Indian J Pediatr DOI 10.1007/s12098-014-1679-x
EDITORIAL COMMENTARY
Audit of Pediatric Transfusion Practices: A Commentary Neelam Marwaha
Received: 15 December 2014 / Accepted: 22 December 2014 # Dr. K C Chaudhuri Foundation 2015
Blood transfusion is an essential component of modern healthcare services. Blood safety has considerably improved in the developed countries and is gradually improving in the developing world, however there still remains a residual risk of adverse transfusion reactions. Blood is also a precious resource as only blood donors constitute the source of blood supply. Improved testing and processing technologies and stringent regulatory oversight for blood safety have led to escalating costs for blood banking activities. In addition to the above factors which pose concerns on supply–demand situations and cost-effectiveness, the indications and dosage of blood and its components was based largely on observational data and/or experience. Conclusive scientific evidence to support what might constitute an appropriate transfusion was lacking for almost three decades of start of blood transfusion therapy in the 1950s [1]. Audits were initially used for review of accounts, but the process of a systematic assessment of services has become an essential tool of quality management within the blood transfusion services. It may be conducted within the blood bank for analysis and evaluation of processes involved in the preparation of blood and components for distribution or at the user level, that is the clinical requests and patient outcomes. Audits can only be conducted if there are standards against which a practice can be measured [2]. Many developed countries have published transfusion guidelines to help clinicians decide upon best clinical practices [3–6]. These guidelines/ recommendations formulated by expert groups take into consideration the transfusion triggers (patient’s pre-transfusion hemoglobin level / platelet counts / coagulation test abnormalities), and patient factors (age of the patient and the clinical status). Clinical transfusion audits should ideally review the
N. Marwaha (*) Department of Transfusion Medicine, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India e-mail: [email protected]
following two processes: (i) Were the blood or its components prescribed for the right indication in the right quantity and (ii) was there lack of blood requisition or transfusion in case it was required to achieve a clinical benefit. Transfusion audits can be conducted on a prospective or retrospective basis. Prospective audits are performed at the time of receiving of requisitions and hence prior to blood issue. This requires good communication between the blood bank staff and clinicians. Such audits may not also be feasible while handling urgent blood requests. However, whenever performed, they have shown significant decline in inappropriate transfusions. In a study on prospective audit for platelet transfusions [7], a decrease in inappropriate transfusions of platelet concentrates by 56 percent was observed over a time when the patient load had increased by 38 per cent. Retrospective audits entail evaluation of requisitions already decided upon and available in the records. There is ease of performance with retrospective review though all desired clinical data for transfusion review may not have been captured. Some authors have performed concurrent audit where transfusion information is collected during the length of patient’s stay within the hospital [8]. Such audits help in assessing patient’s post transfusion outcome as well. A large majority of transfusion audits have been published from the developed countries. Studies from the developing countries are few and a literature search from India reveals scant reports and all these have been conducted on adult patients. A retrospective audit on 5525 units of platelet concentrates revealed that 88 percent of platelet transfusions were appropriate [9] as per guidelines of the British Committee for standards in Hematology. In another study, audit of fresh frozen plasma (FFP) was conducted on 821 transfusion requests for 2915 units. Inappropriate requests accounted for 30.2 percent of total FFP requests. These patients had normal coagulation parameters [10]. The guidelines against which appropriateness was measured were those recommended by College
Indian J Pediatr
of American Pathologists. Transfusion audits on pediatric patients are scant world over. In this context the study on audit of pediatric transfusion practices in a tertiary care hospital from India is timely and adds to the scarce data in this field [11]. The authors had conducted a retrospective audit on a total of 2145 blood components transfused to pediatric patients including neonates and thalassemia major patients on regular blood transfusion. The appropriateness of transfusions was reviewed according to the British Committee of Standards in Hematology guidelines for transfusion in neonates and infants up to 4 mo of age and older children upto 18 y. The whole blood transfusion was analysed according to guidelines of the American Association of Blood Banks (cited as reference 10 in the article by Bahadur et al.) The overall appropriate blood usage was 59.65%. Review of utilization of individual products revealed that whole blood (WB) was most appropriately transfused (82.9%) followed by platelet concentrates (66.7%) red cells (61.35%) and FFP (30%). The platelet utilization compares well with another study in pediatric blood transfusion audit, where platelets were appropriately transfused in 64.7% [12] of patients, FFP in 42.3% and red cells in 79.7% of the patients. The red cell indications for appropriate transfusions were somewhat lower [11]. Another important observation from this study is the greater inappropriate use of blood components in the pediatric surgical and intensive care settings as compared to pediatric medical patients and those in the nursery setting. This study provides useful data for further analysis into clinical factors which go into decision-making for transfusion. The hospital transfusion committees could provide a platform to conduct transfusion audits and promote continuing education programmes for best transfusion practices. Inter-hospital comparisons of transfusion audits would further help in achieving consistency in clinical transfusion.
Conflict of Interest None. Source of Funding None.
References 1. Wallis JP, Stainsby D, McClelland DBL. Audit of red cell transfusion. Transf Med. 2002;12:1–9. 2. MacPherson D, Mann T. Medical audit and quality of care—a new English initiative. Quality Assur Health Care. 1992;4:89–95. 3. Murphy MF, Wallington TB, Kelsey P, Boulton F, Bruce M, Cohen H, et al; British Committee for Standards in Haematology, Blood Transfusion Task Force. Guidelines for the clinical use of red cell transfusions. Br J Haematol. 2001;113:24–31. 4. Gibson BE, Todd A, Roberts I, Pamphilon D, Rodeck C, Boltonmaggs P, et al; British Committee for Standards in Haematology Transfusion Task Force: Writing Group. Transfusion guidelines for neonates and older children. Br J Haematol. 2004;124:433–53. 5. National Health and Medical Research Council, Australasian Society of Blood Transfusion: Clinical practice guidelines on the use of blood components: red cells, platelets, fresh frozen plasma, cryoprecipitate. Available at http://www.dcita.gov.au/infoacess/infoaccessnetwork/ index.html. 6. Crosby E, Ferguson D, Hume HA, Jonathan BK, Bryce L, Le Blond P, et al. Guidelines for red blood cells and plasma transfusion in adults and children. Can Med Assoc J. 1997;156:S1–24. 7. Simpson MB. Prospective concurrent audits and medical consultations for platelet transfusions. Transfusion. 1987;27:192–5. 8. Joshi GP, Landers DF. Audit in transfusion practice. J Eval Clin Pract. 1998;4:141–6. 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 Transf Sci. 2007;1:8–11. 10. Makroo RN, Raina V, Kumar P, Thakur UK. A prospective audit of transfusion requests in a tertiary care hospital for the use of fresh frozen plasma. Asian J Transf Sci. 2007;1:59–61. 11. Bahadur S, Sethi N, Pahuja S, Pathak C, Jain M. Audit of pediatric transfusion practices in tertiary care hospital. Indian J Pediatr. 2014. doi:10.1007/s12098-014-1370-2. 12. Hume HA, Ali AM, Decary F, Blajchman MA. Evaluation of pediatric transfusion practice using criteria maps. Transfusion. 1991;31:52–8.
EDITORIAL COMMENTARY
Audit of Pediatric Transfusion Practices: A Commentary Neelam Marwaha
Received: 15 December 2014 / Accepted: 22 December 2014 # Dr. K C Chaudhuri Foundation 2015
Blood transfusion is an essential component of modern healthcare services. Blood safety has considerably improved in the developed countries and is gradually improving in the developing world, however there still remains a residual risk of adverse transfusion reactions. Blood is also a precious resource as only blood donors constitute the source of blood supply. Improved testing and processing technologies and stringent regulatory oversight for blood safety have led to escalating costs for blood banking activities. In addition to the above factors which pose concerns on supply–demand situations and cost-effectiveness, the indications and dosage of blood and its components was based largely on observational data and/or experience. Conclusive scientific evidence to support what might constitute an appropriate transfusion was lacking for almost three decades of start of blood transfusion therapy in the 1950s [1]. Audits were initially used for review of accounts, but the process of a systematic assessment of services has become an essential tool of quality management within the blood transfusion services. It may be conducted within the blood bank for analysis and evaluation of processes involved in the preparation of blood and components for distribution or at the user level, that is the clinical requests and patient outcomes. Audits can only be conducted if there are standards against which a practice can be measured [2]. Many developed countries have published transfusion guidelines to help clinicians decide upon best clinical practices [3–6]. These guidelines/ recommendations formulated by expert groups take into consideration the transfusion triggers (patient’s pre-transfusion hemoglobin level / platelet counts / coagulation test abnormalities), and patient factors (age of the patient and the clinical status). Clinical transfusion audits should ideally review the
N. Marwaha (*) Department of Transfusion Medicine, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India e-mail: [email protected]
following two processes: (i) Were the blood or its components prescribed for the right indication in the right quantity and (ii) was there lack of blood requisition or transfusion in case it was required to achieve a clinical benefit. Transfusion audits can be conducted on a prospective or retrospective basis. Prospective audits are performed at the time of receiving of requisitions and hence prior to blood issue. This requires good communication between the blood bank staff and clinicians. Such audits may not also be feasible while handling urgent blood requests. However, whenever performed, they have shown significant decline in inappropriate transfusions. In a study on prospective audit for platelet transfusions [7], a decrease in inappropriate transfusions of platelet concentrates by 56 percent was observed over a time when the patient load had increased by 38 per cent. Retrospective audits entail evaluation of requisitions already decided upon and available in the records. There is ease of performance with retrospective review though all desired clinical data for transfusion review may not have been captured. Some authors have performed concurrent audit where transfusion information is collected during the length of patient’s stay within the hospital [8]. Such audits help in assessing patient’s post transfusion outcome as well. A large majority of transfusion audits have been published from the developed countries. Studies from the developing countries are few and a literature search from India reveals scant reports and all these have been conducted on adult patients. A retrospective audit on 5525 units of platelet concentrates revealed that 88 percent of platelet transfusions were appropriate [9] as per guidelines of the British Committee for standards in Hematology. In another study, audit of fresh frozen plasma (FFP) was conducted on 821 transfusion requests for 2915 units. Inappropriate requests accounted for 30.2 percent of total FFP requests. These patients had normal coagulation parameters [10]. The guidelines against which appropriateness was measured were those recommended by College
Indian J Pediatr
of American Pathologists. Transfusion audits on pediatric patients are scant world over. In this context the study on audit of pediatric transfusion practices in a tertiary care hospital from India is timely and adds to the scarce data in this field [11]. The authors had conducted a retrospective audit on a total of 2145 blood components transfused to pediatric patients including neonates and thalassemia major patients on regular blood transfusion. The appropriateness of transfusions was reviewed according to the British Committee of Standards in Hematology guidelines for transfusion in neonates and infants up to 4 mo of age and older children upto 18 y. The whole blood transfusion was analysed according to guidelines of the American Association of Blood Banks (cited as reference 10 in the article by Bahadur et al.) The overall appropriate blood usage was 59.65%. Review of utilization of individual products revealed that whole blood (WB) was most appropriately transfused (82.9%) followed by platelet concentrates (66.7%) red cells (61.35%) and FFP (30%). The platelet utilization compares well with another study in pediatric blood transfusion audit, where platelets were appropriately transfused in 64.7% [12] of patients, FFP in 42.3% and red cells in 79.7% of the patients. The red cell indications for appropriate transfusions were somewhat lower [11]. Another important observation from this study is the greater inappropriate use of blood components in the pediatric surgical and intensive care settings as compared to pediatric medical patients and those in the nursery setting. This study provides useful data for further analysis into clinical factors which go into decision-making for transfusion. The hospital transfusion committees could provide a platform to conduct transfusion audits and promote continuing education programmes for best transfusion practices. Inter-hospital comparisons of transfusion audits would further help in achieving consistency in clinical transfusion.
Conflict of Interest None. Source of Funding None.
References 1. Wallis JP, Stainsby D, McClelland DBL. Audit of red cell transfusion. Transf Med. 2002;12:1–9. 2. MacPherson D, Mann T. Medical audit and quality of care—a new English initiative. Quality Assur Health Care. 1992;4:89–95. 3. Murphy MF, Wallington TB, Kelsey P, Boulton F, Bruce M, Cohen H, et al; British Committee for Standards in Haematology, Blood Transfusion Task Force. Guidelines for the clinical use of red cell transfusions. Br J Haematol. 2001;113:24–31. 4. Gibson BE, Todd A, Roberts I, Pamphilon D, Rodeck C, Boltonmaggs P, et al; British Committee for Standards in Haematology Transfusion Task Force: Writing Group. Transfusion guidelines for neonates and older children. Br J Haematol. 2004;124:433–53. 5. National Health and Medical Research Council, Australasian Society of Blood Transfusion: Clinical practice guidelines on the use of blood components: red cells, platelets, fresh frozen plasma, cryoprecipitate. Available at http://www.dcita.gov.au/infoacess/infoaccessnetwork/ index.html. 6. Crosby E, Ferguson D, Hume HA, Jonathan BK, Bryce L, Le Blond P, et al. Guidelines for red blood cells and plasma transfusion in adults and children. Can Med Assoc J. 1997;156:S1–24. 7. Simpson MB. Prospective concurrent audits and medical consultations for platelet transfusions. Transfusion. 1987;27:192–5. 8. Joshi GP, Landers DF. Audit in transfusion practice. J Eval Clin Pract. 1998;4:141–6. 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 Transf Sci. 2007;1:8–11. 10. Makroo RN, Raina V, Kumar P, Thakur UK. A prospective audit of transfusion requests in a tertiary care hospital for the use of fresh frozen plasma. Asian J Transf Sci. 2007;1:59–61. 11. Bahadur S, Sethi N, Pahuja S, Pathak C, Jain M. Audit of pediatric transfusion practices in tertiary care hospital. Indian J Pediatr. 2014. doi:10.1007/s12098-014-1370-2. 12. Hume HA, Ali AM, Decary F, Blajchman MA. Evaluation of pediatric transfusion practice using criteria maps. Transfusion. 1991;31:52–8.
