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| EDITORIAL |
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| Year : 2021 | Volume
: 6
| Issue : 1 | Page : 1-2 |
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Overcoming challenges in clinicians transfusion practices: A prerequisite for safer transfusions
Rajesh B Sawant
Department of Transfusion Medicine, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India
| Date of Submission | 15-Apr-2021 |
| Date of Decision | 23-Apr-2021 |
| Date of Acceptance | 02-May-2021 |
| Date of Web Publication | 29-May-2021 |
Correspondence Address:
Dr. Rajesh B Sawant
Department of Transfusion Medicine, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2468-8398.317182
How to cite this article:
Sawant RB. Overcoming challenges in clinicians transfusion practices: A prerequisite for safer transfusions. Glob J Transfus Med 2021;6:1-2 |
How to cite this URL:
Sawant RB. Overcoming challenges in clinicians transfusion practices: A prerequisite for safer transfusions. Glob J Transfus Med [serial online] 2021 [cited 2021 Jun 25];6:1-2. Available from: https://www.gjtmonline.com/text.asp?2021/6/1/1/317182 |
| Current Practice of Transfusion Medicine | |  |
Unnecessary transfusions or irrational transfusion practices are more of a norm than an exception. This, despite scientific evidence demonstrating significant harm from unnecessary blood transfusions. Generalized lack of compliance with appropriate transfusion guidelines is the challenge faced by many hospitals. Tremendous variation in transfusion practice exists among different countries, regions, states, institutions, and among individual physicians and surgeons within the same institution. The administration of blood products is surrounded by emotions, misconceptions, myths, and little or no training exists in this area of therapy. Lack of formal training in transfusion medicine is the most common reason for most clinicians, that they practice transfusion therapy as passed on traditionally.
Very little attention has been focused on the various aspects related to patients sample collection, labeling, transport and storage of blood components outside the transfusion services, bed-side blood administration practices, and identification and reporting of adverse events related to transfusion and its appropriateness. Thanks to the various accreditation initiatives, we are seeing a paradigm shift in the above scenario in the recent times.
| Bridging the Gap between Evidence and Practice | | |
Bridging the gap between “Evidence” and “Practice” is the current challenge. Decisions in transfusion practice are still often based on local trends or gut instincts. The varied interventions to modulate clinical transfusion practice described in the literature should be based on the latest available evidence.
| Interventions -When and How? | | |
Changing transfusion practice goes hand in hand with monitoring of transfusion practice. It is essential to look into the existing blood transfusion practices and collect background information about the type of existing blood transfusion practices After a thorough understanding of the existing practices, consider modifying these practices for appropriate utilization of blood in the hospital setting.
| Prospective Versus Retrospective Review Systems | | |
Various methods can be used to monitor transfusion practice and decision-making including both prospective systems that attempt to review decisions to transfuse before blood is administered to the patient, and retrospective reviews that occur after transfusion. Prospective systems have the obvious advantage of protecting patients from unnecessary transfusions. However, prospective review may not be always feasible in certain situations where urgent decision-making is warranted.
| Behavioral Changes are not Easy | | |
The challenges to changing physician practice are many and include environmental factors such as poor communication between physicians and other members of the health care team, misalignment among individuals and departments due to different motivation and reward systems, a lack of experience in the use of cross-functional teams and failure to anticipate and deal with resistance. It has been observed that when educational material is presented in the context of a recent medical decision, everyone involved in the process learns the best and is more likely to be receptive. The “Behavior change theory”[1] may be applied to clinical practice too. Behavior change techniques such as making action plans, setting goals, and providing feedback on the outcome of behavior may be utilized for changing transfusion practices effectively.
| Role of Hospital Transfusion Committee | | |
This needs to be specifically highlighted in this context. An active transfusion committee plays a major role in review of blood usage, finalization of blood ordering strategies, and facilitates active interaction among blood transfusion service and clinicians.
| Role of the Medical Director in a Blood Centre | | |
This is pivotal in changing clinical transfusion practices. The leadership of the blood center is in a position to create a culture of professionalism in delivering quality of care to patient with efficient use of available resources. With the implementation of appropriate use of blood and safe blood administration practices, the national hemovigilance program and patient blood management (PBM) initiatives, we can strengthen the weakest link in our transfusion chain, thus ensuring maximum transfusion safety!
| Audit and Feedback | | |
The most widely used and simple approach to change practice is audit and feedback. Ivers et al.[2] have reviewed audit and feedback interventions to find the most specific intervention which is most effective in changing clinical transfusion practice. The goals of a medical audit in a blood transfusion center are to improve the processes introduced in the ordering, distribution, handling, and administration of blood as well as to monitor the response to transfusion. A multi-disciplinary, systematic approach to change transfusion practices will definitely be accepted readily by the clinicians, more so if it is backed by scientific evidence. This will further lead to improved patient outcomes; minimize costs related to transfusion therapy and save precious resources. So let us work towards the metamorphosis of our specialty from “Providers” to “Partners” in transfusion therapy with appropriate communication, co-operation with our clinician colleagues and in a nonconfrontational manner.
| Recent Updates from India | | |
Contrary to the WHO (2002) and BCSH (2001) recommendations, the recently recommended practice of transfusing single-unit red blood cell for nonbleeding hospitalized patients, followed by the clinical reassessment to determine the need for transfusion has been considered appropriate. Murugesan et al.[3] have reported single unit transfusion in 62% of obstetric patients who received blood transfusion. They conclude that single-unit transfusion decisions are safe in stable hospitalized obstetric patients, and the decision to transfuse subsequent units should be prescribed only after reassessment.
In a developing country like India, with limited resources and access to health-care facilities, dealing with massive hemorrhage is a major challenge. A multidisciplinary expert group evaluated the current practices and protocols of management of abnormal bleeding, in various clinical settings, across India. The expert group identified interdisciplinary education in PBM and bleeding management, bleeding history, viscoelastic and platelet function testing, and the implementation of validated, setting-specific bleeding management protocols (algorithms) as important tools in PBM and perioperative bleeding management.[4] PBM should be implemented as a multidisciplinary and practically applicable concept in India in a timely manner in order to optimize the use the precious resource blood and to increase patients' safety.
| Conclusion | | |
Changing clinician transfusion practices is a humongous task. The first step is to review the gaps in the existing transfusion practices by way of audits and feedback. This should then be followed by the development of transfusion guidelines for patient identification, sample labeling, blood ordering, and clinical indications. Equally important is their communication, dissemination, and acceptance by the clinicians which is achieved by the Medical Director of the blood center acting under the guidance of the hospital transfusion committee.
| References | | |
| 1. | Foy R, Francis JJ, Johnston M, Eccles M, Lecouturier J, Bamford C, et al. The development of a theory-based intervention to promote appropriate disclosure of a diagnosis of dementia. BMC Health Serv Res 2007;7:207.  |
| 2. | Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, O'Brien MA, Johansen M, Grimshaw J, Oxman AD. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012;6:CD000259. |
| 3. | Murugesan M, Doshi K, Subbiah SP. Transfusion practice in obstetrics - Indian scenario. Asian J Transfus Sci 2019;13:151-2. [ PUBMED] [Full text] |
| 4. | Gandhi A, Görlinger K, Nair SC, Kapoor PM, Trikha A, Mehta Y, et al. Patient blood management in India - Review of current practices and feasibility of applying appropriate standard of care guidelines. A position paper by an interdisciplinary expert group. J Anaesthesiol Clin Pharmacol 2021;37:3-13. [Full text] |
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