Transfusion and Apheresis Science 52 (2015) 105–111
Contents lists available at ScienceDirect
Transfusion and Apheresis Science j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / t r a n s c i
Blood transfusion practice: A survey in Sichuan, China Yu Liu a,§, Jia Lin b,§, Ling Zhong b, Yi He b, Jia Yang b, Yanhong Wu b, Jing Yang b, Qian Li b, Jingxing Wang a, Shaoqin Rao b,* a b
Institute of Blood Transfusion, Chinese Academy of Medical Sciences and Peking Union Medical College, Chengdu, China Department of Blood Transfusion, Sichuan Academy of Medical Science & Sichuan Provincial People’s Hospital, Chengdu, China
A R T I C L E
I N F O
Article history: Received 12 May 2014 Received in revised form 1 September 2014 Accepted 7 November 2014 Keywords: Clinical transfusion practice Appropriateness of blood utilization Survey Questionnaire
A B S T R A C T
Objective: : To get full knowledge of current conditions and development in the past seven years of clinical transfusion practice in Sichuan, China. Study Design and Methods: : This survey was performed by means of a questionnaire which consisted of three parts of questions including basic conditions of blood banks in the hospitals, procedures for clinical blood transfusion and the utilization of different types of blood products. Thirty-five representative hospitals from different geographic locations in Sichuan province participated in this survey. Results: : All of the 35 hospitals returned the questionnaires and 33 hospitals (94.3%) answered the questions completely. The blood bank information system began to be used by more hospitals from 2006 (21.21%, 7/33) to 2012 (48.48%, 16/33). Automated grouping and cross-matching systems have not been used in level 2 hospitals and only 3 level 3 hospitals used automated systems in 2012. Still less common were procedures for evaluation of blood order forms for appropriateness (2/33, 6.06%) and evaluation of appropriateness and effect of blood component transfusion (8/33, 24.2%), and all the hospitals having these procedures are level 3 hospitals. The percentage of whole blood usage in the volume of all types of blood products used decreased a lot from 7.45% in 2006 to 0.16% in 2010. Technological instruments for bedside checking are not used by any of the hospitals. Conclusions: : The transfusion service degree of the hospitals in Sichuan, China, has developed a lot in the past seven years; however, there are still some problems including whole blood still being used, albeit decreasing; lack of independent blood banks within the hospitals; lack of dedicated personnel for the transfusion services; lack of education; lack of blood bank information systems and automation; lack of screening for appropriateness for blood orders. Thus, the quality control center of clinical blood transfusion (QCCCBT) of Sichuan province should help the transfusion departments to attract more investment in staffing, equipment and information system from the hospitals, enhance the training of transfusion department staffs, and emphasize the supervision of transfusion department’s work on directing clinical blood utilization and evaluating clinical transfusion appropriateness. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Blood transfusion is an important activity in healthcare. Safe, effective and appropriate transfusion practice is § Joint first authors. * Corresponding author. Department of Blood Transfusion, Sichuan Academy of Medical Science & Sichuan Provincial People’s Hospital, Chengdu, Sichuan, 610052, China. Tel.: +86 28 61646162; fax: +86 28 68169146. E-mail address: [email protected] (SQ. Rao).
http://dx.doi.org/10.1016/j.transci.2014.11.003 1473-0502/© 2014 Elsevier Ltd. All rights reserved.
mandatory for a good quality of care to patients who need transfusion as part of their treatment [1]. In China, wholeblood units for clinical use are collected at blood centers and the clinical blood utilization is conducted by blood banks or transfusion departments in the hospitals. There are more than 10 000 hospital blood banks in China [2]. To safeguard blood safety, the Chinese government has paid great attention to developing voluntary nonremunerated donation and enhancing the quality management of blood centers which led to great improvement of
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donor recruitment and blood supply in the past ten years [2]. Although clinical transfusion also stepped forward a lot in China, it still lags behind developed countries and there is still a big distance between transfusion medicine and other clinical medicine department [3]. In China, most of the hospitals have no independent transfusion department and the blood banks are affiliated to other departments such as clinical laboratory [2]. The degree of service provided by hospital blood banks varies greatly. To ensure the appropriate use of blood, a new management regulation of clinical blood transfusion was issued by the Ministry of Health in July of 2012. A quality control center of clinical blood transfusion (QCCCBT) was demanded by the new regulation to be established in every province to take the responsibility of guiding and evaluating the management of blood utilization in the hospitals. Sichuan is a province located in the southwest of China with a recorded population of 81 million. There are about 300 hospital blood banks in Sichuan and the level of medicine and education lags behind the provinces of East China. The QCCCBT of Sichuan province was established according to the new regulation, with the functions of evaluating the management of clinical transfusion practice and guiding the development of transfusion service in the hospitals in Sichuan. To function better, it is very important for the QCCCBT to get full knowledge of current conditions and the development of clinical transfusion practice in Sichuan. Thus, QCCCBT of Sichuan carried out a survey in the hospitals to obtain data about these issues. 2. Materials and methods This survey was conducted by the QCCCBT of Sichuan province. In China, the hospitals are classified into three levels, including level 1 hospitals, level 2 hospitals and level 3 hospitals according to the hospital scale, equipment, technology, etc. The level 3 hospitals are lager and provide higher medical service than level 1 hospitals and level 2 hospitals. Level 3 hospitals are demanded for having more than 400 beds and 5 technical staff in the blood bank while level 2 hospitals have more than 250 beds and 3 technical staff in the blood bank [4]. One to three representative hospitals in every city of Sichuan province were selected into this survey, and thus 35 hospitals including 14 level 2 hospitals and 21 level 3 hospitals were involved. We did not include level 1 hospitals in this study because there is no blood bank or transfusion department in level 1 hospital and they do not provide transfusion service. The selected hospitals are representative of the average hospitals in Sichuan, China. A questionnaire was developed to collect the data about blood transfusion practice in the hospitals from 2006 to 2012 which includes three questions: (1) the basic conditions of blood banks in the hospitals, including the areas of blood bank, the number of staffs and their educational background, the laboratory apparatus, the method for crossmatching and the information system used by blood banks; (2) the procedures for clinical blood transfusion, including the existence of standard operating procedures, the actions and instruments used to evaluate transfusion appropriateness and the method used for the blood recipients’
identification; (3) the utilization of different types of blood products in the hospitals. The directors of the blood banks or transfusion departments of the hospitals were responsible for data collection and were trained to complete the questionnaire before the start of the survey. The data were collected from the records of blood banks and the hospitals. The study was granted permission by Sichuan Provincial People’s Hospital Ethics Committee. All the data were anonymous and no patient-sensitive information was included in the study. The data collection did not have any consequences for patient care or treatment. The questionnaires were collected by an investigator and the data from the hospitals were entered into a computer spreadsheet (Excel, Microsoft Corp., Redmond, WA), and descriptive analysis was performed by two statisticians. The statistical analyses were performed with SPSS version 17.0 (IBM Corporation, Armonk, NY, USA). The variables were compared between level 2 hospitals and levels 3 hospitals. The changes of the variables were analyzed with the year from 2006 to 2013. Categorical data were analyzed by χ2 test. Quantity variables were expressed as mean ± SD and compared by using Student’s t-test or Mann–Whitney test. P < 0.05 represented statistical significance. 3. Results All of the 35 hospitals returned the questionnaires and 33 hospitals (94.3%) answered the questions completely, in which 8 hospitals were in the east of Sichuan province, 5 in the west, 8 in the north, 7 in the south and 5 hospitals in the middle of Sichuan province. Of the 33 hospitals, 14 were level 2 hospitals with 500 beds in average and 19 were level 3 hospitals with 1263 beds in average. The average accommodation of the 33 hospitals was 1009 patients. Ten of the 33 hospitals (30.30%) have independent transfusion department, all of which are level three, and the transfusion department in other hospitals are affiliated to clinical laboratories. Although there was no independent transfusion department in the 23 hospitals surveyed, an independent group was responsible for the work of transfusion department. 3.1. The basic conditions of blood banks/transfusion departments in the hospitals As shown in Fig. 1A, the percentage of transfusion department staffs in all the staffs of the hospital is 0.53% (4/ 748) in average in 2006 and 0.58% (6/1036) in average in 2012, and the percentage showed no incremental trend from 2006 to 2012 in average of all the hospitals (P = 0.84). In 2012, the percentage of transfusion department staffs in all staffs of level 2 hospitals (1.07%, 6/563) is higher than the percentage in level 3 hospitals (0.44%, 6/1374), although the difference was not significant (P = 0.11). In addition, we surveyed the educational level of staffs working in transfusion department and found that the percentage of staffs with bachelor’s degree or above increased from 25.0% in 2006 to 66.7% in 2012 (Fig. 1B). However, this percentage in level 2 hospitals decreased in the past 6 years from 50.0% (1/2) in 2007 to 16.7% (1/6) in 2012. In 2012, the percentage of
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Fig. 1. The conditions of the transfusion department in the hospitals surveyed from 2006 to 2012.
staffs with relative high educational level was significantly higher in level 3 hospitals (83.3%, 5/6) than in level 2 hospitals (16.7%, 1/6). As shown in Fig. 1C, the area of transfusion department laboratory expanded in the past 7 years which covered 0.12% in average of the total area of the hospitals in 2006 and increased to 0.19% in 2007. The similar expansion trend was observed in both level 2 hospitals and level 3 hospitals. However, in 2012, the transfusion department laboratory in level 2 hospitals covered a significantly higher percent (0.34%, 148/43555) of the total area of the hospitals than that in level 3 hospitals (0.14%, 140/99910, P < 0.001). The blood bank information system (BIS) began to be used by more hospitals from 2006 (21.21%, 7/33) to 2012 (48.48%, 16/33, P = 0.02). BIS was always used more by level 3 hospitals than level 2 hospitals in the past 7 years (Fig. 1D). BIS was not used in any of the 14 level 2 hospitals in 2006 and 2007, and was used in only 2 level 2 hospitals in 2012. All of the level 2 hospitals just used manual polybrene test (MPT) and microcolumn gel test (MGT) for crossmatching, with MPT using less and less (10/14 in 2006 and 3/14 in 2012, P = 0.01) and MGT using more and more (4/ 14 in 2006 and 11/14 in 2012, P = 0.01) in the past 7 years. The level 3 hospitals also used MGT and MPT for cross-
matching mainly. However, saline medium method and antihuman globulin test (tube test) were also used by level 3 hospitals. Automated grouping and cross-matching systems have not been used in level 2 hospitals. One of the 14 level 3 hospitals began to use automated systems in 2009 and only 3 level 3 hospitals used automated systems in 2012. 3.2. The procedures for clinical blood transfusion All hospitals reported having documented procedures for clinical blood transfusion. However, the procedures in 93.93% (31/33) of the hospitals are not complete. All hospitals surveyed have documented standard operating procedures (SOPs) for blood request, blood testing, blood storage, blood release and patient identification. Twenty-seven of the 33 (81.8%) hospitals have SOPs regarding transfusion in emergency, and the rate of level 3 hospitals (18/19, 94.74%) were significantly higher than the rate of level 2 hospitals (9/ 14, 64.29%). Still less common were SOPs for evaluation of blood order forms for appropriateness (2/33, 6.06%) and evaluation of appropriateness and effect of blood component transfusion (8/33, 24.2%), and all the hospitals having these SOPs are level 3 hospitals. The functions of all the level 2 hospitals and most of the level 3 hospitals just include blood
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storage, pre-transfusion tests, and distribution of blood products. Although all the hospitals established the SOPs for patient identification, all of them still use active identification of patients (calling the names of the patients) and technological instruments for bedside checking (wristbands, radiofrequency or biometric devices) are not used by any of the hospitals. 3.3. The utilization of different types of blood products The average volume of blood used by the 33 hospitals yearly increased from 1339.81 ± 56.22 L in 2006 to 2666.11 ± 101.34 L in 2012 (P = 0.046). The blood usage in both the level 2 hospitals and level 3 hospitals showed increasing trend as Fig. 2A shows (P = 0.02 and P = 0.045). However, the blood use volume per inpatient decreased from 93.22 ± 10.54 ml in 2007 to 75.96 ± 8.32 ml in 2012 (P = 0.045). Especially, the level 3 hospitals showed a great decreasing trend in blood use volume per inpatient from 127.94 ± 11.76 ml in 2007 to 85.73 ± 8.79 ml in 2012 (P = 0.04) (Fig. 2B). The average volume of whole blood used by the 33 hospitals surveyed, especially by the 14 level 2 hospitals, decreased significantly from 2006 to 2012 (P < 0.01, Fig. 2C). The percentage of whole blood usage in the volume of all types of blood products used decreased significantly from 7.45% in 2006 to 0.16% in 2010 (P < 0.01, Fig. 2D). Red blood cells (RBC) used by the 33 hospitals increased from 3421 ± 103 units in 2006 to 6762 ± 196 units in 2012 (Fig. 2E). However, the RBC usage per inpatient showed no obvious change in the past 7 years (Fig. 2F). As shown in Fig. 2G, the average volume of plasma used by the surveyed hospitals increased from 377.99 ± 13.56 L in 2006 to 951.92 ± 24.76 L in 2012 (P = 0.03). However, the incremental trend was observed for level 3 hospitals (P = 0.008) but not for level 2 hospitals (P = 0.06). The volume of plasma used per inpatient and the percent of plasma used in all the blood products used showed no significant change in the past 7 years (Fig. 2H). The level 3 hospitals used more plasma than level 2 hospitals as shown by both the volume used per inpatient and the percentage of plasma used in all the blood products. The units of platelet used by the surveyed hospitals did not change a lot in the past 7 years (P = 0.054, Fig. 2I). The average units of platelet used by level 3 hospitals were significantly more than that used by level 2 hospitals (P < 0.01, Fig. 2I and J). The percent of blood used for surgery decreased from 40.34% in 2006 to 27.30% in 2012. The level 2 hospitals decreased more than the level 3 hospitals, with 50.90% in 2006 and 24.94% in 2012 versus 43.64% in 2006 and 31.10% in 2010. 4. Discussion Because hospitals of different level have different scales, equipment, technology and staff force in China, the clinical transfusion practice may be quite different for hospitals of different levels [4]. Thus, we compared the clinical transfusion practice of level 2 hospitals and level 3 hospitals in this survey.
In China, the students should study for five years in medical school to get the bachelor’s degree of clinical laboratory science and then can be qualified as a primary clinical laboratory examiner by passing a national examination. Another three-year study for master’s degree or five years for doctorate degree is open to the examiner. Generally speaking, the examiners with higher degree perform better because of more professional training in clinical laboratory science and more experience in clinical laboratory. The number and education background of staffs in transfusion department may affect the transfusion service level [5]. Thus we surveyed the conditions of staffs working in the transfusion department which showed that the staffs in the transfusion department accounted for a low percentage in all the staffs of the hospital (only 0.58%, 6/1036 in 2012), and the percentage showed no incremental trend in the past seven years with the obvious increase in blood utilization. This indicated that the number of staffs may not be enough to guarantee the quality of transfusion service. Although the percentage of staffs with bachelor’s degree or above increased a lot in the past seven years, the increase occurred mainly in level 3 hospitals, with the decrease occurring in level 2 hospitals. In 2012, the percentage of staffs with relative high educational level was significantly higher in level 3 hospitals than in level 2 hospitals. This may result from the fact that level 3 hospitals can absorb more staffs with high educational background by providing better career future and high salary. However, this may affect the quality of transfusion service of level 2 hospitals. Thus, the QCCCBT of Sichuan province should promote the training of transfusion department staffs in the hospitals especially in level 2 hospitals. Compliance by hospital blood transfusion laboratories with increasing regulatory requirements is dependent on adequate IT systems, which should also play a role in facilitating good transfusion practice [5]. Although BIS began to be used by more hospitals in the past 7 years, only 48.48% (16/33) of the hospitals used BIS in 2012 in which there were only 2 level 2 hospitals. This indicated that QCCCBT of Sichuan province should promote the utilization of BIS in the hospitals, especially level 2 hospitals, to enhance the quality assurance of blood transfusion. The method of cross-matching is also an important index for transfusion service level. This survey showed that level 2 hospitals just used MPT and MGT for cross-matching, while level 3 hospitals also used saline medium method and antihuman globulin test (tube test) in addition to MGT and MPT. This is probably because antibody screening, not compulsory before transfusion in China, is usually done for the recipient who failed cross-matching. MPT and MGT are used for cross-matching usually. In addition to MPT and MGT, saline medium method and anti-human globulin test (tube test) are used for antibody screening on mismatching samples. Level 2 hospitals often send the mismatching samples to provincial blood centers or level 3 hospitals for antibody screening. Thus, they do not use the other two methods. In addition, automated grouping and crossmatching systems have not been used generally in the hospitals in Sichuan. No level 2 hospitals and only 3 level 3 hospitals used automated systems in 2012. It is known that the use of automated system is not only important for
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Fig. 2. The blood utilization of the transfusion department in the hospitals surveyed from 2006 to 2012.
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improving the work efficiency but also important for quality assurance of grouping and cross-matching [5]. Thus, the QCCCBT of Sichuan province should enhance the training of methods of cross-matching especially for difficult samples to improve the technical level of transfusion department and promote the use of automated systems to further guarantee the quality of cross-matching. A widespread use of evidence-based SOPs, a starting point in transfusion practice, could be a first indicator of good quality activities [1]. This survey found that although all hospitals reported having documented procedures for clinical blood transfusion, the procedures in most of the hospitals were not complete and suitable, and the records of procedures were not finished as demanded and contradictive sometimes. In addition, most of the hospitals surveyed lack procedures for evaluating blood order forms for appropriateness and effect of blood component transfusion. This indicated that the quality system in most of the hospitals is not complete and effective, thus the QCCCBT should enhance the training of the establishment and implement a quality system in the transfusion department. In addition, this survey also suggested that functions of a typical hospital transfusion department in China only included blood storage, pretransfusion tests, and distribution of blood products, and the staffs in the transfusion department rarely directed the clinical blood utilization and evaluate the appropriateness of blood transfusion. The evaluation of the appropriateness of blood transfusion has gained a pivotal role in modern Transfusion Medicine [1]. Thus, the QCCCBT should improve the training of transfusion department staffs on appropriate blood transfusion to promote the transfusion department to take the responsibility of directing clinical blood utilization and evaluating appropriateness of blood transfusion and assess their work on these aspects. As reported, the transfusion of incorrect blood components, and especially the administration to a patient of a blood component intended for a different one, has been the main hazard of transfusion therapy [1]. Proper identification of patients could prevent the great majority of these adverse events and the new technology can provide systems to reduce the mistakes in the identification of of patients and ultimately reduce the risk of transfusion errors [6,7]. However, this study found that all the hospitals surveyed still used active identification of patients and technological instruments for bedside checking were not used for patient identification for transfusion even wristbands were used by several large hospitals for other functions. The volume and types of blood product used by the hospitals are also an important indicator for the degree of transfusion service of the hospitals. Our study showed that the average volume of blood used by the 33 hospitals yearly increased by one fold from 2006 to 2012. This resulted from the increase of inpatients. However, the blood use volume per inpatient decreased a lot from 2007 to 2012, which may be related to the transfusion service management of the government. To ensure the safety of blood transfusion, China implemented a non-remunerated blood-donation system in 1998 [2]. Since then, the volume of donated blood from non-remunerated donors has increased every year. However, this growth of supply has not kept pace with increasing
demand because of the increasing inpatients [3]. Thus, the Ministry of Health has paid great attention to saving blood and appropriate transfusion in transfusion service management in recent years. The result of decreasing blood usage per inpatient in our study demonstrated the effectiveness of the management. Referring to the blood components including RBC and plasma, although the average volume used by hospitals yearly soared, the volume used per inpatient did not increase still. In addition, the percentage of whole blood usage in the volume of all types of blood products used decreased a lot from 2006 to 2010, and the use of components increased to 99.84% in 2012. These results indicated that the policies implemented by the Ministry of Health to save blood and to promote appropriate transfusion and blood components utilization were successful. It was observed that the volume of plasma used by the hospitals increased 2.5-fold in the past seven years. This may be caused mainly by the increase of severe hepatitis patients, especially hepatocirrhosis patients who need supplement of albumin or even clotting factors. However, China is in shortage of plasma derivatives, and thus plasma is used as substitute for albumin or clotting factors. In addition, development of plasma exchange therapy in China may be another reason for increasing plasma usage. However, inappropriate use of plasma still existed in the hospitals because many clinicians did not know clearly the indication for plasma transfusion and some of them believed it as nutrition. Thus, the QCCCBT should improve the training and supervision of appropriate use of plasma. In conclusion, the survey seems to show that the transfusion service degree of transfusion departments in hospitals in Sichuan, China, has developed a lot in the past seven years; however, there are still some problems, including whole blood still being used, albeit decreasing; lack of independent blood banks within the hospitals; lack of dedicated personnel for the transfusion services; lack of education (especially in level 2 hospitals); lack of information systems and automation in the majority of hospitals; lack of screening for appropriateness for blood orders; and lack of wristbands for patient identification. In addition, there is still a great distance between level 2 hospitals and level 3 hospitals. In recent years, the pressures on transfusion department increased a lot because of the higher demand from the patients, society and the government. Thus, to ensure the quality of the transfusion service in the hospitals, the QCCCBT should help the transfusion department to attract more investment in staffing, equipment and information system from the hospitals, enhance the training of transfusion department staffs to improve their knowledge and skills in transfusion medicine, and emphasize the supervision of transfusion department’s work on directing clinical blood utilization and evaluating clinical transfusion appropriateness.
Acknowledgments This work was supported by the project of the Establishment of Quality System in Clinical Transfusion in Sichuan Province [3030503N3].
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References [1] Verlicchi F, Facco G, Macri M, Antoncecchi S, Bonomo P. Blood transfusion practice: a nationwide survey in Italy. Blood Transfus 2011;9:430–5. [2] Shan H, Wang JX, Ren FR, Zhang YZ, Zhao HY, Gao GJ, et al. Blood banking in China. Lancet 2002;360:1770–5. [3] Yu X, Huang Y, Qu G, Xu J, Hui S. Safety and current status of blood transfusion in China. Lancet 2010;375:1420–1.
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[4] Wang MX, Ou L, Gao Y. Transition of hospital accreditation management in China. Chin Med J (Engl) 2013;126:4816–7. [5] Murphy MF, Allard S, Newland AC. Modernizing hospital transfusion laboratory services. Transfus Med 2009;19:153–5. [6] Pagliaro P, Turdo R, Capuzzo E. Patients’ positive identification systems. Blood Transfus 2009;7:313–8. [7] Pagliaro P, Rebulla P. Transfusion recipient identification. Vox Sang 2006;91:97–101.
Contents lists available at ScienceDirect
Transfusion and Apheresis Science j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / t r a n s c i
Blood transfusion practice: A survey in Sichuan, China Yu Liu a,§, Jia Lin b,§, Ling Zhong b, Yi He b, Jia Yang b, Yanhong Wu b, Jing Yang b, Qian Li b, Jingxing Wang a, Shaoqin Rao b,* a b
Institute of Blood Transfusion, Chinese Academy of Medical Sciences and Peking Union Medical College, Chengdu, China Department of Blood Transfusion, Sichuan Academy of Medical Science & Sichuan Provincial People’s Hospital, Chengdu, China
A R T I C L E
I N F O
Article history: Received 12 May 2014 Received in revised form 1 September 2014 Accepted 7 November 2014 Keywords: Clinical transfusion practice Appropriateness of blood utilization Survey Questionnaire
A B S T R A C T
Objective: : To get full knowledge of current conditions and development in the past seven years of clinical transfusion practice in Sichuan, China. Study Design and Methods: : This survey was performed by means of a questionnaire which consisted of three parts of questions including basic conditions of blood banks in the hospitals, procedures for clinical blood transfusion and the utilization of different types of blood products. Thirty-five representative hospitals from different geographic locations in Sichuan province participated in this survey. Results: : All of the 35 hospitals returned the questionnaires and 33 hospitals (94.3%) answered the questions completely. The blood bank information system began to be used by more hospitals from 2006 (21.21%, 7/33) to 2012 (48.48%, 16/33). Automated grouping and cross-matching systems have not been used in level 2 hospitals and only 3 level 3 hospitals used automated systems in 2012. Still less common were procedures for evaluation of blood order forms for appropriateness (2/33, 6.06%) and evaluation of appropriateness and effect of blood component transfusion (8/33, 24.2%), and all the hospitals having these procedures are level 3 hospitals. The percentage of whole blood usage in the volume of all types of blood products used decreased a lot from 7.45% in 2006 to 0.16% in 2010. Technological instruments for bedside checking are not used by any of the hospitals. Conclusions: : The transfusion service degree of the hospitals in Sichuan, China, has developed a lot in the past seven years; however, there are still some problems including whole blood still being used, albeit decreasing; lack of independent blood banks within the hospitals; lack of dedicated personnel for the transfusion services; lack of education; lack of blood bank information systems and automation; lack of screening for appropriateness for blood orders. Thus, the quality control center of clinical blood transfusion (QCCCBT) of Sichuan province should help the transfusion departments to attract more investment in staffing, equipment and information system from the hospitals, enhance the training of transfusion department staffs, and emphasize the supervision of transfusion department’s work on directing clinical blood utilization and evaluating clinical transfusion appropriateness. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Blood transfusion is an important activity in healthcare. Safe, effective and appropriate transfusion practice is § Joint first authors. * Corresponding author. Department of Blood Transfusion, Sichuan Academy of Medical Science & Sichuan Provincial People’s Hospital, Chengdu, Sichuan, 610052, China. Tel.: +86 28 61646162; fax: +86 28 68169146. E-mail address: [email protected] (SQ. Rao).
http://dx.doi.org/10.1016/j.transci.2014.11.003 1473-0502/© 2014 Elsevier Ltd. All rights reserved.
mandatory for a good quality of care to patients who need transfusion as part of their treatment [1]. In China, wholeblood units for clinical use are collected at blood centers and the clinical blood utilization is conducted by blood banks or transfusion departments in the hospitals. There are more than 10 000 hospital blood banks in China [2]. To safeguard blood safety, the Chinese government has paid great attention to developing voluntary nonremunerated donation and enhancing the quality management of blood centers which led to great improvement of
106
Y. Liu et al./Transfusion and Apheresis Science 52 (2015) 105–111
donor recruitment and blood supply in the past ten years [2]. Although clinical transfusion also stepped forward a lot in China, it still lags behind developed countries and there is still a big distance between transfusion medicine and other clinical medicine department [3]. In China, most of the hospitals have no independent transfusion department and the blood banks are affiliated to other departments such as clinical laboratory [2]. The degree of service provided by hospital blood banks varies greatly. To ensure the appropriate use of blood, a new management regulation of clinical blood transfusion was issued by the Ministry of Health in July of 2012. A quality control center of clinical blood transfusion (QCCCBT) was demanded by the new regulation to be established in every province to take the responsibility of guiding and evaluating the management of blood utilization in the hospitals. Sichuan is a province located in the southwest of China with a recorded population of 81 million. There are about 300 hospital blood banks in Sichuan and the level of medicine and education lags behind the provinces of East China. The QCCCBT of Sichuan province was established according to the new regulation, with the functions of evaluating the management of clinical transfusion practice and guiding the development of transfusion service in the hospitals in Sichuan. To function better, it is very important for the QCCCBT to get full knowledge of current conditions and the development of clinical transfusion practice in Sichuan. Thus, QCCCBT of Sichuan carried out a survey in the hospitals to obtain data about these issues. 2. Materials and methods This survey was conducted by the QCCCBT of Sichuan province. In China, the hospitals are classified into three levels, including level 1 hospitals, level 2 hospitals and level 3 hospitals according to the hospital scale, equipment, technology, etc. The level 3 hospitals are lager and provide higher medical service than level 1 hospitals and level 2 hospitals. Level 3 hospitals are demanded for having more than 400 beds and 5 technical staff in the blood bank while level 2 hospitals have more than 250 beds and 3 technical staff in the blood bank [4]. One to three representative hospitals in every city of Sichuan province were selected into this survey, and thus 35 hospitals including 14 level 2 hospitals and 21 level 3 hospitals were involved. We did not include level 1 hospitals in this study because there is no blood bank or transfusion department in level 1 hospital and they do not provide transfusion service. The selected hospitals are representative of the average hospitals in Sichuan, China. A questionnaire was developed to collect the data about blood transfusion practice in the hospitals from 2006 to 2012 which includes three questions: (1) the basic conditions of blood banks in the hospitals, including the areas of blood bank, the number of staffs and their educational background, the laboratory apparatus, the method for crossmatching and the information system used by blood banks; (2) the procedures for clinical blood transfusion, including the existence of standard operating procedures, the actions and instruments used to evaluate transfusion appropriateness and the method used for the blood recipients’
identification; (3) the utilization of different types of blood products in the hospitals. The directors of the blood banks or transfusion departments of the hospitals were responsible for data collection and were trained to complete the questionnaire before the start of the survey. The data were collected from the records of blood banks and the hospitals. The study was granted permission by Sichuan Provincial People’s Hospital Ethics Committee. All the data were anonymous and no patient-sensitive information was included in the study. The data collection did not have any consequences for patient care or treatment. The questionnaires were collected by an investigator and the data from the hospitals were entered into a computer spreadsheet (Excel, Microsoft Corp., Redmond, WA), and descriptive analysis was performed by two statisticians. The statistical analyses were performed with SPSS version 17.0 (IBM Corporation, Armonk, NY, USA). The variables were compared between level 2 hospitals and levels 3 hospitals. The changes of the variables were analyzed with the year from 2006 to 2013. Categorical data were analyzed by χ2 test. Quantity variables were expressed as mean ± SD and compared by using Student’s t-test or Mann–Whitney test. P < 0.05 represented statistical significance. 3. Results All of the 35 hospitals returned the questionnaires and 33 hospitals (94.3%) answered the questions completely, in which 8 hospitals were in the east of Sichuan province, 5 in the west, 8 in the north, 7 in the south and 5 hospitals in the middle of Sichuan province. Of the 33 hospitals, 14 were level 2 hospitals with 500 beds in average and 19 were level 3 hospitals with 1263 beds in average. The average accommodation of the 33 hospitals was 1009 patients. Ten of the 33 hospitals (30.30%) have independent transfusion department, all of which are level three, and the transfusion department in other hospitals are affiliated to clinical laboratories. Although there was no independent transfusion department in the 23 hospitals surveyed, an independent group was responsible for the work of transfusion department. 3.1. The basic conditions of blood banks/transfusion departments in the hospitals As shown in Fig. 1A, the percentage of transfusion department staffs in all the staffs of the hospital is 0.53% (4/ 748) in average in 2006 and 0.58% (6/1036) in average in 2012, and the percentage showed no incremental trend from 2006 to 2012 in average of all the hospitals (P = 0.84). In 2012, the percentage of transfusion department staffs in all staffs of level 2 hospitals (1.07%, 6/563) is higher than the percentage in level 3 hospitals (0.44%, 6/1374), although the difference was not significant (P = 0.11). In addition, we surveyed the educational level of staffs working in transfusion department and found that the percentage of staffs with bachelor’s degree or above increased from 25.0% in 2006 to 66.7% in 2012 (Fig. 1B). However, this percentage in level 2 hospitals decreased in the past 6 years from 50.0% (1/2) in 2007 to 16.7% (1/6) in 2012. In 2012, the percentage of
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Fig. 1. The conditions of the transfusion department in the hospitals surveyed from 2006 to 2012.
staffs with relative high educational level was significantly higher in level 3 hospitals (83.3%, 5/6) than in level 2 hospitals (16.7%, 1/6). As shown in Fig. 1C, the area of transfusion department laboratory expanded in the past 7 years which covered 0.12% in average of the total area of the hospitals in 2006 and increased to 0.19% in 2007. The similar expansion trend was observed in both level 2 hospitals and level 3 hospitals. However, in 2012, the transfusion department laboratory in level 2 hospitals covered a significantly higher percent (0.34%, 148/43555) of the total area of the hospitals than that in level 3 hospitals (0.14%, 140/99910, P < 0.001). The blood bank information system (BIS) began to be used by more hospitals from 2006 (21.21%, 7/33) to 2012 (48.48%, 16/33, P = 0.02). BIS was always used more by level 3 hospitals than level 2 hospitals in the past 7 years (Fig. 1D). BIS was not used in any of the 14 level 2 hospitals in 2006 and 2007, and was used in only 2 level 2 hospitals in 2012. All of the level 2 hospitals just used manual polybrene test (MPT) and microcolumn gel test (MGT) for crossmatching, with MPT using less and less (10/14 in 2006 and 3/14 in 2012, P = 0.01) and MGT using more and more (4/ 14 in 2006 and 11/14 in 2012, P = 0.01) in the past 7 years. The level 3 hospitals also used MGT and MPT for cross-
matching mainly. However, saline medium method and antihuman globulin test (tube test) were also used by level 3 hospitals. Automated grouping and cross-matching systems have not been used in level 2 hospitals. One of the 14 level 3 hospitals began to use automated systems in 2009 and only 3 level 3 hospitals used automated systems in 2012. 3.2. The procedures for clinical blood transfusion All hospitals reported having documented procedures for clinical blood transfusion. However, the procedures in 93.93% (31/33) of the hospitals are not complete. All hospitals surveyed have documented standard operating procedures (SOPs) for blood request, blood testing, blood storage, blood release and patient identification. Twenty-seven of the 33 (81.8%) hospitals have SOPs regarding transfusion in emergency, and the rate of level 3 hospitals (18/19, 94.74%) were significantly higher than the rate of level 2 hospitals (9/ 14, 64.29%). Still less common were SOPs for evaluation of blood order forms for appropriateness (2/33, 6.06%) and evaluation of appropriateness and effect of blood component transfusion (8/33, 24.2%), and all the hospitals having these SOPs are level 3 hospitals. The functions of all the level 2 hospitals and most of the level 3 hospitals just include blood
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storage, pre-transfusion tests, and distribution of blood products. Although all the hospitals established the SOPs for patient identification, all of them still use active identification of patients (calling the names of the patients) and technological instruments for bedside checking (wristbands, radiofrequency or biometric devices) are not used by any of the hospitals. 3.3. The utilization of different types of blood products The average volume of blood used by the 33 hospitals yearly increased from 1339.81 ± 56.22 L in 2006 to 2666.11 ± 101.34 L in 2012 (P = 0.046). The blood usage in both the level 2 hospitals and level 3 hospitals showed increasing trend as Fig. 2A shows (P = 0.02 and P = 0.045). However, the blood use volume per inpatient decreased from 93.22 ± 10.54 ml in 2007 to 75.96 ± 8.32 ml in 2012 (P = 0.045). Especially, the level 3 hospitals showed a great decreasing trend in blood use volume per inpatient from 127.94 ± 11.76 ml in 2007 to 85.73 ± 8.79 ml in 2012 (P = 0.04) (Fig. 2B). The average volume of whole blood used by the 33 hospitals surveyed, especially by the 14 level 2 hospitals, decreased significantly from 2006 to 2012 (P < 0.01, Fig. 2C). The percentage of whole blood usage in the volume of all types of blood products used decreased significantly from 7.45% in 2006 to 0.16% in 2010 (P < 0.01, Fig. 2D). Red blood cells (RBC) used by the 33 hospitals increased from 3421 ± 103 units in 2006 to 6762 ± 196 units in 2012 (Fig. 2E). However, the RBC usage per inpatient showed no obvious change in the past 7 years (Fig. 2F). As shown in Fig. 2G, the average volume of plasma used by the surveyed hospitals increased from 377.99 ± 13.56 L in 2006 to 951.92 ± 24.76 L in 2012 (P = 0.03). However, the incremental trend was observed for level 3 hospitals (P = 0.008) but not for level 2 hospitals (P = 0.06). The volume of plasma used per inpatient and the percent of plasma used in all the blood products used showed no significant change in the past 7 years (Fig. 2H). The level 3 hospitals used more plasma than level 2 hospitals as shown by both the volume used per inpatient and the percentage of plasma used in all the blood products. The units of platelet used by the surveyed hospitals did not change a lot in the past 7 years (P = 0.054, Fig. 2I). The average units of platelet used by level 3 hospitals were significantly more than that used by level 2 hospitals (P < 0.01, Fig. 2I and J). The percent of blood used for surgery decreased from 40.34% in 2006 to 27.30% in 2012. The level 2 hospitals decreased more than the level 3 hospitals, with 50.90% in 2006 and 24.94% in 2012 versus 43.64% in 2006 and 31.10% in 2010. 4. Discussion Because hospitals of different level have different scales, equipment, technology and staff force in China, the clinical transfusion practice may be quite different for hospitals of different levels [4]. Thus, we compared the clinical transfusion practice of level 2 hospitals and level 3 hospitals in this survey.
In China, the students should study for five years in medical school to get the bachelor’s degree of clinical laboratory science and then can be qualified as a primary clinical laboratory examiner by passing a national examination. Another three-year study for master’s degree or five years for doctorate degree is open to the examiner. Generally speaking, the examiners with higher degree perform better because of more professional training in clinical laboratory science and more experience in clinical laboratory. The number and education background of staffs in transfusion department may affect the transfusion service level [5]. Thus we surveyed the conditions of staffs working in the transfusion department which showed that the staffs in the transfusion department accounted for a low percentage in all the staffs of the hospital (only 0.58%, 6/1036 in 2012), and the percentage showed no incremental trend in the past seven years with the obvious increase in blood utilization. This indicated that the number of staffs may not be enough to guarantee the quality of transfusion service. Although the percentage of staffs with bachelor’s degree or above increased a lot in the past seven years, the increase occurred mainly in level 3 hospitals, with the decrease occurring in level 2 hospitals. In 2012, the percentage of staffs with relative high educational level was significantly higher in level 3 hospitals than in level 2 hospitals. This may result from the fact that level 3 hospitals can absorb more staffs with high educational background by providing better career future and high salary. However, this may affect the quality of transfusion service of level 2 hospitals. Thus, the QCCCBT of Sichuan province should promote the training of transfusion department staffs in the hospitals especially in level 2 hospitals. Compliance by hospital blood transfusion laboratories with increasing regulatory requirements is dependent on adequate IT systems, which should also play a role in facilitating good transfusion practice [5]. Although BIS began to be used by more hospitals in the past 7 years, only 48.48% (16/33) of the hospitals used BIS in 2012 in which there were only 2 level 2 hospitals. This indicated that QCCCBT of Sichuan province should promote the utilization of BIS in the hospitals, especially level 2 hospitals, to enhance the quality assurance of blood transfusion. The method of cross-matching is also an important index for transfusion service level. This survey showed that level 2 hospitals just used MPT and MGT for cross-matching, while level 3 hospitals also used saline medium method and antihuman globulin test (tube test) in addition to MGT and MPT. This is probably because antibody screening, not compulsory before transfusion in China, is usually done for the recipient who failed cross-matching. MPT and MGT are used for cross-matching usually. In addition to MPT and MGT, saline medium method and anti-human globulin test (tube test) are used for antibody screening on mismatching samples. Level 2 hospitals often send the mismatching samples to provincial blood centers or level 3 hospitals for antibody screening. Thus, they do not use the other two methods. In addition, automated grouping and crossmatching systems have not been used generally in the hospitals in Sichuan. No level 2 hospitals and only 3 level 3 hospitals used automated systems in 2012. It is known that the use of automated system is not only important for
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Fig. 2. The blood utilization of the transfusion department in the hospitals surveyed from 2006 to 2012.
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improving the work efficiency but also important for quality assurance of grouping and cross-matching [5]. Thus, the QCCCBT of Sichuan province should enhance the training of methods of cross-matching especially for difficult samples to improve the technical level of transfusion department and promote the use of automated systems to further guarantee the quality of cross-matching. A widespread use of evidence-based SOPs, a starting point in transfusion practice, could be a first indicator of good quality activities [1]. This survey found that although all hospitals reported having documented procedures for clinical blood transfusion, the procedures in most of the hospitals were not complete and suitable, and the records of procedures were not finished as demanded and contradictive sometimes. In addition, most of the hospitals surveyed lack procedures for evaluating blood order forms for appropriateness and effect of blood component transfusion. This indicated that the quality system in most of the hospitals is not complete and effective, thus the QCCCBT should enhance the training of the establishment and implement a quality system in the transfusion department. In addition, this survey also suggested that functions of a typical hospital transfusion department in China only included blood storage, pretransfusion tests, and distribution of blood products, and the staffs in the transfusion department rarely directed the clinical blood utilization and evaluate the appropriateness of blood transfusion. The evaluation of the appropriateness of blood transfusion has gained a pivotal role in modern Transfusion Medicine [1]. Thus, the QCCCBT should improve the training of transfusion department staffs on appropriate blood transfusion to promote the transfusion department to take the responsibility of directing clinical blood utilization and evaluating appropriateness of blood transfusion and assess their work on these aspects. As reported, the transfusion of incorrect blood components, and especially the administration to a patient of a blood component intended for a different one, has been the main hazard of transfusion therapy [1]. Proper identification of patients could prevent the great majority of these adverse events and the new technology can provide systems to reduce the mistakes in the identification of of patients and ultimately reduce the risk of transfusion errors [6,7]. However, this study found that all the hospitals surveyed still used active identification of patients and technological instruments for bedside checking were not used for patient identification for transfusion even wristbands were used by several large hospitals for other functions. The volume and types of blood product used by the hospitals are also an important indicator for the degree of transfusion service of the hospitals. Our study showed that the average volume of blood used by the 33 hospitals yearly increased by one fold from 2006 to 2012. This resulted from the increase of inpatients. However, the blood use volume per inpatient decreased a lot from 2007 to 2012, which may be related to the transfusion service management of the government. To ensure the safety of blood transfusion, China implemented a non-remunerated blood-donation system in 1998 [2]. Since then, the volume of donated blood from non-remunerated donors has increased every year. However, this growth of supply has not kept pace with increasing
demand because of the increasing inpatients [3]. Thus, the Ministry of Health has paid great attention to saving blood and appropriate transfusion in transfusion service management in recent years. The result of decreasing blood usage per inpatient in our study demonstrated the effectiveness of the management. Referring to the blood components including RBC and plasma, although the average volume used by hospitals yearly soared, the volume used per inpatient did not increase still. In addition, the percentage of whole blood usage in the volume of all types of blood products used decreased a lot from 2006 to 2010, and the use of components increased to 99.84% in 2012. These results indicated that the policies implemented by the Ministry of Health to save blood and to promote appropriate transfusion and blood components utilization were successful. It was observed that the volume of plasma used by the hospitals increased 2.5-fold in the past seven years. This may be caused mainly by the increase of severe hepatitis patients, especially hepatocirrhosis patients who need supplement of albumin or even clotting factors. However, China is in shortage of plasma derivatives, and thus plasma is used as substitute for albumin or clotting factors. In addition, development of plasma exchange therapy in China may be another reason for increasing plasma usage. However, inappropriate use of plasma still existed in the hospitals because many clinicians did not know clearly the indication for plasma transfusion and some of them believed it as nutrition. Thus, the QCCCBT should improve the training and supervision of appropriate use of plasma. In conclusion, the survey seems to show that the transfusion service degree of transfusion departments in hospitals in Sichuan, China, has developed a lot in the past seven years; however, there are still some problems, including whole blood still being used, albeit decreasing; lack of independent blood banks within the hospitals; lack of dedicated personnel for the transfusion services; lack of education (especially in level 2 hospitals); lack of information systems and automation in the majority of hospitals; lack of screening for appropriateness for blood orders; and lack of wristbands for patient identification. In addition, there is still a great distance between level 2 hospitals and level 3 hospitals. In recent years, the pressures on transfusion department increased a lot because of the higher demand from the patients, society and the government. Thus, to ensure the quality of the transfusion service in the hospitals, the QCCCBT should help the transfusion department to attract more investment in staffing, equipment and information system from the hospitals, enhance the training of transfusion department staffs to improve their knowledge and skills in transfusion medicine, and emphasize the supervision of transfusion department’s work on directing clinical blood utilization and evaluating clinical transfusion appropriateness.
Acknowledgments This work was supported by the project of the Establishment of Quality System in Clinical Transfusion in Sichuan Province [3030503N3].
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