European Journal of Cardiovascular Medicine

Blood transfusion is a critical procedure in medical practice, offering a lifesaving resource for patients in need. However, the process is not without its risks, including the potential for transfusion-transmissible infections such as HIV, hepatitis viruses, and malaria, as well as acute or delayed complications.^(1,2) The scarcity of blood and the risks associated with transfusion necessitate a judicious approach to its use, ensuring that every unit of blood is utilized in a manner that maximizes patient benefit while minimizing risk.

Guidelines for the appropriate use of blood and blood products have been developed to aid clinicians and transfusion specialists in making informed decisions about transfusion practices. These guidelines emphasize the importance of transfusing blood only when necessary to save a life and based on a comprehensive assessment of the patient's clinical status rather than solely on laboratory values.⁽³⁾ Despite the widespread dissemination of clinical guidelines, research suggests that a significant proportion of transfusions may not adhere to these recommendations, highlighting a gap between guideline development and clinical practice⁽⁴⁾

Inappropriate use of blood not only puts patients at risk but also exacerbates the gap between blood supply and demand, making it imperative to audit and review transfusion practices regularly. The establishment of hospital transfusion committees and the implementation of patient blood management programs are among the strategies recommended to improve the appropriateness of blood use.⁽⁵⁾

The present study aims to evaluate the implementation of guidelines regarding the judicious use of blood transfusion in a teaching hospital, focusing on the rationale behind transfusion decisions and the adherence to established guidelines. By auditing transfusion practices, this study seeks to identify areas for improvement in the management of blood transfusion services and enhance the quality of care provided to patients.

This study was conducted at the Blood Bank attached to a Teaching Hospital & Medical College, which did not possess a blood component separation facility but had a component storage center of a private blood bank for procurement. A descriptive (observational) retrospective study spanning one year (January 1 to December 31, 2010) was carried out, analyzing the transfusion of 755 whole blood units within the hospital.

Study Design: The study adopted a descriptive, observational approach, focusing on the retrospective analysis of whole blood transfusions administered in 2010.

Eligibility Criteria: The study included all ages and genders, with specific inclusion and exclusion criteria as follows:

• Inclusion Criteria: All whole blood units transfused to patients admitted to the Teaching Hospital, covering patients receiving single as well as multiple units.
• Exclusion Criteria: Blood units requested but not issued and units issued for patients admitted outside the Teaching Hospital were excluded from the study.

Data Collection:

Data were collected on the distribution of blood to various departments within the hospital, employing the following methods:

1. Review of Blood Requisition Forms: These forms, filled out by clinicians, were reviewed for completeness and rationale for transfusion, including indication for transfusion, pre-transfusion investigation values, patient demographic information (name, age, sex), the department of admission, and the number of units ordered.
2. Review of Patient Files & Records: When the study of the requisition form could not determine the appropriateness of the whole blood transfusion, patient files and records were further reviewed for missing data and additional information regarding the transfusion's appropriateness.
3. Single Unit Transfusions: The study critically evaluated the use of single unit transfusions, especially in adults, as discouraged by WHO guidelines, to assess their appropriateness.

Assessment of Appropriateness: The appropriateness of whole blood transfusions was categorized into three groups - appropriate (unavoidable), inappropriate (avoidable), and indeterminate (where appropriateness could not be determined based on available records). Criteria for appropriateness were established based on acute blood loss leading to hypovolemia, exchange transfusion in infants, and clinical signs indicating a loss of over 25% of blood volume.

Audit: An audit of blood transfusion practices was conducted to evaluate the rationale and appropriateness of blood transfusion within the hospital setting. This included a methodical review of practices and policies to ensure safe and appropriate transfusion.

The methodology employed in this study provided a comprehensive assessment of blood transfusion practices within the hospital, aiming to identify adherence to guidelines and areas for improvement in patient blood management.

The study analyzed the transfusion of 755 units of whole blood given to 421 patients within the teaching hospital in the year 2010, focusing on the distribution and appropriateness of blood use across various departments.

1. Blood Component Distribution in 2010

The total blood usage in the hospital for the year 2010 was categorized into Whole Blood (WB), Packed Red Blood Cells (PRBCs), Fresh Frozen Plasma (FFP), and Platelets, with the following distribution:

• Whole Blood: 16%
• PRBCs: 37%
• FFP: 26%
• Platelets: 21%

1. Whole Blood Distribution by Departments

The distribution and cross-match to transfusion (C/T) ratio of Whole Blood across various departments were as follows:

Table 1

The highest usage of Whole Blood was in the Surgery department, whereas the Pediatrics department showed the lowest usage and the most appropriate C/T ratio.

1. Appropriateness of Transfusion

The appropriateness of transfusion based on the review of blood requisition forms and patient files & records was classified into appropriate, inappropriate, and indeterminate categories:

Table 2

The Pediatrics department showed the highest percentage of appropriateness in Whole Blood use, while the Medicine department had the lowest.

1. Evaluation of Inappropriate Transfusions

Inappropriate transfusions were evaluated in detail for each department, identifying major reasons such as single unit transfusions in adults and transfusions for anemia without justifiable causes.

The overall results indicate that while a significant portion of blood transfusions were appropriate, nearly half were found to be inappropriate, highlighting the need for improved adherence to transfusion guidelines and practices.

These findings emphasize the critical need for ongoing education, auditing, and the implementation of strict transfusion protocols to ensure the judicious use of blood transfusions in hospital settings.

The findings of this study underscore the complexities and challenges inherent in blood transfusion practices within a teaching hospital environment. While the overall goal of transfusion medicine is to ensure patient safety and optimal use of blood resources, this audit reveals a considerable degree of non-adherence to established guidelines, with nearly half of the transfusions deemed inappropriate.

The significant rate of inappropriate transfusions, particularly in departments like Medicine and Surgery, aligns with previous research indicating a gap between transfusion guidelines and actual practice. ^(6,7) The reasons for this gap are multifaceted, involving factors such as clinician awareness and understanding of guidelines, the urgency of clinical situations, and perhaps over-reliance on transfusion as a default intervention in cases of uncertainty.

The highest appropriateness of blood use in the Pediatrics department may reflect more stringent adherence to guidelines, potentially due to the higher perceived risks of transfusion in this vulnerable population. This is consistent with literature suggesting that pediatric transfusion practices often undergo more rigorous scrutiny and conservative management strategies compared to adult practices. ⁽⁸⁾

Single unit transfusions, particularly in adults, were identified as a significant contributor to the inappropriate use category. This finding is particularly concerning given the World Health Organization's recommendations against such practices due to the risks of immunomodulation and the inefficient use of scarce blood resources. ⁽⁹⁾ The study's results support the need for enhanced education and monitoring to reduce single unit transfusions, echoing the conclusions of other studies emphasizing the importance of adherence to evidence-based transfusion thresholds. ⁽¹⁰⁾

Moreover, the absence of informed consent procedures for transfusions points to a broader issue of patient rights and the need for transparency in clinical decision-making. The adoption of informed consent protocols, as recommended by best practice guidelines, not only respects patient autonomy but also provides an opportunity for clinicians to reassess the necessity of the transfusion. ⁽¹¹⁾

The study's findings also highlight the critical role of hospital transfusion committees in overseeing transfusion practices, developing local guidelines, and conducting regular audits. Such committees can serve as a bridge between national guidelines and local practice, tailoring recommendations to the specific context of the hospital and its patient population. ⁽¹²⁾

In conclusion, this audit reveals significant opportunities for improving blood transfusion practices within the studied hospital. It underscores the need for ongoing education, adherence to evidence-based guidelines, and the establishment of robust systems for audit and feedback. By addressing these areas, hospitals can enhance patient safety, optimize the use of blood resources, and ensure that transfusions are reserved for situations where they are truly warranted.

1. The Clinical Use of Blood Handbook. Geneva: World Health Organization; 2002.
2. Isbister JP. The three-pillar matrix of patient blood management--an overview. Best Pract Res Clin Anaesthesiol. 2013 Mar;27(1):69-84.
3. Guidelines for the appropriate use of blood and blood products. NACO guidelines. Available from: http://naco.gov.in/sites/default/files/Guidelines%20For%20Appropriate%20Use%20Of%20Blood%20%26%20Blood%20Products.pdf
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