INAPPROPRIATE BLOOD REQUESTS:

Transcription

1 INAPPROPRIATE BLOOD REQUESTS: A LABORATORY AUDIT Donna Knight Associate Practitioner Transfusion Department

2 INTRODUCTION Concern over red cell availability Challenges over financial restraints Various studies: - increased mortality & morbidity Chronic anaemia Transfusion practice changing to try reduce blood usage

3 WHAT WE DO Laboratory based approach Pro active Team effort - Laboratory & Clinical - All grades Inappropriate transfusions - deficiency related anaemias - TACO

4 REQUESTS A component request is just that. a request! Each one is assessed by laboratory staff Either honoured or referred

5 LABORATORY TOOLS Staff empowerment - all grades, especially MLA s Algorithm for inappropriate requests Referral forms Telephone request sheet Support from clinical staff

6 REFERRAL PROCESS MLA / Associate Practitioner AP / BMS Transfusion Practitioner On-Call Haematology SPR / Consultant

7 Algorithm for inappropriate requests for blood components Yes Is the patient actively bleeding? Complete request form Is there a valid sample? No Re-bleed Yes No Is the patient actively bleeding? Honour request Is the transfusion appropriate according to Trust Transfusion Policy/BSCH guidelines? Yes No No Yes In an emergency use flying squad units Honour request Is the cause of anaemia known? Yes No Supply group compatible blood/fully cross-matched as soon as possible Suggest alternative e.g. iron or refer to Cons. Haem. / TP Suggest investigations or refer to Cons. Haem. / TP

8 NAME: PATIENTS DETAILS K / S No: D. O. B: SAMPLE No: LOCATION: BLOOD GROUP: CONS: IRR / CMV- / ABS: REQUESTED BLOOD COMPONENT DETAILS Number of units requested Required Results Reason RED CELL Hb R Pt weight If <60 Kg and not bleeding give 1 unit Kg then re-assess Hb & symptoms PLATELET PC P CRYO Fibrinogen C FFP INR F Pt weight Kg APTT Date & Time required: (OK to come on round if needed?) MASSIVE BLOOD LOSS Team Leader: Extension: Notification: Primary: Secondary: Clinical Information: Group compatible required before sample fully completed Minutes left for sample to run: TELEPHONE CALL DETAILS Requesting Dr: Bleep / Tel No: Lab staff: Date & Time call taken:

9 FURTHER INFORMATION Checked on LIMS by lab staff Hb & MCV (compared with historical FBC) Then Haematinics, retics, ferritin Symptoms Relevant clinical details (Ca? CVD? Pre-op? on rx?)

10 PATIENT INFORMATION Patient Name: Hospital Number: Date of Birth: Ward: REQUEST INFORMATION Date & Time: Name: Grade: Bleep: Requested: RC Platelets FFP Cryoprecipitate Details: e.g post / pre op, elective / emergency, known cancer, symptoms, CHD Relevant blood results: e.g Hb, MCV, Fe, PC, INR, Fib Weight: REFERRAL INFORMATION Referred By: Grade Date & Time requestor spoken to: Reason for referral: e.g. known / suspected deficiency Referred To: Grade: Date & Time: OUTCOME Additional testing requested: Suggested treatment: Other comments: Refused / Accepted / Part Date & time closed:

11 INITIAL FINDINGS Some reluctance - BMS (rotating staff of a certain age ) Some offence taken - Requesting clinicians (all grades) Reputation as transfusion terriers

12 EMPOWERMENT Improved staff knowledge = greater confidence Laboratory staff aware of shared responsibility Limits are known - Transfusions never refused by laboratory staff - Still a clinical decision Ensures best possible service is offered

13 PROCESS REVIEW Retrospective ~1000 individual patients transfused p/a (some regular customers) ~ 530 units a month 2011 / 2012 Recorded referrals = / 2013 Recorded referrals = 33

14 REFERRAL OUTCOME 36% 33% 31% Refused n=21 Accepted n=20 Part n=23

15 ADDITIONAL TESTING 33% 67% No additional testing n=43 Additional testing n=21

16 ALTERNATIVES TO BLOOD 31% 69% Suggested alternative rx n=44 No suggestions n=20

17 RIPPLE EFFECT Eagerness is contagious Clinicians now phone for advice Medical & Surgical directorates both engaged & developing own policies Some wards better than others Still room for improvement

18 THE FUTURE How many are we missing? Formal follow up? Did they actually put them on iron? Confirmed long term improvement? Adverse outcomes in rejected requests? Improving lab paperwork Structured lab staff training

19 CONCLUSION Pro active approach required Can have positive effect throughout hospital Needs haematology clinician support Changing attitude amongst clinicians Beneficial to junior clinical staff

20 TRANSFUSED PATIENTS ? Jan to Jun 2012 Jan to Jun 2013 Jul to Dec 2012 Jul to Dec 2013

21 Thank you