1. Part of the Zambia Anaesthesia Development Programme
Quality Improvement in Major Haemorrhage and Transfusion Practice
Part of the Zambia Anaesthesia Development Programme
E. Coley1, P. Hart2, C. Parikh, C. Daly
1. Papworth Hospital, Cambridge. 2. Leeds Teaching hospitals Trust
Introduction
The provision of safe and adequate blood is integral to national health care policy and infrastructure.
At the University Teaching Hospital (UTH), Lusaka, Zambia, lack of blood product availability is the leading systems cause of avoidable peri-operative mortalityi.
The scarcity of donated blood may be compounded by unnecessary requesting and use of blood products, which also have the potential for harm to patients.
We studied blood use in various hospital settings, and examined the management of cases of major haemorrhage, to provide a baseline for a 20-month quality improvement project, and to inform educational elements of the project.
Methods
Blood use in operating theatres
Prospective collection of data on blood product requests and use in operating theatres.
Transfusion requests
Analysed transfusion request database and request forms to investigate ‘clinicians’ reasons for requesting blood.
Blood use and wastage
Tracked blood products issued from the blood bank to ascertain how many of them are actually transfused, and whether unused were returned.
Major haemorrhage case series
Studied individual cases of major haemorrhage and compared them to best practice.
Key Results
29%
The proportion of emergency surgical cases with a pre-operative haemoglobin (Hb) measurement. Without this measurement it is difficult to make appropriate decisions about whether to transfuse a bleeding patient.
30%
Proportion of transfusion requests with a appropriate justification for requesting blood written on the form. Only 9% of the total also had this reason correctly recorded in the electronic request database. This means that the blood transfusion service can’t be sure whether the blood it issues is being used appropriately or not.
1 hour 28 mins
Median time to first transfusion after recognition of major haemorrhage. This ranged from 0 mins (in patients with blood immediately available already) to 5 hours. 3 patients received no blood at all.
Post-partum haemorrhage
Most common diagnosis in patients suffering a major haemorrhage. 85% of cases are women, and the median age is only 30 years old.
26%
Proportion of blood products that could not be traced at all. For a further 18% there was significant uncertainty about whether they had been transfused, or returned to blood bank unused. This means that the blood transfusion service can’t tell whether blood is being used at all; it is likely much of this blood is being wasted.
Proportion of blood requested for planned surgery which isn’t transfused. This blood is held in theatres all day and therefore isn’t available for patients in genuine need elsewhere.
30%
30-day mortality in patients suffering a major haemorrhage in UTH from our case series.
Training, point of care testing and protocols
Training and protocols
Implementation of major haemorrhage and blood transfusion workshops for multidisciplinary hospital staff members.
Full ratification of adult and obstetric major haemorrhage protocols.
Training of local hospital staff to deliver further workshops improving sustainability.
Simulation training for patient monitoring.
Ethics approval for data collection.
Blood transfusion services and monitoring
Introduction of the Prospect point of care haemoglobin analyser.
Monthly hospital transfusion committee meetings to review data and discuss transfusion practice.
Adaptation of transfusion product ordering form.
Implementation of returning all of units used or unused to blood transfusion services in order to track products better.
References
i Lillie EM, Holmes CJ, O’Donohoe EA, Bowen L, Ngwisha CL, Ahmed Y, Snell DM, Kinnear JA, Bould MD. Avoidable perioperative mortality at the University Teaching Hospital, Lusaka, Zambia: a retrospective cohort study. Canadian Journal of Anesthesia/Journal canadien d'anesthésie Dec 1;62(12):
Meara JG, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet Aug 8;386(9993):