Comparing transfusion practice at multiple hospitals using electronically collected and analysed data.

Hospitals prepare for emergencies, but the impact on transfusion staff is rarely discussed. We describe the transfusion response to four major incidents (MIs) during a 6-month period. Three events were due to terrorist attacks, and the fourth was the Grenfell Tower fire. The aim of this paper was to share the practical lessons identified. This was a retrospective review of four MIs in 2017 using patient administration systems, MI documentation and post-incident debriefs. Blood issue, usage and adverse events during the four activation periods were identified using the Laboratory Information Management System (TelePath). Thirty-four patients were admitted (18 P1, 4 P2, 11 P3 and 1 dead). Forty-five blood samples were received: 24 related to nine MI P1 patients. Four P1s received blood components, three with trauma and one with burns, and 35 components were issued. Total components used were six red blood cells (RBC), six fresh frozen plasma (FFP) and two cryoprecipitate pools. Early lessons identified included sample labelling errors (4/24). Errors resolved following the deployment of transfusion staff within the emergency department. Components were over-ordered, leading to time-expiry wastage of platelets. Careful staff management ensured continuity of transfusion services beyond the immediate response period. Debriefing sessions provided staff with support and enabled lessons to be shared. Transfusion teams were involved in repeated incidents. The demand for blood was minimal. Workload was related to sample handling rather than component issue. A shared situational awareness would improve stock management. A laboratory debriefing system offered valuable feedback for service improvement, staff training and support.

To compare the transfusion practices between two neonatal intensive care units (NICUs) to assess the impact of local practice styles on the timing, number, and total volume of packed red cell transfusions in very low birth weight infants. To derive multivariate models to describe practice and to identify potential areas for improvement in the future. We reviewed phlebotomy losses and transfusion rates between two NICUs (A and B) for 270 consecutive admissions of birth weight < 1500 g. We stratified for birth weight and for illness severity by the Score for Neonatal Acute Physiology (SNAP). Measures of short-term outcome were compared. We derived multivariate models to describe and compare the practices in the two NICUs. Patients in NICU A had smaller phlebotomy losses than those in NICU B. A lower percentage of the patients in NICU A (65% vs 87%) received transfusions, but they tended to receive a greater total volume per kg per patient (67 mL/kg vs 54.8 mL/kg). Transfusion timing differed between the NICUs; in NICU A only approximately one-half of their transfusions occurred in the first 2 weeks, whereas in NICU B almost 70% of the transfusions were given in this time period. Multivariate models showed that phlebotomy losses were significantly related to lower gestational age (GA) and higher SNAP. Hospitalization in NICU B resulted in 10.7 cc of additional losses relative to NICU A for a comparable GA and illness severity score. The volume of blood transfused per kilogram of body weight was a function of GA, SNAP, and hospital. Care practices in NICU A added an additional 19 cc of transfused volume in the first 14 days of life, and an additional 26 cc thereafter when adjusted for GA and SNAP. These differences in phlebotomy and transfusion were not associated with differences in the days of oxygen therapy or mechanical ventilation, the oxygen requirement at 28 days, the incidence of chronic lung disease, or the rate of growth by day 28. We identified significant differences in phlebotomy and transfusion practices between two NICUs. We found no differences in short-term outcome, suggesting that the additional use of blood in one of the NICUs was discretionary rather than necessary. Our multivariate models can be used to characterize and quantify transfusion and phlebotomy practices. By predicting which patients are likely to require multiple transfusions, clinicians can target patients for erythropoietin therapy and identify those patients for whom donor exposure can be reduced by a unit of blood for multiple use. The models may help in monitoring changes in practice as they occur.

Introduction and Background The development of a sustainable system that would provide information about the clinical use of blood was a requirement of the Better Blood Transfusion Programme (BBTP). The system was to be designed to identify variations in practice, encourage clinical review of blood used and contribute to the goal of reducing avoidable transfusions. The system would assist with achieving the target of reducing the population exposure to Red Blood Cells (RBCs) by 10%, this translates to the achievement of a target of 41 RBC units transfused per 1000 population.Study Design The sustainable system has been developed and named STED (Scottish Transfusion Epidemiology Database). Hospital Blood Bank records are regularly extracted from the majority of hospital blood banks in Scotland. The records are then linked to hospital inpatient and day case records (SMR1) records by probability matching based on patient details (name, address, postcode, date of birth). The linked datasets are available for analysis in an Oracle data warehouse and the Business Objects reporting suite enables NHSS wide access to the datasets.Results The initial development of STED has been to provide access to a surgical view of RBCs. Surgical blood use reports at a National, Divisional, Hospital and Consultant level has enabled clinical review of blood use across Scotland. The project is in its early stages and evaluation must take account of other initiatives for better transfusion as well as environmental factors over recent years. The programme and results, mainly related to surgical interventions has so far been presented to 21 groups of practitioners (totalling 380 individuals), in 15 hospitals. For most this was the opportunity to view local practice data in the context of other centres in the NHSS. 49 groups of operations likely to be transfused have been identified based on OPCS groups and from 2002/03 to 2004/05 the probability of transfusion for patients in these groups has reduced from 14.3% to 11.2% and the average RBC per operation has reduced from 0.6 to 0.4 during the same time period. New actions and projects can be directly attributable to STED development including a project to explore relationships between transfusion and mortality data in cardiac surgery patients. The reports are supporting business case development for support of cell salvage in Cardiac Surgery and to evaluate the effectiveness of salvage in revision hip surgery. The reports are also being used as a resource for Transfusion Practitioners of the BBTP to support local audit work.Conclusion The results reflect the combined effect of BBTP interventions and other influences. Further data will be presented on changes in blood use for surgical and nonsurgical patient groups, in addition to current developments in the programme.

Blood transfusion has been associated with poor outcomes in many disciplines, yet transfusion practices and related outcomes in esophagectomy are unknown. We analyzed the Society of Thoracic Surgeons General Thoracic Database to determine patient factors associated with transfusion after esophagectomy, risk-adjusted variation in transfusion practice among institutions, and the association of transfusion practice with mortality. We performed a retrospective review of patients undergoing esophagectomy for cancer from October 2008 to December 31, 2014. Patient comorbidities and procedure variables were used to construct a risk model for transfusion. Using this model, each institution was assigned an observed to expected (O:E) transfusion rate. We examined institutional factors associated with variation in O:E transfusion rate. Finally, O:E transfusion rate was compared to risk-adjusted mortality to determine if there was an association of transfusion practice and survival. Seven thousand one hundred thirty-seven patients underwent esophagectomy at 182 institutions during the study period. The median unadjusted transfusion rate was 23.1%. The risk model for transfusion demonstrated patients who received transfusions were more likely to be older, female, and have low preoperative hemoglobin and other comorbidities, such as CAD, COPD, and low creatinine clearance. Patients who received a minimally invasive procedure were less likely to have received a transfusion.After adjusting for the characteristics above, 13 centers (7.1%) were classified as having lower than average O:E transfusion rate and 16 centers (8.7%) were classified as higher than average O:E transfusion rate.Institutions with lower than expected transfusion rates also had lower risk-adjusted perioperative mortality than institutions with higher than expected transfusion rates (median [IQR] = 0.90 [0.77-0.94] vs. 0.99 [0.94-1.06], P = 0.028). Age, female sex, CAD, COPD, renal insufficiency, and open technique are associated with transfusion after esophagectomy, while tumor stage and preoperative chemoradiation are not. There is wide variation in transfusion practice. Centers with lower than expected transfusion rate also had lower than expected perioperative mortality. At an institutional level, lower transfusion rates are associated with improved outcomes.

Objective: To examine changes in the rate of seeing patients between 1990 and 2004 and to see whether performance might be related to patient age, using data held on the...

From March 2020 through August 2021, 97,762 hospital-onset SARS-CoV-2 infections were detected in English hospitals. Resulting excess length of stay (LoS) created a potentially substantial health and economic burden for patients and the NHS, but we are currently unaware of any published studies estimating this excess. We implemented appropriate causal inference methods to determine the extent to which observed additional hospital stay is attributable to the infection rather than the characteristics of the patients. Hospital admissions records were linked to SARS-CoV-2 test data to establish the study population (7.5 million) of all non-COVID-19 admissions to English hospitals from 1st March 2020 to 31st August 2021 with a stay of at least two days. The excess LoS due to hospital-onset SARS-CoV-2 infection was estimated as the difference between the mean LoS observed and in the counterfactual where infections do not occur. We used inverse probability weighted Kaplan-Meier curves to estimate the mean survival time if all hospital-onset SARS-CoV-2 infections were to be prevented, the weights being based on the daily probability of acquiring an infection. The analysis was carried out for four time periods, reflecting phases of the pandemic differing with respect to overall case numbers, testing policies, vaccine rollout and prevalence of variants. The observed mean LoS of hospital-onset cases was higher than for non-COVID-19 hospital patients by 16, 20, 13 and 19days over the four phases, respectively. However, when the causal inference approach was used to appropriately adjust for time to infection and confounding, the estimated mean excess LoS caused by hospital-onset SARS-CoV-2 was: 2.0 [95% confidence interval 1.8-2.2] days (Mar-Jun 2020), 1.4 [1.2-1.6] days (Sep-Dec 2020); 0.9 [0.7-1.1] days (Jan-Apr 2021); 1.5 [1.1-1.9] days (May-Aug 2021). Hospital-onset SARS-CoV-2 is associated with a small but notable excess LoS, equivalent to 130,000 bed days. The comparatively high LoS observed for hospital-onset COVID-19 patients is mostly explained by the timing of their infections relative to admission. Failing to account for confounding and time to infection leads to overestimates of additional length of stay and therefore overestimates costs of infections, leading to inaccurate evaluations of control strategies.

Retrospective descriptive study in two geriatric short stay units, including patients aged 80 years-old or over, transfused in 2012 and 2015. 103 patients were included. More than 30% patients had a chronic heart failure, and there was no significant difference on general characteristics between the groups in the two years. Compared to 2012, the transfused population in 2015 was more fragile with a higher Charlson comorbidity index (p=0.005). The main symptoms of anemia bad tolerance were cardiovascular symptoms. The average pre-transfusion hemoglobin concentration was 7.9 g/dL in 2015, 8 g/dL in 2012 (p=0.63). By 2015, 72.3% transfusions respected the hemoglobin thresholds recommended in guidelines, compared to 50% in 2012 (p=0.023). Transfusion thresholds in our study were lower than those recommended; 13 adverse reactions were identified, 12 of them were heart failure. There was no significant difference in transfusion benefit between the two years. This study helped describe profile of elderly transfused patients, their geriatric characteristics and the transfusion data, without showing any changes in transfusion practices following the guidelines, despite a more fragile population in 2015. It seems difficult, because of the diversity in the geriatric population, to have a single threshold of hemoglobin recommended, only non-specific symptoms of intolerance and to consider only the cardiovascular comorbidities to decide whether or not to provide a transfusion.

‘Blind’ transfusion of blood products in exsanguinating trauma patients

The Rh blood group is highly polymorphic, and individuals with RHD variant alleles can form antibodies against antigens found in the conventional RhD protein. To prevent transfusion of D+ blood to groups at risk of forming anti-D antibodies, such as women of childbearing age and newborns, our transfusion service has established protocols to accurately identify D variants that can be missed by automated testing platforms in these important patient populations. We implemented a blood bank protocol at Yale New Haven Hospital to identify patients to perform RHD genotyping on and evaluated the effectiveness of the protocol to detect D variants in patients undergoing ABO/D typing from December 2020 to January 2024. We compared serological reactivities between automated platforms (Grifols gel column and Werfen solid phase) and traditional tube testing on patients with confirmed RHD genotyping. Among 74 patients genotyped, 53 exhibited D variants, yielding a positive predictive value (PPV) of 71.6%. A total of 29 patients had variant D types associated with anti-D formation. Tube testing showed significantly lower reactivity compared to the gel platform (p = .0001). Solid-phase testing did not demonstrate significant differences from tube testing (p = .15). Our findings reveal a critical "blind spot" in automated gel platforms, which may lead to misclassification of D variants. Our established protocol effectively identifies high-risk patients who need RHD genotyping by using routine tube testing. This approach aims to minimize missed cases of clinically significant D variants, ultimately improving patient safety in transfusion practices.

Efficacy of preoperative autologous blood donation: analysis of blood loss and transfusion practice in total hip replacement

Patient blood volume impacts most facets of perfusion care, including volume management, transfusion practices, and pharmacologic interventions Unfortunately, there is a wide variability in individual blood volumes, and experimental measurement is not practical in the clinical environment. The purpose of this study was to evaluate a mathematical algorithm for estimating individual blood volume. After institutional review board approval, volumetric and transfusion data were prospectively collected for 165 patients and applied to a series of calculations. The resultant blood volume estimate (BVE) was used to predict the first and last bypass hematocrit. The estimated hematocrits using both BVE and 65 mL/kg were compared with measured hematocrits using the Pearson moment correlation coefficient and the Bland Altman measures of accuracy and precision. There was a wide range of BVE (minimum, 35 mL/kg; mean ± SD, 64 ± 22 mL/kg; maximum, 129 mL/kg). Using BVE, the estimated hematocrit was similar to the measured first (24.7 ± 6.4% vs. 24.5 ± 6.2%, r = 0.9884, p &gt; .05) and last (24.5 ± 5.9% vs. 25.1 ± 5.7%, r = 0.9001, p &gt; .05) bypass hematocrit. Using 65 mL/kg resulted in a larger difference between estimated and measured hematocrits for the first (25.6 ± 4.5% vs. 24.5 ± 6.2%, r = 0.6885, p = .030) and last (23.8 ± 3.6% vs. 25.1 ± 5.7%, r = 0.5990, p = .001) bypass hematocrits. Compared with using 65 mL/kg for blood volume, the BVE allowed for a more precise estimated hematocrit during CPB.

North American Cooperative Group Members' Patterns of Blood Products Transfusion for Patients with Acute Leukemia

Comparative effectiveness research (CER) is the study of existing treatments or ways to deliver health care to determine what intervention works best under specific circumstances. CER evaluates evidence from existing studies or generates new evidence, in different populations and under specific conditions in which the treatments are actually used. CER does not embrace one research design over another but compares treatments and variations in practice using methods that are most likely to yield widely generalizable results that are directly relevant to clinical practice. Treatments used in transfusion medicine (TM) are among the most widely used in clinical practice, but are among the least well studied. High-quality evidence is lacking for most transfusion practices, with research efforts hampered by regulatory restrictions and ethical barriers. To begin addressing these issues, the National Heart, Lung, and Blood Institute convened a workshop in June 2011 to address the potential role of CER in the generation of high-quality evidence for TM decision making. Workshop goals were to: 1) evaluate the current landscape of clinical research, 2) review the potential application of CER methods to clinical research, 3) assess potential barriers to the use of CER methodology, 4) determine whether pilot or vanguard studies can be used to facilitate planning of future CER research, and 5) consider the need for and delivery of training in CER methods for researchers.

Blood transfusion is one of the commonest clinical interventions, but there are considerable data to indicate that much of current transfusion practice is sub-optimal, and varies widely between different hospitals and clinical teams1. Explanations for this variation in practice include that clinicians may not be aware of relevant clinical guidelines or may be reluctant to follow them. Reluctance to implement them may be at least partly due to perceived weaknesses in the evidence base for their recommendations. There are a number of areas of transfusion practice where there are few or no published randomised controlled trials (RCTs) e.g. blood donor screening and selection, and paediatric transfusion. Even for those areas of transfusion medicine in which clinical trials have been carried out, formal assessment has often indicated that the quality of their methodology is poor. A review in the ISBT Science Series in 2008 described the strengths and weaknesses of the evidence base in transfusion medicine and how to develop it2. This review provides an update on those issues.

Background/IntroductionHeart Failure is frequently associated with several comorbidities such as ischaemic heard disease, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease and frailty. This level of complexity is best...