Operative blood transfusion quality improvement audit.

CONTEXT: To determine how current anesthesia team handless the identification of surgical anaesthetized patient (right patient). And the check of blood unit before collecting and immediately before blood administration (right blood) in operating rooms where nurses have minimal duties and responsibility to handle blood for transfusion in anaesthetized patients. AIMS: To elicit the degree of anesthesia staff compliance with new policies and procedures for anaesthetized surgical patient the blood transfusion administration.
SETTING: A large tertiary care reference and teaching hospital.
DESIGN: A prospective quality improvement. Elaboration on steps for administration of transfusion from policies and procedures to anaesthetized patients; and analysis of the audit forms for conducted transfusions. SUBJECTS AND METHODS: An audit form was used to get key performance indicators (KPIs) observed in all procedures involve blood transfusion and was ticked as item was met, partially met, not met or not applicable. STATISTICAL ANALYSIS USED: Descriptive statistics as number and percentage Microsoft excel 2003. Central quality improvement committee presented the results in number percentage and graphs.
RESULTS: The degree of compliance in performing the phases of blood transfusion by anesthesia staff reached high percentage which let us feel certain that the quality is assured that the internal policy and procedures (IPP) are followed in the great majority of all types of red cells and other blood products transfusion from the start of requesting the blood or blood product to the prescript of checking the patient in the immediate post-transfusion period.
CONCLUSIONS: Specific problem area of giving blood transfusion to anaesthetized patient was checking KPI concerning the phases of blood transfusion was audited and assured the investigators of high quality performance in procedures of transfusion.

INTRODUCTION

The blood transfusion is managed, in hospital setting, by nursing staff. This team works according to set policies and procedures.[12] On the other hand, in certain hospital places like operating surgical rooms; blood administration is done by anesthesiologists and their associate anesthesia technicians who may or may not mastering these policies and procedures. An internal policies and procedures were introduced in author's anesthesia department to govern the requirements of blood transfusion

These are the key performance indicators (KPIs) to be monitored.

REQUIREMENTS

Pre-requesting for blood

Consent for blood transfusion obtained and signed by a witness

Arterial blood gas (ABG) analysis has been done

Blood is available and ready in blood bank

The required units of red blood cells ara requested

The requested blood product is requested

Patient vital signs are monitored and documented.

Requesting procedure

Blood products collection form is filled with all required information

Blood bank was informed

The blood is delivered iced in blood bank box.

Checking procedure

All blood units in the theatre has been checked

The blood is checked by the anesthesiologist with the nurse or technician

The blood transfusion form is filled by the anesthesiologist

Patient vital signs are monitored and recorded

All transfused units are documented in patient in the anesthesia operative form.

Post transfusion

Patient's vital signs are documented

If transfusion reaction occurred the correct procedure has been applied

ABG was performed

If additional units of blood needed the same correct procedure was followed

If the blood units are no more needed for the patient then the correct procedure has been applied.

There are many reports discussing audit of blood transfusion in relation to complications and appropriate indications triggered the transfusion.[23456] According to our knowledge, no audit was found discussing handling anesthesia staff administering blood transfusion to anaesthetized patient, which would call for more attention to verification of the right patient and right blood before administration[34] and extra care to prevent complications like transfusion reaction or giving wrong blood to anaesthetized patient. This paper report the result of a quality assurance audit used KPIs stemmed from IPP governing steps to follow for administration of blood during operation by privileged certified anesthesia technicians and anesthesia medical staff [Figure 1].

Figure 1

The result of audit report tables in number. Percentages and graphs

SUBJECTS AND METHODS

The practice of blood transfusion was monitored by an audit form since October 2011, which was distributed to all operating rooms. These forms are filled by qualified anesthesia technicians and counter signed by Anesthesiologists for patients undergoing surgery who needed blood or blood products. Completed forms were collected by quality team, the quarterly results, evaluated and reported. Over the period of a year, data was collected and classified into 5 steps checking procedure as follows:

Pre-requesting for blood-set criteria

Requesting for blood criteria

Blood products checking procedures

Post-transfusion procedure.

Met Partially met Not met Not applicable

Met = 2 Partially met = 1 Not met = 0

Data collected and presented in a tabular form for each step of checking and results were in percentages.

RESULTS

The number of procedures of blood transfusion performed by anesthesia was summarized by tables in numbers and percentages. Degree of compliance to proper required action is presented as graph [Figures 1 and 2].

Figure 2

Blood audit

DISCUSSION

Blood transfusion is considered in surgical sense a form of therapy. It aimed to enhance oxygen carriage during surgery, it also help to reduce morbidity and save patient's lives.

It is sort of tissue transplant from donated by one person or pool of persons to recipient. Also it has certain shortcomings like transmission of diseases and major allergic reactions. Medical and paramedical management must be practiced. That will, hopefully, eliminate the associated dangers.[3] Anesthesiologists and anesthesia technicians as they manage blood transfusion in surgical operating rooms should be like the nurses administering blood transfusion in other area of the hospital, must have the skills and knowledge required to care for patients receiving blood components. As it is important for nurses to understand the correct and safe way to approach transfusion practice so anesthesiologists and anesthesia technicians. Blood transfusion procedures are constant and central component of modern health care. The current concern that the number of people eligible to donate blood is reducing and this blood component is precious as it comes from willing donation given in good faith: It is given voluntarily and expected to be used effectively to help needy patients. Therefore at every stage of the transfusion process the administrator of transfusion be the blood bank staff, anesthesia team and nurses are responsible in their part they play into ensure that the correct patient receives the correct blood and also that blood components are used and handled with care. This report monitored the key principles and practicalities to be observed in blood transfusion to anaesthetized surgical patient who were in need according to acceptable practice. Areas covered include legal obligations like checking identity with witness, documentation and signatures, appropriate handling of blood components; offering checking blood group, expiry date of the blood components available and provided by blood bank in proper containers and storing boxes, the different elements of the transfusion process, recognition and management of transfusion reactions and education.

The literature is wealthy with studies, guidelines and initiatives for safe blood transfusion safe practice.[3456] A key theme running throughout is that despite an array of initiatives designed to support the delivery of safe and appropriate transfusion practice, incidences of patients receiving the wrong blood continue to be reported. Nurses play a key role in delivering safe and appropriate transfusion care and have a responsibility to support national initiatives, such as Europian health services, had certain initiatives and guidelines Better Blood Transfusion programmed action and the National Patient Safety Agency Safer Practice Notice,[4] Right Patient, Right Blood initiatives workers tested factors leading to best transfusion practice. They concluded that the application of certain organizational support, insuring leadership and improving staff education, competency and assessment.[345] Also they stressed on the importance of the role of conducting regular periodic audits and feedback reports, this can be handled. By systematic assessment of transfusion procedures, the implementation of education and guidelines and the use of innovative approaches, such as care bundles, we can ensure that nurses have the appropriate knowledge, skills and understanding to provide the highest standards of transfusion care to surgical and medical patients.[34] The importance of auditing is to assure firmly that the blood transfusion is conducted according to the highest standards of patient safety.[456] The results measuring the compliance of doing the procedure in the operating rooms where the patient is not awake to alert attendance about any improper sensation and transfusion is managed for except by anesthesiologists and anesthesia technicians. The compliances were as near as possible were very encouraging and promising to continue the filling of audit forms to achieve 100% compliance and zero error in safe administering blood and blood products. The completion of the audit form has become mandatory in our practice, as the missed out manual errors are monitored through cross-checking and review on the check-list audit form.