|Year : 2017 | Volume
| Issue : 2 | Page : 113-117
Evaluation of blood requisition and utilization practices at a tertiary care hospital blood bank in Islamabad, Pakistan
Usman Waheed1, Muneeba Azmat2, Akhlaaq Wazeer2, Sadia Sultan3, Syed Muhammad Irfan3, Hasan Abbas Zaheer1
1 Safe Blood Transfusion Programme, Ministry of National Health Services, Government of Pakistan; Department of Pathology and Blood Bank, Shaheed Zulfiqar Ali Bhutto Medical University, PIMS, Islamabad, Pakistan
2 Safe Blood Transfusion Programme, Ministry of National Health Services, Government of Pakistan, Islamabad, Pakistan
3 Department of Haematology, Liaquat National Hospital and Medical College, Karachi, Pakistan
|Date of Web Publication||11-Sep-2017|
Safe Blood Transfusion Programme, Ministry of National Health Services, Government of Pakistan; Department of Pathology and Blood Bank, Shaheed Zulfiqar Ali Bhutto Medical University, PIMS, Islamabad
Source of Support: None, Conflict of Interest: None
Introduction: The significance of appropriate completion of blood request forms (BRFs) is frequently underrated by the clinicians which results in wastage and increased risk of inappropriate therapy. The judicious use of blood components can be assessed by the crossmatch-to-transfusion ratio (C:T), transfusion probability (%T), and transfusion index (TI). The current study assessed the standard of completion of BRFs and blood components utilization at a Tertiary Care Hospital Blood Bank. Materials and Methods: This was a cross-sectional, prospective study conducted at the Department of Blood Transfusion Services, Shaheed Zulfiqar Ali Bhutto Medical University Hospital, Islamabad, from January to April 2016. A total of 5957 BRFs received between January and April 2016 were reviewed. The data were entered in SPSS version 20.0 (IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY, USA) and analyzed for completeness, legibility, and blood component utilization through calculation of key indicators including C:T ratio, transfusion probability (%T), and TI. Results: Out of the 5957 request forms reviewed, only 12.7% forms were completed in full. The overall C:T ratio, %T, and TI were 1.52, 65.38, and 0.65, respectively. The same indicators for the Maternal and Child Health Centre (MCHC) were 10.7, 9.32, and 0.09. Conclusion: Incomplete blood transfusion request forms create difficulties for the blood bank staff in comprehending the requests which may compromise patient safety. Similarly, the efficiency of MCHC blood transfusion services is far from optimum. The Hospital Transfusion Committee can play a key role in solving this problem and thus improving the standards of Patient Blood Management.
Keywords: Blood component utilization, blood transfusion request, hemovigilance
|How to cite this article:|
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
|How to cite this URL:|
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 [serial online] 2017 [cited 2021 May 12];2:113-7. Available from: https://www.gjtmonline.com/text.asp?2017/2/2/113/214279
| Introduction|| |
An efficient blood transfusion service remains the basis of modern health-care systems. The quality of a blood service is evaluated in three analytical phases (preanalytical, analytical, and postanalytical). A step-wise analysis of the procedural chain indicates that focusing on preanalytical phase yields better outcomes in resource-constrained areas which accounts for 68% of total errors. The preanalytical phase includes hospital-based procedures outside the domain of blood bank such as requisition form filling, proper identification, sample handling, labeling, and transportation of sample., Preanalytical errors, such as the absence of important clinical information on blood requisition or request form (BRF), can have severe adverse effects on recipients by causing postanalytical errors. The BRF is the first line of communication between the clinician and blood bank staff. A standard BRF contains demographic data and other information such as location of the patient, laboratory information, physician's name and signature, and telephone number of the requesting physician, among others.
Evaluation in a health-care setting is a broad term that implies assessment for the sake of quality assurance and improvement of patient care. Evaluation delivers the services providers with a continuous stream of data to scrutinize and improve the current practices and identifies key intervention points in a system. In blood banking, the auditing of blood transfusion requests and calculation of a number of quality metrics (crossmatch-to-transfusion ratio [C:T] ratio, %T, TI) have been considered the most efficient and effective way of evaluating the appropriateness of transfusion. BRFs designed to incorporate the indications for transfusion could help to lower the rate of unassessable cases, as well as to reduce the inappropriate use of blood and blood products. Unfortunately, the clinical circumstances demanding transfusion are often poorly documented on the BRF and the patient's record.
In Pakistan, the scarce supply of blood and blood components is not always judiciously utilized and the significance of appropriate completion of BRFs is frequently underrated by clinicians. This results in wastage and increased risk of inappropriate therapy. The prescription practices are in many cases not consistent with the recommended guidelines. The current study was designed to assess the standard of filling the BRF and to calculate the key performance indicators including C:T ratio, transfusion probability (%T), and transfusion index (TI).
| Materials and Methods|| |
This cross-sectional prospective study was conducted from January to April 2016, at the Department of Blood Transfusion Services, Shaheed Zulfiqar Ali Bhutto (SZAB) Medical University Hospital, PIMS, Islamabad. The ethical consent was granted by the Ethical Review Board of the SZAB Medical University.
A total of 5957 consecutive BRFs that were submitted to the Blood Transfusion Services between the study period were compiled and reviewed. The data were entered and analyzed using SPSS (IBM SPSS Statistics for Windows, version 20.0, IBM Corp., Armonk, NY, USA). The data were entered anonymously and recognized by a unique research ID.
The request form was evaluated for the fullness of the data requested therein: patient's name, patient's patient control number (PCN), patient's ward and bed, type of blood components required, number of blood components required, a clinical history (defined as a clinical history and/or differential diagnosis), previous history of transfusions; patient's blood group, and referring doctor's name and signature. These data should be present on 100% of requests if completed correctly. The red cell concentrate utilization practices were assessed using C:T ratio, transfusion probability (%T), and TI using the following equations:
This ratio should be 1.0 but a ratio of 2.5 and below is suggestive of effective blood usage.
A %T value of 30 or above is considered appropriate.
A TI value of 0.5 or above is suggestive of effective blood utilization.
| Results|| |
During the study period, a total of 5957 blood requests including 1544 from mother and child health-care centre (MCHC) were received. Almost 3509 (58.9%) were females and 2448 (41.1%) were males. About 3895 patients (65.4%) were actually transfused whereas 2062 (34.6%) were not transfused (only crossmatched). Out of 1544 BRFs from MCHC, only 144 (9.3%) were transfused.
A total of 5957 BRFs were analyzed, of which only 12.7% were completed. Parameters of BRF remained incomplete were patient's name; 31.9%, patients PCN; 7.3%, patient's age; 14.6%, patient's sex; 19.9%, type of blood components required; 10.4%, number of blood components required; 19%, date and time when components are required; 43%, patient's blood group: 21.6%, and referring doctor's signature; 10.2. Previous history of transfusion (96.6%) and referring doctor's name (83.6%) were the most incomplete parameters. No patient's diagnosis was provided on 39% of forms and when a diagnosis was present it was abbreviated. Incomplete ward and bed information were found on 60.8% of forms [Table 1].
The overall C:T ratio, transfusion probability, and TI calculated were 1.52, 65.38% and 0.65, respectively, whereas, for MCHC, these values were 10.7, 9.3%, and 0.09, respectively [Table 2].
| Discussion|| |
Transfusion of blood and blood products is a common and useful therapy, unfortunately always linked with the risk of an adverse event or reaction, which can be life threatening. Safety in transfusion medicine is the result of the implementation of quality strategies at all levels of the chain stretched from donor to patient. Audits must be organized prospectively to review the appropriateness of blood and blood components prescribed in accordance with patient needs, and in the process, to make clinicians more familiar about transfusion triggers and indications.
The completion of BRF according to international standards can abate the irregularities encountered in completion and subsequently standardize the vein-to-vein transfusion practice resulting in superior hemovigilance, improved patient care and cost-effectiveness. Our audit revealed that only 12.7% forms were completed in full. Details pertaining to demographics such as gender and age were not stated on 19.92% and 14.6% request forms. Location, age, and gender of a patient become necessary in identifying patients with similar names. The referring doctor's name is frequently left from the request forms. In the current study, around 16.4% request forms had the doctor's name mentioned. In a study conducted on the completion and legibility of consent forms, it was recommended to commence the use of standardized rubber stamps for ensuring the completion and legibility of the forms. It has been seen that the new medical graduates are more prone to obtain consent for transfusion.
Our figure of 12.7% is comparable to some extent with a study from Brazil where only 14.07% requests for red cell transfusions were categorized as adequate. Studies from Nigeria  and India  reported that 81.2% and 97% of BRFs were filled out completely.
Previous history of blood transfusion was mentioned in only 3.4% of the cases, this is an alarming situation because the information if left incomplete can result in avoidable transfusion-related reactions and hence increased morbidity and mortality.,
Several research groups have studied the unnecessary use of blood products.,, In a study reported from Australia, 16% of the red cell transfusions were not appropriate mostly because the clinician did not document the indication for transfusion.
Overordering of blood is common and was first reported in 1976 in many countries with utilization ranging from 5% to 40%. It has been reported from Saudi Arabia that only 30% of crossmatched blood was used in elective surgery. In South Africa, 7%–10% of blood is wasted annually because of overordering of blood. Studies from North India and Kuwait report the utilization rate as 41% and 13.6%. The current study revealed that 65.4% of the crossmatched blood was utilized. This finding was comparable to that reported in Nigeria (69.7%), India (76.8%), Nepal (86.4%), and Egypt (74.8%). However, the utilization was on a lower level (9.3%) in the MCH centre of our hospital.
One of the strategies to evaluate the blood utilization practice is the determination of the C:T ratio, which was first used by Boral and Henry in 1975. Normally, this ratio is 1.0, and a ratio of <2.5 is indicative of effective blood utilization. The current study has reported the overall C:T ratio of 1.52 and for the MCH centre it was 10.7. This ratio of 1.52 is comparable with a study conducted in the UK (2.1), Iran (1.33), Nigeria (2.2), and India (2.5). Our C:T ratio is low when compared with studies from Malaysia (5.0), Poland (9.0), and Iran (3.71).
The transfusion probability (%T) was first used in 1980 and a value of >30 is indicative of appropriate transfusion. The overall %T in our study was 65.38 (9.32 in case of MCHC) which is comparable with studies from Ethiopia (47%) and India (59%). Our values are comparatively high when compared with Poland (2.94%–18.8%), Nigeria (26.9%), Iran (16.83%), and Egypt (36.9%).
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, overall TI was 0.65 (0.09 for MCHC). This is comparable with studies from Ethiopia (0.77), Egypt (0.69), and Iran (1.81) whereas comparatively high when compared with other studies from Iran (0.31) and India (0.36).
| Conclusion|| |
The current study provides evidence that the rate of completion of BRFs at the current study site is not appropriate. The request forms evaluated were not covering acceptable demographic and clinical data of the patients.
The overall values of C:T ratio, %T, and TI were acceptable according to international standards except for the values from MCHC. Instead of directed efforts in all hospitals, the MCHC should be given priority for enhanced blood and blood component utilization.
The Hospital Transfusion Committee (HTC) can play a key role in improved Patient Blood Management. The HTC should organize sensitization and advocacy session with the clinicians and especially with the new house officers and the MCH centre for proper ordering and utilization practices. In our hospital, quality management is not yet well advanced or even missing completely in some departments. The HTC development program could serve as an opportunity to implement a quality tool into the hospital.
Medical graduates should be adequately sensitized regarding the blood bank and its functions; this, in return, will help them in understanding the complementary role played by blood service in clinical practice.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Plebani M. Errors in clinical laboratories or errors in laboratory medicine? Clin Chem Lab Med 2006;44:750-9.
Erasmus RT, Zemlin AE. Clinical audit in the laboratory. J Clin Pathol 2009;62:593-7.
Vanker N, van Wyk J, Zemlin AE, Erasmus RT. A Six Sigma approach to the rate and clinical effect of registration errors in a laboratory. J Clin Pathol 2010;63:434-7.
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.
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.
Hassan R, Ramli A, Callanan I. Practice of the principle of right conduct in obtaining informed consents and legibility of the consent forms – A clinical audit. BMC Proc 2015;9 Suppl 1:A16.
de Souza DA, Silva FG, Costa PJ. 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.
Jegede F, Mbah HA, Dakata A, Dalhatu H, Gwarzo DH, Abdulrahman SA, et al
. Evaluating laboratory request forms submitted to haematology and blood transfusion departments at a hospital in Northwest Nigeria. Afr J Lab Med 2016;5:a381.
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.
Stainsby D, Cohen H, Jones H, Knowles S, Milkins C, Chapman C, et al
. Serious Hazards of Transfusion (SHOT) Annual Report 2004, Serious Hazards of Transfusion Office. Manchester Blood Centre; 2004.
Sazama K. Reports of 355 transfusion-associated deaths: 1976 through 1985. Transfusion 1990;30:583-90.
Leal-Noval SR, Arellano-Orden V, Maestre-Romero A, Muñoz-Gómez M, Fernández-Cisneros V, Ferrándiz-Millón C, et al.
Impact of national transfusion indicators on appropriate blood usage in critically ill patients. Transfusion 2011;51:1957-65.
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.
Sekine L, Wirth LF, Faulhaber GA, Seligman BG. Blood-based products request profile analysis in Hospital de Clínicas de Porto Alegre in 2005. Rev Bras Hematol Hemoter 2008;30:208-12.
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.
Sowayan SA. Use of blood in elective surgery: An area of wasted hospital resource. Ann Saudi Med 1994;14:326-8.
Efraim K. Blood conservation in South Africa. A vital need. Bloodless Med Surg 2001;43:7-9.
Subramanian A, Rangarajan K, Kumar S, Sharma V, Farooque K, Misra MC. Reviewing the blood ordering schedule for elective orthopedic surgeries at a level one trauma care center. J Emerg Trauma Shock 2010;3:225-30.
] [Full text]
Basnet RB, Lamichhane D, Sharma VK. A study of blood requisition and transfusion practice in surgery at Bir Hospital. Postgrad Med J NAMS 2009;9:14-9.
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]
Ibrahim SZ, Mamdouh HM, Ramadan AM. Blood utilization for elective surgeries at main University Hospital in Alexandria, Egypt. J Am Sci 2011;7:683-9.
Boral LI, Henry JB. The type and screen: A safe alternative and supplement in selected surgical procedures. Transfusion 1977;17:163-8.
Hall TC, Pattenden C, Hollobone C, Pollard C, Dennison AR. Blood transfusion policies in elective general surgery: How to optimise cross-match-to-transfusion ratios. Transfus Med Hemother 2013;40:27-31.
Nikpoor AR, Daneshvar H, Sanei ME, Askari M. Assessment of requisition and consumption indices of blood in educational hospitals in Kerman city. Sci J Iran Blood Transfus Organ 2013;10:12-9.
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. J Emerg Trauma Shock 2012;5:321-7.
] [Full text]
Jayaranee S. An analysis of blood utilization for elective surgery in a tertiary medical centre in Malaysia. Malaysian J Pathol 2002;24:59-66.
Kozarzewska M, Mackowiak M, Steler J, Krefta M, Hasak L, Kardel-Reszkiewicz E. The analysis of surgical blood order protocol. Anestezjol Intens Ter 2011;43:71-3.
Yazdi AP, Alipour M, Jahanbakhsh SS, Gharavifard M, Gilani MT. A survey of blood request versus blood utilization at a university hospital in Iran. Arch Bone Jt Surg 2016;4:75-9.
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.
Belayneh T, Messele G, Abdissa Z, Tegene B. Blood requisition and utilization practice in surgical patients at university of Gondar hospital, Northwest Ethiopia. J Blood Transfus 2013;2013:758910.
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.
[Table 1], [Table 2]
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