National Comparative Audit of Overnight Red Blood Cell Transfusion Prepared by Tanya Hawkins Clinical Audit Lead & John Grant-Casey Project Manager This slideshow presents the main findings from the audit and gives comparable data for hospitals in the South West RTC. If you wish, you could augment these slides with local information which will be found in your hospital’s audit report. Please note that some caution should be applied when interpreting some of the bar charts used in these slides. To make comparison easier, numbers are expressed as a percentage of the whole. For some hospitals the actual numbers represented by the graphs are quite small, so care must be taken that the charts are not over interpreted. For all hospitals included in this slideshow, actual numbers of cases were included, together with the % shown on these slides, in the hospital’s report. Presenters using this slideshow should advise their audience that this show is best viewed in conjunction with hospital reports. . South West RTC March 2008

The National Comparative Audit Programme Background information A series of audits designed to look at the use and administration of blood and blood components Open to all NHS Trusts and Independent hospitals in the UK Collaborative programme between NHS Blood and Transplant & Royal College of Physicians Endorsed by the Healthcare Commission This slide describes the National Comparative Audit programme

Overnight red cell transfusion Why was this audit necessary? The Serious Hazards of Transfusion (SHOT) report has highlighted the increased risk of overnight transfusion and found that 37% of errors in which the time was reported took place between 20:00 and 08:00. A major learning point from the SHOT report is that transfusions should not take place out of core hours unless clinically indicated (SHOT report 2005). There is likely to be an increased risk of a transfusion complication not being detected when a patient is transfused overnight because there may be fewer nurses to monitor the patient and there is likely to be fewer medical and laboratory staff available to respond to the complication. Monitoring the patient at night may be more difficult than in the day time because of reduced lighting. The Serious Hazards of Transfusion (SHOT) report has highlighted the increased risk of overnight transfusion and found that 37% of errors in which the time was reported took place between 20:00 and 08:00. In its 2005 report, SHOT recommended avoiding blood transfusion out of core hours (SHOT 2005, recommendation 4). The audit Project Group suggests that there is an increased risk of a transfusion complication not being detected when a patient is transfused overnight because there may be fewer nurses to monitor the patient and there is likely to be fewer medical and laboratory staff available to respond to the complication. Monitoring the patient at night may be more difficult than in the day time because of reduced lighting.

Overnight red cell transfusion What were the aims of this audit? Establish the percentage of red cell units administered between the hours of 20:00 and 08:00 hours nationally. Look in detail at 14 overnight red cell transfusions to see if they were appropriate according to pre-defined criteria. Produce a follow-up audit which hospitals can use to identify reasons why transfusions are given inappropriately out of hours. Achieve a reduction in the number of red cells transfusions which are performed between the hours of 20:00 and 08:00 unless they are clinically or pragmatically indicated. Use the data from the report to compare the quality of patient monitoring in patients transfused overnight during the 2008 re-audit of bedside transfusion practice.

30 Independent hospitals Who took part Overnight red cell transfusion Participation We invited 199 NHS hospitals 30 Independent hospitals Who took part 190 (93%) NHS hospitals sent information 14 (47%) Independent hospitals sent information Number of patients audited Nationally = 2138 South West RTC = 196 199 NHS and 30 independent hospitals were invited to take part in the audit. 190 (93%) of NHS hospitals contributed data as did 14 (47%) independent hospitals. In total, 2138 patients were audited, with hospitals in the South West RTC contributing 196 cases.

Overnight red cell transfusion Methodology Hospitals were asked to identify all units of blood collected for transfusion in the period starting 07:31 Monday 24th September 2007 to 07:30 Monday 1st October 2007. They were asked to audit 14 patients who had been transfused in the overnight period (20:00 to 08:00). Hospitals selected their own cases, based on a quota suggested by the Project Group. The audit was in two parts. For the purposes of this audit, overnight transfusion is defined as those transfusions taking place between 20:00 and 08:00 the following day. The time a unit of blood was collected for transfusion was used as a proxy for transfusion start time, as this information is easier for hospitals to collect. To enable delivery and checking processes to occur, units were included in the audit if they were collected between the hours of 19:30 and 07:30 the following day. Some hospitals provided transfusion start time in lieu of the collection time. In the first part hospitals were asked to identify all units of red cells collected for transfusion in the period starting 07:31 Monday 24th September 2007 to 07:30 Monday 1st October 2007. In the second part hospitals were asked to audit 14 patients who had been transfused overnight. Hospitals selected their own cases for this audit based on a quota suggested by the project team to reflect the specialities involved.

Number of cases audited Overnight red cell transfusion Number of cases audited Hospital n cases audited A 21 B 16 D 18 E 12 F 14 G 15 H J 2 K 11 L M 8 N P Q 19

Overnight red cell transfusion Standards used Patients are not transfused overnight unless clinically indicated or for practical, pragmatic reasons. STANDARD 2 Patients transfused overnight are monitored in accordance with BCSH guidelines. STANDARD 3 The reason for administration of red cell transfusion is documented in the patients’ medical records (BCSH 1999). Standards and criteria were created by the Project Group and are based on published guidelines or papers where possible.

% units collected that were transfused overnight Overnight red cell transfusion % units collected that were transfused overnight % patients transfused overnight Part 1 of this audit looked at the incidence of blood collected for overnight transfusion. During the week 24th September to October 1st 2007, 25630 units of blood were collected for transfusion. Of these, 7376 were collected between the hours of 19:30 and 07:30 the next day. This slide shows that fewer units were collected overnight in this region.

% units collected for overnight transfusion – a regional picture Overnight red cell transfusion % units collected for overnight transfusion – a regional picture

Where do overnight transfusions take place? Overnight red cell transfusion Where do overnight transfusions take place? Table A National (4949) Clinical Speciality % N A&E 8 388 Elderly care 2 109 Gynaecology 120 Haematology 7 340 ITU 11 543 Maternity 4 188 Medicine 23 1131 Oncology 3 159 Orthopaedic 359 Paediatric 1 71 Surgery 19 961 Other 12 580 Table B This table shows the distribution of units collected for overnight transfusion by clinical speciality for 4949 (67%) of the 7376 units collected overall.

Overnight red cell transfusion When do overnight transfusions take place? National (6104) Time range % N 19:31-21:30 26 156 21:31-23:30 21 1297 3:31-01:30 18 1071 01:31-03:30 12 760 03:31-05:30 10 623 05:31-07:30 13 790 This table shows the distribution of 6104 of 7376 (83%) units, divided into two hour time zones of collection. The table suggests that there is no time period overnight when transfusion do not take place.

Overnight red cell transfusion Categories for overnight transfusion used in the audit Group 1 – Acute clinical need Patients with active bleeding / haemolysis at the time of transfusion Patients with low haemoglobin and symptoms Group 2 – Less acute clinical need Patients transfused while in theatre Patients transfused to raise their haemoglobin prior to surgery the following day Patients transfused to raise their haemoglobin prior to a procedure the following day Group 3 – Pragmatic need Patients transfused so they can be discharged same/next day Oncology/Haematology patients with a limited line time Patients transfused out of hours because they are finishing off a transfusion episode Group 4 – Other Patients transfused for reasons that do not fall into the above categories The second part of the audit looked at patients transfused in the overnight period in more detail. The number of patients audited in this section was 2138, which represents 30% (2138/7206) of all units collected for overnight transfusion for the 181 hospitals submitting data to the clinical audit. This audit classifies the reasons for transfusion overnight into 4 groups. Please note that transfusions in Group 3 that were defined as “finishing off” were those transfusions that had started before 20:00 but continued to transfuse after 20:00, so although some of the blood was transfused “out of hours” it would be inappropriate to discontinue the transfusion part way simply because of the time factor.

Reason for transfusion overnight Overnight red cell transfusion Reason for transfusion overnight STANDARD 1 - Patients are not transfused overnight unless clinically indicated or for practical, pragmatic reasons. The coloured sections of the bars in this slide shows the distribution of patients into the 4 groups shown on the previous slide. Patients falling in Group 4 (shown as light blue) are those who, in the opinion of the Project Group, received a transfusion overnight for no apparent clinical or pragmatic reason. Nationally, this accounts for 676 or nearly one-third of the sample audited. For this region, nearly one quarter of patients fall into this category. All but one hospital had patients in Group 4, and, most notably, hospital Q with over 80% of patients included in this category. Recommendation 1 Patients without a clinical need should not be transfused overnight. Recommendation 2 Hospitals should review the practice for patients in Group 3 who are being transfused to facilitate discharge, since it can be argued that those fit for discharge do not need inpatient transfusions. Recommendation 3 Hospitals should review the practice for patients in Group 4, since there appears to be neither a clinical nor a pragmatic reason for transfusing them overnight. Recommendation 4 Hospitals should include guidelines for transfusion overnight in their transfusion policy.

Observations within 15 minutes – Acute Clinical Need Overnight red cell transfusion Observations within 15 minutes – Acute Clinical Need STANDARD 2 - Patients transfused overnight are monitored in accordance with BCSH guidelines. BCSH advises that visual observation of the patient is often the best way of assessing patients during transfusion (BCSH 1999). Therefore transfusions should only be given in clinical areas where patients can readily be observed by members of the clinical staff. It can be argued that with reduced night time illumination, visual observation of patients is hampered. In a retrospective clinical audit it is impossible to tell if a nurse has observed a patient. BCSH guidelines require that pulse and temperature are measured 15 minutes after the start of each unit to detect any adverse reaction. To this we add Blood Pressure measurement, because if any of these is recorded at 15 minutes after the transfusion start time, it can be taken as proxy evidence that the patient is being monitored. Nationally, 61% of patients transfused because of acute clinical need are monitored in accordance with guidelines, and regionally the figure is lower at 45%. While this is encouraging, it nonetheless remains the case that, regionally, over half of patients are not being monitored and so are at risk of an undetected transfusion reaction.

Overnight red cell transfusion Observations within 15 minutes – Less Acute Clinical Need Continuing the theme of monitoring patients, this slide looks at those patients transfused when they had a less-acute clinical need. Nationally, 41% of these patients were monitored, but for this region there were no patients included in this category.

Overnight red cell transfusion Observations within 15 minutes – Pragmatic Nationally, 51% of those patients transfused for a pragmatic rather than a clinical reason had observations taken. Regionally, the figure is lower at 23%. Note that several hospitals did not have patients in this category.

Overnight red cell transfusion Observations within 15 minutes – Other One of the principal findings of this audit is that of the 676 patients transfused for no apparent clinical or pragmatic reason, only 324 (48%) of these had observations taken and recorded at 15 minutes after the transfusion started.. Failing to monitor patients puts them at risk as has already been rehearsed, but the risk may be acceptable if there is an acute clinical need for transfusion. Where there is apparently no need for transfusion overnight, the risk cannot be acceptable. Regionally, the number of patients monitored is lower than the national %, and notably even the best performing hospital (B) only monitored 80% of those transfused. As indicated earlier, though, care should be taken in the interpretation of these graphs, since the numbers of patients is unlikely to be large. Recommendation 5 For all overnight transfusions, clinical staff should, within 15 minutes of the start of each unit, take and record observations in the clinical notes. Recommendation 6 Overnight transfusions should only be started if observations can be undertaken within 15 minutes of the start time.

Overnight red cell transfusion Reason for transfusion stated in the notes STANDARD STATEMENT 3 - The reason for administration of red cell transfusion is documented in the patients’ medical records. The question asked in the audit relates to whether the reason for transfusion was stated in the notes, and not specifically about the reason for having the transfusion overnight. Nationally, reason for transfusion was not stated in the notes of 20% of patients audited. Regionally the reason was found in 80% of notes, but there are only 2 hospitals in which a reason was found in all the notes. Recommendation 7 The reason for transfusion, beneficial effects and adverse incidents must be documented in the patients’ clinical notes.

Overnight red cell transfusion Best Case Scenario There will always be clinical situations where blood transfusions are required to be given overnight. To minimise risk to the patient they should satisfy the following criteria:- A reason for giving the transfusion was documented in medical notes A good clinical reason for overnight transfusion was given, defined as active bleeding / haemolysis or low Hb with symptoms The patient’s temperature, pulse or BP was monitored within 15 minutes of the start of transfusion and the result was documented in the patient’s notes. An Hb result was available within 2 days before transfusion

Overnight red cell transfusion % of patients meeting Best Case Scenario criteria This slide shows that in only 30% (636/2138) of cases were all these criteria met. Regionally the % was lower, suggesting that many of the transfusions audited in this region did not meet all our suggested criteria for best practice.

Overnight red cell transfusion Audit Recommendations 1 - Patients without a clinical need should not be transfused overnight. 2 - Hospitals should review the practice for patients in Group 3 who are being transfused to facilitate discharge, since it can be argued that those fit for discharge do not need inpatient transfusions. 3 - Hospitals should review the practice for patients in Group 4, since there appears to be neither a clinical nor a pragmatic reason for transfusing them overnight. 4 - Hospitals should include guidelines for transfusion overnight in their transfusion policy. 5 - For all overnight transfusions, (as with all transfusions), clinical staff should, within 15 minutes of the start of each unit, take and record observations in the clinical notes. 6 - Overnight transfusions should only be started if observations can be undertaken within 15 minutes of the start time. 7 - The reason for transfusion, beneficial effects and adverse incidents must be documented in the patients’ clinical notes.

Hospital staff who collected the audit data Overnight red cell transfusion Acknowledgements Project team: Tanya Hawkins, Tony Davies, Hazel Tinegate, Liz Ambler, Derek Lowe, John Grant-Casey and David Dalton Hospital staff who collected the audit data With thanks to Mike McCarthy

National Comparative Audit of Overnight Red Blood Cell Transfusion Prepared by Tanya Hawkins Clinical Audit Lead & John Grant-Casey Project Manager South West RTC March 2008