|Year : 2021 | Volume
| Issue : 2 | Page : 118-121
Audit of blood utilization in a tertiary care hospital: Our experience over a period of 2 years
Urmi Chakravarty-Vartak, Amrita Neelakantan, Shailesh Vartak, Rohini Shewale
Department of Pathology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra, India
|Date of Submission||17-Jun-2021|
|Date of Acceptance||19-Dec-2021|
|Date of Web Publication||10-Feb-2022|
Dr. Shailesh Vartak
Department of Pathology, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: Blood transfusion plays a vital role in saving lives. However, owing to its many side effects, it should be used judiciously. Aim: The aims of this study were: audit of blood utilization in our tertiary care set up, formulation of a maximum surgical blood ordering schedule (MSBOS) for procedures where a complete cross-match appears mandatory, and improvement in the efficiency of blood utilization in trauma care. Methods: All patients admitted to Lokmanya Tilak Municipal Medical College and General Hospital during the study period for whom cross-match requests were sent to blood bank were included in this study. They were divided into groups according to the departments under which they were admitted. Data were analyzed and cross-match to transfusion ratio (C/T ratio), transfusion index, and transfusion probability (%T) were calculated. C/T ratio was used as an index of the efficacy of blood ordering practice, and a ratio of >2.5 was considered an indication of the excess cross match. Results: The maximum C/T ratio of 34.11 was noted in the Department of Cardiology. Only three departments (Artificial Kidney Dialysis, Pediatrics, and Medical Intensive Care Unit) showed effective utilization of blood. Minimum C/T ratio of 1.34 observed in the Department of Artificial Kidney Dialysis. Conclusion: We found gross over-ordering of blood by different departments. Hence we propose the formulation of a blood ordering schedule. We drafted a MSBOS which provides guidelines for frequently performed elective surgical procedures by recommending the maximum number of units of blood to be cross-matched preoperatively, implementation of which will result in more efficient use of blood.
Keywords: Blood ordering schedule, C/T ratio, transfusion index
|How to cite this article:|
Chakravarty-Vartak U, Neelakantan A, Vartak S, Shewale R. Audit of blood utilization in a tertiary care hospital: Our experience over a period of 2 years. J Mahatma Gandhi Inst Med Sci 2021;26:118-21
|How to cite this URL:|
Chakravarty-Vartak U, Neelakantan A, Vartak S, Shewale R. Audit of blood utilization in a tertiary care hospital: Our experience over a period of 2 years. J Mahatma Gandhi Inst Med Sci [serial online] 2021 [cited 2022 Oct 3];26:118-21. Available from: https://www.jmgims.co.in/text.asp?2021/26/2/118/337437
| Introduction|| |
Blood transfusion plays a vital role in medical and surgical practice. Its efficacy in saving life in the primary, secondary, and tertiary health care settings in developing countries has been demonstrated. Transfusion can save life and improve health when used appropriately. However, owing to its many side effects, transfusion should be prescribed only to treat conditions associated with significant morbidity or mortality which cannot be prevented or managed effectively by other means.
It is always essential to weigh the risks of transfusion as a result of fluid overload, risk of infection, and unnecessary increase in hospital stay duration. There is a need to develop strategies in order to reduce unnecessary blood and component transfusions, ensure the safe and appropriate use of blood and blood products, develop specific guidelines for the transfusion of blood components and decrease over-ordering of blood by changing the pattern of blood cross-matching and ordering according to different types of surgeries performed.
Injudicious preoperative over-ordering of blood can burden the physical and human resources of health care facility and increase the cost of medical care. In the absence of an explicit maximum blood order policy, ordering for blood transfusion is frequently based on subjective anticipation of blood loss instead of evidence-based estimates of average requirement in a particular procedure, which has greater implications in resource-constrained settings. Data collected from many developing countries have shown gross over-ordering of blood in 40%–70% of the transfused patients.,
The ultimate goals are to provide safe blood, have adequate inventory, reduce wastage of blood products, and avoid unnecessary use of laboratory services without jeopardizing patient safety. Review of blood ordering habits and blood utilization statistics can help in improving these services and initiate measures to regulate blood ordering and utilization. A strong institutional commitment in the form of guidelines, workshops, revision of blood bank data (blood bank audits), and implementation of new blood ordering policies (like type and screen (T/S) and maximum surgical blood ordering schedule (MSBOS) for surgical procedures where blood is actually seldom needed) are required.
The primary aims of our study were to audit blood utilization in a tertiary care hospital; to formulate a rational blood ordering schedule to emphasize the problem of blood over-ordering and the need of reasonable utilization of blood derivatives; to determine whether blood cross-match was well-adjusted to actual blood requirement and whether standards should be revalidated; and to improve efficacy of the blood ordering system for maximum utilization of blood.
| Methods|| |
This study was conducted in the blood bank of Lokmanya Tilak Municipal Medical College and General Hospital in Mumbai, over a period of 2 years. All the patients admitted in our tertiary health care centre during the 2-year study period for whom blood cross-match requests were sent to the blood bank were included in the study. These patients were divided into groups according to the department or ward under which they are admitted. Patients from the Cardiovascular and Thoracic Surgery departments and thalassemia patients who are transfused repeatedly under the thalassemia day-care center have been excluded from this study.
Data were collected from the daily blood bank records. The number of cross-matches was calculated from the blood cross-match requisition forms. The requisition form specifies the following details: Name of the patient, ward, and unit of the doctor under whom patient was admitted, age and sex of the patient, pretransfusion hemoglobin (Hb) and number of units to be cross- matched. The number of units issued to the patient is calculated from the blood issue register. The following details of the patient and the issued blood unit were obtained from the blood issue register: Name of the patient, ward, unit, number of units issued to that patient, blood group of patient and the unit, and unit number.
Patients and the number of units were divided into groups according to the different departments under which they were admitted and the most common indications for requesting the cross match in all the departments.
The data collected from records were analyzed, and the following parameters were calculated: C/T ratio, transfusion index (TI), and Transfusion probability (%T). These parameters are defined as follows:
- Cross-match to transfusion ratio (C/T ratio) = Number of units cross matched ÷ Number of units transfused
- TI = Number of units transfused ÷ Number of units cross matched
- Transfusion probability (%T) = Number of patients transfused ÷ number of patients cross matched ×100.
The cross-match to transfusion ratio (C/T ratio) was used as an index of efficacy of blood ordering practice, and C/T ratio of more than 2.5 was considered an indication of excess cross-match. The TI, was defined as the average number of units transfused for a given procedure. A TI >0.5 was an indication that pre-operative cross-matching of blood was necessary for the procedure.
| Results|| |
In our study, of the 68,560 blood units arranged for 37,511 patients, only 15,496 units were transfused in 11,858 patients. This means that only 31% of blood was utilized, while 69% of blood was not needed [Table 1]. The C/T ratio and TI were found to be <2.5 and >0.5, respectively, only for the Departments of Pediatrics, Artificial Kidney Dialysis, and Medical Intensive Care Unit. In all other departments, C/T ratio and TI were found to be >2.5 and <0.5, respectively. Artificial Kidney Dialysis department showed the lowest C/T ratio among all, of 1.34. For each and every indication in pediatric patients, blood was used efficiently (C/T ratio <2.5). In the medical intensive care unit, there was no excess ordering of blood. C/T ratio in most of the indications was <2.5. Cardiology department showed the highest C/T ratio of 34.11.
|Table 1: Blood ordering and transfusion pattern of patients in various departments|
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| Discussion|| |
Despite the importance of appropriate usage of blood, there is a significant difference in the clinical patterns of blood requests and usage among hospitals, physicians, and clinicians, which shows us that most blood and many of its products are not being used appropriately.
The C/T ratio is considered an index of blood ordering efficiency. Our results showed a C/T ratio of >2.5 in most of the departments, indicating that blood is usually over-ordered. Higher C/T ratios were observed in the surgical departments due to their usual policy of ordering two units of blood for every surgical procedure irrespective of all the parameters. Other causes for high C/T ratios were unanticipated medicolegal issues, absence of definite blood ordering policy, lack of clinical audits, and poor communication between clinicians and blood bank doctors.
High C/T ratios were observed in the emergency department, which might be attributed to a panic response toward a bleeding patient. A study conducted by Vibhute et al. suggests a transfusion trigger of Hb <8 g/dl. Some authors have evaluated and identified some independent risk factors that are predictive of increased likelihood of blood transfusion such as age >70 years, preoperative Hb <11 g/dl, locally advanced tumors, and perioperative complications such as postsurgical sepsis or anastomotic leak.
Many hospitals in developed countries have adopted the policy of using G and S (Group and Save) instead of cross-match for a proportion of surgical procedures. This technique has proven to be effective without compromising patient safety,,, A TI >0.5 was an indication that preoperative cross-matching was necessary. Effective utilization of blood and blood components is fundamental for the proper functioning of blood banks. There is always a shortage of blood and its components because of increased demand in surgeries, trauma, and oncology patients.
It is also essential to curb and efficiently use blood and its products, as there are a lot of complications to blood transfusions. Both immune and nonimmune complications could be contracted as a result of repeated blood transfusions.
There may also be an increased risk of transfusion-transmitted infections such as Hepatitis B and Hepatitis C. Mead et al. suggested that surgical procedures which would have less than 30% probability of using blood are recommended for T and S (Type and Screen). They also recommended that for procedures with a greater than 30% probability of transfusion, the cross-match order should not exceed 1.5 times the number of units transfused per patient.
A study conducted by Gupta et al. observed that the maximum blood was ordered by the surgical branches of general surgery and gynecology [Table 2]. This was comparable to our study, which also showed a lot of blood being ordered by the emergency department, in additional to surgical departments.
|Table 2: Common indications for ordering blood in various departments in other studies|
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| Conclusion|| |
Blood is a scarce resource, which is critical for patient care, and it must be utilized judiciously so that it is available for crisis. There is an indiscriminate ordering of blood done for elective surgeries, which results in holding up of blood bank reserve. Our study showed that many units of blood routinely ordered by surgeons are not utilized but are held in reserve, making them unavailable for other needy patients. This can impose inventory problems for blood bank, loss of shelf life, and wastage of blood. To reduce unnecessary cross-matching, formulation of a blood ordering schedule catering to surgeon and patient requirements is the need of the hour. It is essential for every institutional blood bank to formulate a blood ordering schedule in conjunction with their clinicians for appropriate blood usage. Regular auditing of blood usage and periodic feedbacks are also essential to improve the blood utilization practices.
We propose a draft of a MSBOS. This will provide guidelines for frequently performed elective surgical procedures by recommending the maximum number of units of blood to be cross-matched preoperatively. The following points may be suggested as a part of a blood ordering schedule:
- Quick and timely identification of patients with a clear indication of blood transfusion
- Holding meetings and presenting information to doctors to introduce strict indications of blood donation in patients with trauma and patients requiring surgery (especially elective surgery such as hernia, thyroidectomy, etc.)
- Group and save method for elective surgeries which may not need transfusion during the procedure
- Routine follow-up of patients who have been transfused repeatedly, with blood tests and other investigations to better evaluate the need for repeated blood transfusions.
Implementation of MSBOS will result in about 60% reduction of cost to the patients, thus reducing wastage of blood and its components and making this scarce resource available for patients in need.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dutta AB. Transfusion practice clinical aspects and application. In: Blood Banking and Transfusion. 1st
ed. New Delhi: CBS Publishers; 2006. p. 213-321.
World Health Organisation. Blood Transfusion Safety: The Clinical Use of Blood. Geneva: World Health Organisation; 2016. p. 16-7, 101-2, 126-7.
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]
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.
Hardy NM, Bolen FH, Shatney CH. Maximum surgical blood order schedule reduces hospital costs. Am Surg 1987;53:223-5.
Saran RK. Compatibility Testing: Transfusion Medicine Technical Manual. Directorate General of Health Services, Ministry of Health and Family Welfare. 2nd
ed. 2003. p. 124-25.
Gharebaghian A, Ladani A, Hossein T. Recommendations of WHO in Relation to Clinical Application of Blood and Blood By-Products by Special Look to Gynaecology and Obstetrics Ward, Burn, Surgery, Pediatrician. 1st
ed. Iran: Blood Transfusion Organization Research Center; 2004.
Mintz PD, Lauenstein K, Hume J, Henry JB. Expected hemotherapy in elective surgery. J American Med Assoc 1987;239:623-5.
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.
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.
Napier JA, Biffin AH, Lay D. Efficiency of use of blood for surgery in south and mid Wales. Br Med J (Clin Res Ed) 1985;291:799-801.
Dulara SC, Jangid P, Jain R, Jangid A. A prospective study of blood transfusion practice in elective orthopaedic surgeries. Int J Recent Trends Sci Technol 2014;10:36-9.
Gupta PK, Kumar H, Diwan RN. Blood ordering strategies in the armed forces – A proposal. Med J Armed Forces India 2003;59:302-5.
Chawla T, Kakepoto GN, Khan MA. An audit of blood cross-match ordering practices at the Aga Khan University Hospital: First step towards a Maximum Surgical Blood Ordering Schedule. J Pak Med Assoc 2001;51:251-4.
Smallwood JA. Use of blood in elective general surgery: An area of wasted resources. Br Med J (Clin Res Ed) 1983;286:868-70.
Ibrahim SZ, Mamdouh HM, Ramadan AM. Blood utilization for elective surgeries at Main University Hospital in Alexandria, Egypt. J Am Sci 2011;7:70-2.
Ebose ME, Osalumese IC. Blood shortage situation: An audit of red blood cells order and pattern of utilization. Afr J Biotechnol 2009;8:5922-5.
[Table 1], [Table 2]