CLINICAL AUDIT ABSTRACT

Title of Audit
EVALUATION OF APPROPRIATE USAGE OF RED BLOOD CELLS IN DISTRICT
BASE HOSPITAL DICKOYA
Date of report Department
22/08/2022 Blood bank – District Base Hospital, Dickoya

Blood bank
Audit
Dr.K.K.G.Lahiru Praboda District Base Hospital
author Department
Dickoya
Contact TP:0716496687
Job title Medical Officer – Blood bank
details Email:LP89129@gmail.com
Stakeholders 01. Dr.Chaminthi Senevirathna, 01. Blood bank, GH
Consultanat Transfusion Department Nuwaraeliya
02. Dr.Shamla Hameed, Medical 02. MOH, Welikanda
Officer
03. Mrs. P.D.Dissanayaka, 03. Blood bank, DBH
NOIC Dickoya
04. Mr.Dasun 04. Nuwaraeliya

INTRODUCTION:

At District Base Hospital Dickoya we encounter a high volume of unnecessary blood transfusions based on a
high haemoglobin level without any anaemic symptoms. In addition, to that transfusion reactions have been
frequently occurring and when we traced the details we found it to have occurred due to errors of transfusion by
not adhering to “rule of 4 hours” and “rule of 30 minutes”. Therefore, for better patient care and to improve good
medical practice, we decided to carry out a clinical audit about Red cells concentration transfusion practices in
District Base Hospital Dickoya. This way we could also find out the percentage of these best practices vs. errors.

This audit started on 2/5/2022 and we checked both urgent and routine transfusions requested from
medical and surgical wards from 1/2/2022 to 31/3/2022. This consisted of 130 requests and 197
total transfusions.

Our main aims were,

1. To find out the percentage of appropriate blood transfusions vs. inappropriate blood transfusions in DBH
Dickoya.
2. To identify the percentage of blood transfusions occurring according to the “4 hour rule” in DBH
Dickoya.
3. To find out the percentage of blood transfusions occurring according to the “30 minute rule” in DBH
Dickoya.
Our main concern was to reduce unnecessary harm to the patient by avoiding unnecessary transfusions and
reducing unnecessary work load in the ward setup and save resources and reagents in the blood bank.

STANDARDS:

To carry out this clinical audit we have used standard guidelines for clinical use of blood by NBTS, Health
Ministry of Sri Lanka. In addition to that we used Guidelines for the clinical use of red cell transfusions in UK.
 I. Considering national guidelines which are currently being followed in the hospital and BSH guideline,
the below criteria have been made for assessing an appropriate usage of RCC in DBH Dickoya.
Transfusions which are not met according to the below criteria will be considered as inappropriate
transfusions. Expected target is 100%.

CRITERIA SOURCE AND STRENGTH OF EVIDENCE

1. Hemoglobin level < Section 4.0, Guideline for clinical transfusion practice, Guidelines for
8g/dl clinical use of blood by NBTS, Health Ministry, Sri Lanka, 1st edition
2006
British Society for Haematology, Guidelines for the clinical use of
red cell transfusions, British Society for Haematology, UK, First
edition 2002 [online] Available from: https://doi.org/10.1046/j.1365-
2141.2001.02701.xCitations: 242
2. Hemoglobin level > Section 4.0, Guideline for clinical transfusion practice, Guidelines for
8g/dl with signs of clinical use of blood by NBTS, Health Ministry, Sri Lanka, 1st edition
symptoms pallor, 2006
fatigue, tachycardia, British Society for Haematology, Guidelines for the clinical use of
SOB red cell transfusions, British Society for Haematology, UK, First
edition 2002 [online] Available from: https://doi.org/10.1046/j.1365-
2141.2001.02701.xCitations: 242
3. Hemoglobin level > Section 4.0, Guideline for clinical transfusion practice, Guidelines for
8g/dl with co clinical use of blood by NBTS, Health Ministry, Sri Lanka, 1st edition
morbidities such as 2006
cardiovascular British Society for Haematology, Guidelines for the clinical use of
disease, red cell transfusions, British Society for Haematology, UK, First
cerebrovascular edition 2002 [online] Available from: https://doi.org/10.1046/j.1365-
disease, angina, 2141.2001.02701.xCitations: 242
shock
4. Hemoglobin level > Section 4.0, Guideline for clinical transfusion practice, Guidelines for
8g/dl with imminent clinical use of blood by NBTS, Health Ministry, Sri Lanka, 1st edition
bleeding such as 2006
major surgery British Society for Haematology, Guidelines for the clinical use of
red cell transfusions, British Society for Haematology, UK, First
edition 2002 [online] Available from: https://doi.org/10.1046/j.1365-
2141.2001.02701.xCitations: 242
CRITERIA SOURCE AND STRENGTH OF EVIDENCE
1) Once a unit of blood has been issued from the Sub section 4.64, Section 4.0, Guideline for
blood bank, it needs to be completely transfused clinical transfusion practice, Guidelines for
within 4 hours. clinical use of blood by NBTS, Health Ministry,
Sri Lanka, 1st edition 2006
2) Once a unit of blood has been issued from the Sub section 4.50, Section 4.0, Guideline for
blood bank, transfusion should be started within clinical transfusion practice, Guidelines for
30 minutes. clinical use of blood by NBTS, Health Ministry,
Sri Lanka, 1st edition 2006
II. Considering national guidelines which are currently being followed in the hospital, the below criteria
have been made for assessing an appropriate usage of RCC in DBH Dickoya. Transfusions which are not
met according to the below criteria will be considered as inappropriate transfusions. Expected target is
100%.
METHODODLOGY:

Question
Where did the audit take place?
When did it begin?
How long did it last?
Who was involved?
What item was being audited?
How was the sample selected?
The size of the sample
Response
Blood bank – DBH Dickoya
2022.05.20
94 days
Blood bank doctor, NOIC, IT analyzer
DT forms and RCC transfusion requests received to the blood from
1/2/2022 to 31/3/2022.
Eligibility: DT forms and RCC transfusion requests received to
the blood bank from Surgical and Medical wards in DBH
Dickoya from 1/2/2022 to 31/3/2022 under routine and urgent
basis.
Exclusions:Any DT form received to the blood bank from
Gynecology & Obstetrics wards and Pediatrics wards in DBH
Dickoya from 1/2/2022 to 31/3/2022.
130 DT requests and 197 total transfusions.

Data collecting and analyzing tools 1. DT request forms.

2. Relevant bed head tickets of patients.
3. Data collecting customized table (Annex 1).
4. MS Excel for data analysis.
Method of data collection Retrospectively
What data was collected? BHT, Reason for request, Pre transfusion(Tx) Hb level, Pre Tx
clinical symptoms, Number of packs requested, Number of packs
Tx, Post Tx Hb level, Post Tx clinical symptoms, Blood pack
issued time, Tx start time, Tx over time
Objective MEDICINE SURGERY DBH Dickoya
Total transfusions in 166 31 197
February and March, 2022
Appropriate transfusions in 153 17 170
Feb and March, 2022
Inappropriate Tx in Feb and 13 14 27
March, 2022
Adhered to rule of 4 hours 160 30 190

Not adhered to rule of 4 6 1 7

hours
Adhered to rule of 30 151 30 181
minutes
Not adhered to rule of 30 15 1 16
minutes

RESULTS:
DISCUSSION:

In this audit we assessed a total number of 130 DT requests and 197 transfusions. Out of all these
transfusions, 166 were carried out in the medical ward and 31 in the surgical ward. At the end of the audit
we found that 92.2% were appropriate transfusions in the medical ward. We also found 54.8% appropriate
transfusions in the surgical ward. Inappropriate transfusion rates in the medical ward were 7.8% and 45.2%
in the surgical ward. According to the final results we found that there were 96.4% transfusions that adhered
to the 4 hour rule in the medical ward and 96.8% transfusions in the surgical ward. However, 3.6%
transfusions in the medical ward and 3.2% transfusions in the surgical ward have not adhered to the 4 hour
rule. In conclusion even though 91% transfusions in the medical ward and 96.8% transfusions in the surgical
ward have adhered to the 30 min rule. And 9% transfusions in the medical ward and 3.2% transfusions in the
surgical ward have not adhered to the 30 minute rule.

During the audit process we noticed few strengths and weaknesses. Strengths were: active participation of
the team during data collection and analysis. Weaknesses were: difficulties in finding relevant BHTs and
lack of information in BHTs. In many BHTs there were no details of post transfusion data such as the time
at which the blood transfusion was completed, post transfusion haemoglobin level etc. Some BHT's didn’t
have pre transfusion check list of patients’ details either.

CONCLUSION AND RECOMENDATIONS:

In conclusion the audit results show that a significant percentage of inappropriate transfusions (13.7%) have
occurred in medical and surgical wards in February and March in DBH Dickoya. Also, there has been a
significant percentage of malpractice in transfusions in medical and surgical wards in February and March
2022 in DBH Dickoya due to not adhering the 4 hour rule (3.6%) and not adhering the 30 minute rule
(8.1%).

These errors are preventable. So we recommend the following implementations to minimize these errors and
help to provide a better transfusion service in DBH Dickoya.

1. Conduct a lecture for all intern house officers and nurses in charge of medical and surgical wards in
DBH Dickoya to teach “the rule of 4 hours” & “the rule of 30 minutes” and its importance. In
addition make them aware about the importance of the documentation in BHTs such as pre and post
transfusion notes.

2. Give a copy of the guidelines of transfusion requirements to all medical and surgical wards.

3. Reintroduce the orientation lectures from the blood bank for all new inter house officers in future.

JUSTIFICATION FOR PRESENTATION:

Through this clinical audit we found that there were much unnecessary transfusion occurred in medical and
surgical wards. To prevent further occurrence in all hospitals, can implement a new guideline specifically
for blood transfusion criteria’s to prevent unnecessary burden and cost.

REFERENCES:

1. National Blood Transfuse Service. Guideline for clinical transfusion practice. Guidelines for
clinical use of blood. Ministry of Health, Sri Lanka: National Blood Transfuse Service; 2006. P.
36-42.
2. National Blood Transfuse Service. Guideline for blood transfusion in major surgery.
Guidelines for clinical use of blood. Ministry of Health, Sri Lanka: National Blood Transfuse
Service; 2006. P. 54-64.
3. British Society for Haematology. Guidelines for the clinical use of red cell transfusions.1st ed.
BCSH Secretary, British Society for Haematology, 2 Carlton House Terrace, London SW1Y
5AF, UK; 12 January 2002. Available from: https://doi.org/10.1046/j.1365-
2141.2001.02701.xCitations: 242
4. Tiwari AK, Ratan A, Arora D, Aggarwal G, Mehta SP, Setya D, Acharya DP. Audit of clinical
use of red blood cells in a tertiary care setting: An algorithmic approach!. Glob J Transfus Med
[serial online] 2017 [cited 2022 May 10];2:109-12. Available from:
https://www.gjtmonline.com/text.asp?2017/2/2/109/214282
5. Danish health authority. National clinical guidelines for the indication for transfusion using
blood components. Danish health authority, Denmark; 2018. [online] Available from:
https://www.sst.dk/da/udgivelser/2018/~/media/37469F25DE1B4430BB7B95C8B0DF63A4.ash
x
6. Clinical transfusion practice guidelines for medical interns Bangladesh. [online] Bangladesh:
Available from: https://www.scribd.com/document/323039874/Clinical-Transfusion-Practice-
Guidelines-for-Medical-Interns-Bangladesh
7. NICE guidelines: Blood transfusion. [PDF version] London: NICE guidelines; 2015.
Available from: https://www.nice.org.uk/guidance/ng24/resources/blood-transfusion-pdf-
1837331897029
8. Dr Derek Norfolk (ed.) Handbook of Transfusion Medicine. [PDF version] 5th ed. the United
Kingdom: The Stationery Office; 2013.
9. Patidar GK, Kaur D. Audit and education: Role in safe transfusion practice. Asian J Transfus
Sci 2018;12:141-5.
10. https://vbidhealth.com/wp-content/uploads/2021/04/Reducing-unnecessary-red-blood-cell -
transfusion-in-hospitalised-patients.pdf
11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6327772/
12. https://doi.org/10.1136/bmj.n830 (Published 06 April 2021) BMJ 2021;373:n830