Multiple transfusion request audit.
Published Date: 01st April 2024
Publication Authors: Shahidianakbar. M, Bickley. E, Chahwale. P
Abstract:
Introduction: This audit addresses practices concerning multiple blood transfusion requests of more than three units of blood, focusing on patients at Whiston Hospital, UK. Our findings highlight issues of inadequate documentation in blood transfusions, resource waste, and suggest potential process improvements.
Motivation: Blood transfusions are common in hospitals but are not without risks [e.g. 2, 8, 6]. For instance, the risks associated with the transfusion of multiple units can be, e.g., transfusion associated circulatory overload (TACO) [e.g. 1], iron overload [e.g. 5], dilutional coagulopathy [e.g. 3], and hyperkalaemia [e.g. 9]. Moreover, excessive blood requests can result in unused units, place extra burden on laboratory resources, and even lead to product wastage. Hence, transfusion audits are valuable tools for the evaluation and education of those requesting blood components [e.g. 4].
Aims and objectives: The audit should meet three targets, namely: all patients should be investigated for the cause of anaemia; all patients should be evaluated clinically between units of red blood cells (RBC); and there should not be any non-urgent blood transfusion overnight.
Data and method: We analyse a dataset collected between June, July, and August 2022, from Whiston Hospital, UK, accounting for 121 patients in total. The data can be broken down as follows (after 17 patients are excluded from the dataset because in emergency or we were unable to locate records): i) Single order patients = 57 (55% of the sample); ii) Multiple requests within 24 h = 47 patients (45% of the sample). Data from additional 10 patients was excluded due to lack of evidence.
Results: Fig. 1 reports the data for the units transfused to patients who had requested more than three units of blood within 24 h. We observe that 40% of those with three or more units requested did not have more than two units transfused (data in the red square). Moreover, for 70% of the patients, at least one unit of blood was deemed appropriate overnight due to the clinical status of the patient; either haemodynamically unstable or significantly symptomatic.
Further, from Fig. 2, we observe that about half of the patients who were requested multiple transfusion units were tested for B12, folate or iron, suggesting that investigations by the clinical team coincide only in one part with the multiple transfusion requests. Our audit reveals also a significant issue with poor documentation related to blood transfusions. We observe minimal to no documentation in the pre-operative requests for three or more units of RBC, often with no reference to, or inconsistency with the Maximum Surgical Blood Ordering Schedule (MSBOS) guidance [e.g. 7].
Recommendations: It is crucial to conduct clinical reviews between each unit of blood transfused, focusing on evaluating any adverse effects and the need for additional transfusions to prevent resource wastage.
Conclusion: We encourage further considerations on the number of units ordered to improve the blood transfusion process. Our audit fosters dialogue about the risks associated with multiple transfusions, the importance of frequent clinical reviews and ongoing risk monitoring assessment, and the effective management of resources.
Shahidianakbar, M; Bickley, E; Chahwala, P; Et al. (2024). Multiple transfusion request audit. Clinical Medicine. 34(Sup 1), p.1. [Online]. Available at: https://dx.doi.org/10.1016/j.clinme.2024.100168 [Accessed 25 July 2024].