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 Table of Contents  
Year : 2017  |  Volume : 2  |  Issue : 2  |  Page : 109-112

Audit of clinical use of red blood cells in a tertiary care setting: An algorithmic approach!

Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, Haryana, India

Date of Web Publication11-Sep-2017

Correspondence Address:
Aseem K Tiwari
Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/GJTM.GJTM_36_17

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Objective: There have been quite a few publications on audit of clinical use of blood components. However, there is paucity of studies on red blood cell (RBC) clinical use. Therefore, a study was designed to determine the appropriate clinical use of RBC in various departments in a tertiary care setting. Materials and Methods: It was a prospective observational study conducted from January 2017 to April 2017 in a large tertiary care hospital in north India. The study population included all consecutive admitted patients who received RBC transfusion during the study period. Patients undergoing RBC transfusions the in operation theater were excluded. An algorithmic approach was used which analyzed the “appropriateness” on the basis of hemoglobin thresholds, symptoms in patient, comorbidities, and imminent blood loss in a sequential manner. Results and Discussion: Of a total of 1024 transfusions, 924 (90.02%) episodes were appropriate. This was higher than the previous published reports because of algorithmic approach, higher hemoglobin threshold (8 g%), and possibly better informed physicians in tertiary care setting. Conclusion: There were a high percentage of appropriate RBC transfusions in large tertiary care settings.

Keywords: Appropriate transfusion, clinical transfusion, evidence-based medicine, red blood cell audit, red blood cell transfusion

How to cite this article:
Tiwari AK, Ratan A, Arora D, Aggarwal G, Mehta SP, Setya D, Acharya DP. Audit of clinical use of red blood cells in a tertiary care setting: An algorithmic approach!. Glob J Transfus Med 2017;2:109-12

How to cite this URL:
Tiwari AK, Ratan A, Arora D, Aggarwal G, Mehta SP, Setya D, Acharya DP. Audit of clinical use of red blood cells in a tertiary care setting: An algorithmic approach!. Glob J Transfus Med [serial online] 2017 [cited 2021 Jun 25];2:109-12. Available from: https://www.gjtmonline.com/text.asp?2017/2/2/109/214282

  Introduction Top

The goal of modern transfusion therapy is to provide appropriate blood components for specific hematologic deficiencies as opposed to earlier practice of using whole blood for patients. Evidence-based medicine approach dictates that specific blood components are used to correct specific deficiencies; for example, in patients with low platelet counts and showing mucosal bleed, platelet concentrate should be administered and not whole blood. The decision to transfuse has to be based on clinical features and laboratory parameters. The world is, therefore, moving from whole-blood therapy to specific component therapy for various ailments, with the decision based on evident clinical assessment and laboratory values.

Moreover, health-care organizations now routinely monitor whether blood components are being used appropriately or not? There have been several reports published from India evaluating the appropriate use of various blood components.[1],[2],[3],[4],[5] Most of these publications evaluate the use of fresh frozen plasma;[6],[7],[8] few are on clinical use of platelet concentrates,[9],[10] and yet other few on both.[1],[2],[3],[4],[5] However, there have been only few audit reports on the use of red blood cell (RBC) component, that too in a small number of patients. Therefore, we decided to conduct a prospective pilot audit of RBC component transfused in at least 500 patients in a large tertiary care hospital over a period of 4 months. The aim was to analyze the usage of RBCs in various departments of the hospital.

  Materials and Methods Top


The study was carried out by Department of Transfusion Medicine and Department of Medical Administration of a large tertiary care hospital in north India. It was a prospective observational study conducted from January 2017 to April 2017. The study population included all consecutive patients who were admitted in the in-patient department, day-care department, emergency department, and Intensive Care Unit and received RBC transfusion during the study period. Patients undergoing RBC transfusions in the operation theater were excluded from the study.

Data collection

Information regarding transfusion was collected from the Hospital Information System (HIS), and the requisition form that was sent to the blood bank and from the case-file of the patient at bed-side. Each day patients who were issued RBC units in last 24 h were identified from the requisition forms received at the blood bank. The patients' details including full name, age, gender, unique hospital identification number, bed number of patient, department of admission, and indication for transfusion were noted along with number and time of issue of RBC unit(s). Bed number of patient in the hospital was re-confirmed from HIS. The patient's case file was checked bedside for the start time of transfusion. The immediate pre- and post-transfusion hemoglobin values were taken from HIS. The patient's physician was consulted for detailed clinical status of patient, indication for transfusion, and expected rise in hemoglobin.

Appropriateness – An algorithmic approach!

The appropriate use of RBC was assessed by predetermined criteria based on an algorithm. A transfusion episode was considered inappropriate only if these predetermined criteria were not met.

Transfusion was considered appropriate if any one of following criteria was present:

  1. Hemoglobin <8 g/dl
  2. Hemoglobin >8 g/dl with signs and symptoms such as pallor, fatigue, breathlessness, and tachycardia
  3. Hemoglobin >8 g/dl with comorbidities such as cardiovascular disease, cerebrovascular disease, angina, shock, and hemolysis
  4. Hemoglobin >8 g/dl with imminent bleeding such as surgery, delivery, active bleeding, and bone marrow failure.

If none of above criteria was fulfilled, then transfusion was considered as 'inappropriate.”

[Figure 1] shows the algorithmic approach of evaluation of “appropriateness” of clinical use of RBC.
Figure 1: The algorithmic approach of evaluation of “appropriateness” of clinical use of red blood cell

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  Results Top

This study included 764 patients who had RBC transfusion during the defined study period from January 2017 to April 2017 in different departments. Among 764 patients, 265 (34.6%) were female and 499 (65.3%) were male patients. A total of 1024 transfusion episodes (one unit of blood product was considered as one transfusion episode) were evaluated. [Table 1] shows the use of blood components in various departments, with maximum being in cardiac surgery (189) and minimum in respiratory medicine (9). Two units remained untransfused, one each in gastroenterology and nephrology, respectively
Table 1: Number of red blood cell transfusions in various clinical departments

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Of the 1024 transfusions, 760 were considered appropriate since the patients had a hemoglobin of 8 g/dl or lower. In 164/264 RBC units, although the hemoglobin was more than 8 gm/dl, the transfusion was deemed appropriate because of patient symptoms, co-morbidity or imminent bleeding. Therefore, a total of 924 (90.23%) transfusions were considered appropriate.

Increase in hemoglobin following one unit of RBC in our study was found to on an average of 0.7 g/dl.

  Discussion Top

It is important that blood components are used appropriately, and there is a mechanism to monitor the “appropriateness” of its use. It was in this context that a pilot study was conducted on the appropriate use of RBC, to begin with, in a hospital setting. In this study, 1024 transfusions across various departments were evaluated.

We used an algorithmic approach to decide upon the “appropriateness” of a transfusion episode in contrast to several other previous studies [1],[2],[3],[4],[5] which have used only a hemoglobin trigger to decide on appropriateness or otherwise. Besides hemoglobin, symptomatic anemia, comorbidity, and imminent blood loss were also considered in the algorithmic decision-making approach [Table 1]. This approach was based on a study published in 2008.[11] We also took the same hemoglobin trigger, though few studies suggest a lower threshold of 7 g%.[3] The reasoning was to get an initial insight into the actual hospital practices before possible re-drawing of the thresholds.

A total of 760 units (74.2%) were transfused in patients with a hemoglobin of lower than 8 g% and were deemed appropriate in this study. Further 164 units though transfused at hemoglobin of more than 8 g% were deemed appropriate because of symptomatic anemia (3), comorbidity (3), and imminent blood loss (158). Appropriate use based on low hemoglobin, symptomatic anemia, comorbidity, and impending blood loss totaled 924/1024 (90.23%).

[Table 2] shows the number of transfusions considered as appropriate and inappropriate following algorithmic approach.
Table 2: Number of transfusions considered as appropriate and inappropriate based on “algorithmic” approach

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The overall percentage of appropriate transfusion in the present study was 90.23% (924/1024). This is much higher than the other published reports; Richa and Chetna showed appropriate the use of red cell as 60.21%,[5] while another study conducted by Wade et al. showed appropriate red cell use as 64.5%.[12] This is easily understandable since both these studies used only hemoglobin trigger to decide upon “appropriateness.” The present study used an algorithmic approach, and there were 16.01% additional episodes considered appropriate on the basis of parameters other than hemoglobin trigger (symptoms, comorbidity, and imminent bleeding). Moreover, we chose 8 g% as the threshold as compared to 7 g% in previous studies.[3] We also postulate that appropriate use may also be influenced by the type of hospital and training of physicians. The present study was conducted in a large tertiary care hospital in a metropolitan city with several ordering physicians trained abroad who were possibly better informed about “appropriate” use. However, this aspect of being “better informed” has not been measured objectively in the present study.

We also observed that average increase in hemoglobin in our cohort of patients was 0.7%, which was lower than the thumb rule of 1 g% increment. This is quite possible since increase in hemoglobin depends on several variables such as the hemoglobin content of the unit, weight of the patient, loss because of frequent sampling, surgical loss like drains, etc. This information may be useful for physicians to manage their patients in real-life conditions. However, this information is based on sampling in around 760 patients only, and larger controlled trials are needed to confirm these initial findings.

  Conclusion Top

Clinical use of RBC in a large tertiary care hospital was largely appropriate. This “appropriate use” may further be enhanced by formulating hospital-specific guidelines and education of physicians.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Wahid Bhatt A, Nabi Koul A. Resident doctors education on appropriate utility of blood components. J Med Sci Clin Res 2014;4:14490-5.  Back to cited text no. 1
Gomathi G, Varghese RG. Audit of use of blood and its components in a tertiary care center in South India. Asian J Transfus Sci 2012;6:189.  Back to cited text no. 2
[PUBMED]  [Full text]  
Ahmed M, Sushma US. Blood component therapy in paediatric Intensive Care Unit in tertiary care centre: An audit. Int J Contemp Med Res 2016;3:1506-10.  Back to cited text no. 3
Katara AA, Agravat AH, Dhruva G, Dalsania JD, Dave RG. An audit of appropriate usage of blood products in blood bank in a tertiary care hospital Rajkot. Int J Curr Res Rev 2014;6:37-40.  Back to cited text no. 4
Richa S, Chetna J. An audit of appropriate use of blood components in tertiary care hospital. Int J Med Sci Educ 2015;2:2349-3208.  Back to cited text no. 5
Kulkarni N. Evaluation of fresh frozen plasma usage at a medical college hospital - A two year study. Int J Blood Transfus Immunohematol 2012;2:16-20.  Back to cited text no. 6
Jayanthi N, Pitchai R. Audit of fresh frozen plasma usage and study the effect of fresh frozen plasma on the pre-transfusion & post-transfusion international normalized ratio. Int J Curr Med Appl Sci 2015;7:34-3.  Back to cited text no. 7
Shinagare SA, Angarkar NN, Desai SR, Naniwadekar MR. An audit of fresh frozen plasma usage and effect of fresh frozen plasma on the pre-transfusion international normalized ratio. Asian J Transfus Sci 2010;4:128-32.  Back to cited text no. 8
[PUBMED]  [Full text]  
Mahapatra S, Krushna Ray G, Panigrahi R, Mishra D, Bhusan Sahoo B, Parida P. Platelet audit: To weigh the rationality between requirement and uses in blood transfusion. Int J Res Med Sci 2016;4:4548-51.  Back to cited text no. 9
Saluja K, Thakral B, Marwaha N, Sharma RR. Platelet audit: Assessment and utilization of this precious resource from a tertiary care hospital. Asian J Transfus Sci 2007;1:8-11.  Back to cited text no. 10
[PUBMED]  [Full text]  
Nel T. Clinical guidelines, audits and hemovigilance in managing blood transfusion needs. Transfus Altern Transfus Med 2008;10:61-9.  Back to cited text no. 11
Wade M, Sharma R, Manglani M. Rational use of blood components - an audit. Indian J Hematol Blood Transfus 2009;25:66-9.  Back to cited text no. 12


  [Figure 1]

  [Table 1], [Table 2]

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