivi M, Naderi-Nabi B, et al
. A survey on transfusion status in orthopedic surgery at a trauma center. Arch Bone Jt Surg 2016;4:70-4.
Vibhute M, Kamath SK, Shetty A. Blood utilisation in elective general surgery cases: Requirements, ordering and transfusion practices. J Postgrad Med 2000;46:13-7.
] [Full text]
Subramanian A, Sagar S, Kumar S, Agrawal D, Albert V, Misra MC. Maximum surgical blood ordering schedule in a tertiary trauma center in Northern India: A proposal. J Emerg Trauma Shock 2012;5:321-7.
] [Full text]
Waheed U, Azmat M, Wazeer A, Sultan S, Irfan SM, Zaheer HA. Evaluation of blood requisition and utilization practices at a tertiary care hospital blood bank in Islamabad, Pakistan. Glob J Transfus Med 2017;2:113-7. [Full text]
Tuckfield A, Haeusler MN, Grigg AP, Metz J. Reduction of inappropriate use of blood products by prospective monitoring of transfusion request forms. Med J Aust 1997;167:473-6.
Kansay S, Verma M. Evaluation of request forms received in blood bank and biochemistry laboratory in a teaching hospital in North India: A comparative study of preanalytical errors. J Natl Accredit Board Hosp Healthc Provid 2016;3:20-6.
National Blood Transfusion Service. National Guideline on Clinical Use of Blood for Doctors and Nurses. 1st
ed. National Blood Transfusion Service; 2009.
Friedman BA. An analysis of surgical blood use in United States hospitals with application to the maximum surgical blood order schedule. Transfusion 1979;19:268-78.
Boral LI, Henry JB. The type and screen: A safe alternative and supplement in selected surgical procedures. Transfusion 1977;17:163-8.
Olawumi HO, Bolaji BO. Blood utilization in elective surgical procedures in Ilorin. Trop J Health Sci 2006;13:15-7.
Friedman BA, Oberman HA, Chadwick AR, Kingdon KI. The maximum surgical blood order schedule and surgical blood use in the United States. Transfusion 1976;16:380-7.
Mead JH, Anthony CD, Sattler M. Hemotherapy in elective surgery: An incidence report, review of the literature, and alternatives for guideline appraisal. Am J Clin Pathol 1980;74:223-7.
Umesh D, Subash S. A prospective study on blood requisition and utilization practice in a tertiary care teaching hospital. JMSCR 2017;5:32230-5.
Musa AU, Ndakotsu MA, Hassan A, Kilishi A, Kwaifa IK. Pattern of blood transfusion request and utilization at a Nigerian University Teaching Hospital. Sahel Med J 2014;17:19-22. [Full text]
Jegede F, Mbah HA, Dakata A, Gwarzo DH, Abdulrahman SA, Kuliya-Gwarzo A. Evaluating laboratory request forms submitted to haematology and blood transfusion departments at a hospital in Northwest Nigeria. Afr J Lab Med 2016;5:381.
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.
Metz J, McGrath KM, Copperchini ML, Haeusler M, Haysom HE, Gibson PR, et al
. Appropriateness of transfusions of red cells, platelets and fresh frozen plasma. An audit in a tertiary care teaching hospital. Med J Aust 1995;162:572-3, 576-7.
Bhutia SG, Srinivasan K, Ananthakrishnan N, Jayanthi S, Ravishankar M. Blood utilization in elective surgery – Requirements, ordering and transfusion practices. Natl Med J India 1997;10:164-8.
Jayaranee S, Prathiba R, Vasanthi N, Lopez CG. An analysis of blood utilization for elective surgery in a tertiary medical centre in Malaysia. Malays J Pathol 2002;24:59-66.
[Table 1], [Table 2]