1. This presentation includes parts of unpublished, preliminary results of a larger study. The contents of this presentation may not be quoted or used in any form without prior written permission of the Principal Investigator. Important

2. This activity was accredited for 1.5 CME hours for nurses by the General Authority of Health Services (GAHS) for the Emirate of Abu Dhabi. Unique ID #: 280307Q4BH

3. Nurses’ Practice of Blood Transfusion. Results of the First Observational Research Study in the United Arab Emirates Belal M. Hijji 1, Kader Parahoo 1, Mohammad M. Hossain 2, Owen Barr 1, Shirley Murray 3 1 School of Nursing, Faculty of Life & Health Sciences, University of Ulster, UK 2 Institute of Medicine, Universiti Brunei Darussalam 2 Institute of Medicine, Universiti Brunei Darussalam 3 Royal Group of Hospitals, Belfast, UK 3 Royal Group of Hospitals, Belfast, UK

4. Learning objectives

5. Upon completion of this activity, participants should be able to: Describe the importance of preparing the patient before blood collection Identify the steps required for proper identification of patient prior to initiating a transfusion Recognise traditional practices, not grounded in evidence, that would increase the risk for patient suffering an acute transfusion reaction Identify the type of information to be disclosed to patient (relative) prior to transfusion Recognise the importance of recording vital signs prior to, and at 15 minutes after, initiating a transfusion Recognise the importance of adhering to recommendations aiming at minimising the risk for bacterial contamination

6. Background

7. Nurses play a crucial role in the administration of blood/ blood components Their skills and relevant practices are important determinants of the safety and effectiveness of transfusions Published information about nurses' blood transfusion practices in the Gulf region, in general, and in the UAE, in particular, is lacking To fill this information gap and other gaps identified in the literature, this study was undertaken in Abu Dhabi Emirate, UAE

8. Literature review

9. Six published observational studies located worldwide Six published observational studies located worldwide Turkey (Bayraktar and Erdil, 2000) Turkey (Bayraktar and Erdil, 2000) UK (Royal College of Physicians, 2005) UK (Royal College of Physicians, 2005) America (Shulman et al. 1994 & 1999; Whitsett & Robichaux, 2001; Saxena et al. 2004). America (Shulman et al. 1994 & 1999; Whitsett & Robichaux, 2001; Saxena et al. 2004).

10. Aim

11. Principal aim To observe and document nurses’ actual blood transfusion practices

12. Specific questions Are nurses’ blood transfusion practices based on recommendations? Are essential procedures done as recommended? Are unnecessary procedures performed? If there are any practice deficits What are these? Are these likely to jeopardize patient safety and well- being?

13. Methods

14. Data presented here were collected as part of a larger study of nurses’ knowledge and practice related to blood transfusion Data were collected in early 2005

15. 2 medium-sized, public, general hospitals in Abu Dhabi Emirate, UAE 3 wards were selected in each hospital Study settings

16. Altogether 140 registered nurses in 6 selected wards in both study hospitals Study population Study sample 50 nurses selected randomly from the study population

17. Non-participant observation by the PI Observation method A structured observation schedule was used

18. Based on the schedule in Turkish developed by Bayraktar and Erdil (2000) Translated into English Modified and expanded based on British Committee for Standards in Haematology (BCSH) 1999 guidelines, experts’ advice, local practices Modified and expanded based on British Committee for Standards in Haematology (BCSH) 1999 guidelines, experts’ advice, local practices The observation schedule Had 4 sections (slides 19, 20, 21)192021 Other important variables were included

19. Observation form related to nurses’ blood transfusion practices (18) (18)(18) RemarksNAApplied Activities related to transfusion Yes No A. In ward before collecting blood 1. Venous access is available 2. The nurse checked patency of line with the appropriate solution with the appropriate solution B. In the blood bank 1. The nurse brought a documentation containing patient details containing patient details 2. The nurse performed checks in the blood bank blood bank 3. Used a special blood transport box

20. Observation form related to nurses’ blood transfusion practices (18) (18)(18) C. In the Ward Before Transfusion Applied Yes No NARemarks 1. Blood commenced within 30 min. post collection 2. Wrapped the blood pack with linen/ blanket 3. Two nurses performed checks at nurses' station 4. Wore disposable non-sterile gloves 5. Provided relevant information to patient 6. Appropriateness of patient identification 6.1 Asked the patient to state his/her name 6.2 Asked the patient to state his/her DOB 6.3 Checked the patient ID band 6.4 Compared together patient's ID, blood bag, blood bank form and prescription chart 7. Recorded baseline pulse, BP and temperature 8. Used set with proper filter size

21. Observation form related to nurses’ blood transfusion practices (18) (18)(18) RemarkNAApplied Yes No Activities related to transfusion D. After initiating the transfusion 1. Regulating the blood transfusion flow rate 1.1 Transfused (25-30 ml) for the first 15 minutes (adult) 1.2 Transfused (1/10) of the total volume for the first 15 minutes (pediatric) 1.3 Regulated the transfusion rate to complete as ordered or within 4 hours post collection 2. Observation of patient for reaction symptoms 2.1 Physical monitoring for the first 10-15 min. 2.2 Recorded temp and pulse 15 minutes post initiation

22. Validity and reliability of the observation schedule Transfusion experts from the UK established content validity. Transfusion experts from the UK established content validity. Three pilot studies using 12 nurses. Three pilot studies using 12 nurses. Inter-observer reliability: Perfect (kappa = 1) for most items. Where kappa was poor, item removed. Kappa calculations as recommended by Rigby (2000). Inter-observer reliability: Perfect (kappa = 1) for most items. Where kappa was poor, item removed. Kappa calculations as recommended by Rigby (2000).

23. Anonymity assurance Official Approvals Ministry of Health research ethics committee, UAE Hospital A research ethics committee Hospital B administration Confidentiality assurance Ethical issues Voluntary informed consent was obtained from all study participants including those who participated in the pilot studies

24. Data collection Each selected nurse was observed once. Each selected nurse was observed once. Recognising when a request of blood has been made was facilitated by the researcher personal follow up, ward nurses, and/ or blood bank staff. Recognising when a request of blood has been made was facilitated by the researcher personal follow up, ward nurses, and/ or blood bank staff. Assessment began 10 minutes before blood collection until 15 minutes post initiation. Assessment began 10 minutes before blood collection until 15 minutes post initiation. Performance or non-performance of each observable activity was recorded. Field notes taken- vital Performance or non-performance of each observable activity was recorded. Field notes taken- vital Non measurable activities were also recorded Non measurable activities were also recorded

25. Practice scores were summed for each nurse Data analysis Descriptive statistics Frequencies, percentages, medians, and inter-quartile ranges Inferential statistics Chi squared test The ‘median test’ was used to test for statistical significance in the difference between the median practice scores of nurses in the 2 hospitals

26. Results

27. 49 of the 50 selected nurses participated resulting in a response rate of 98% The nurses’ length of ward experience and their blood transfusion practices are shown in the tables on the next 5 slides For some practices, the ‘n’ was not 49 due to inapplicability or missing data

28. Nurses’ length of ward experience

29. PracticeNo.% Venous access available 49100 Checking patency of IV line 36 Using blood transport box 00

30. PracticeNo.% Covering bag with linen / blanket (belief) Remote checks at nurses’ station 7301463 Starting blood within 30 min post-collection 2857 Giving information to patient / relative: 1. Reasons/ benefits of transfusion 00 2. Risks of transfusion 00 3. Reaction symptoms 1335 Wearing gloves (surgical and disposable) 4796

31. PracticeNo.% Blood pressure recording 1650 Pulse recording 1856 Temperature recording 2962 Asking patient to state name 38 Asking patient to state DOB 00 Number of patients wearing ID bands 3270 Checking patient's ID band 2143 Comparing bracelet with blood bag 1429 Comparing together bracelet, blood bag, request form, and drug chart 24

32. PracticeNo.% Using administration set with appropriate filter size 4592 Transfusion rate 25-30 ml in the 1st 15 minutes (adult) 2576 Transfusion rate 1/10 of total volume 1st 15 minutes (child) 1381 Physical attendance 1 st 10-15 minutes post initiation 1837 Transfusion regulation at 15 minutes post initiation, or: Completing within 4 hours post collection 223450 Pulse recording 15 minutes post initiation 1238 Temperature recording 15 minutes post initiation 1634

33. Risk of acquiring bacterial infections Initiation of transfusion after collection # Nurses % Completion time after commencement [1] Completion time after collection 4 h 4 h 4.5 h [2] 4.5 h [2] Within 10 min. 48 40404040 4 0 Within >10 -30 min. 2449 203 > 30 min. [3] 2143 154 11 8 Total49100 397 35 11 [1] Completion time was not documented for three units [2] Range between 4 hours 37 minutes and 6 hours 30 minutes (mean 5 hours 18 min.) [3] Range between 35 – 138 minutes, mean 54 minutes

34. Nurses’ blood transfusion practice scores Number of nurses

35. HospitalRangeMedian 25 th percentile 75 th percentile A 4 to 13 6.558 B 3 to 13 10812 Nurses blood transfusion practice scores by hospital. Median score was 8. Maximum possible score was 21

36. Median test of practice score Hospital AHospital BTotal > median5 (25%)15 (75%)20 (41%) median5 (25%)15 (75%)20 (41%) <= median 191029 Total242549 X 2 = 7.77, df = 1, p <0.01

37. Conclusions

38. Specific questions Are nurses’ blood transfusion practices based on recommendations? Are essential procedures done as recommended? Low practice scores indicate practice deficits Are unnecessary procedures performed? Yes Wrapping the blood pack with linen / blanket Remote identity check at the nurses’ station

39. Specific questions If there are any practice deficits What are these? Practices related to proper identification of the patient Practices that could increase the risk of bacterial contamination of the blood Are these likely to jeopardize patient safety and well-being? Yes

40. The Outcome

41. "There is one mistake done in the hospital here. In ……. ward one member of staff was admitted; one of the staff went to collect the blood. She collected a unit for another patient and she gave to our staff. When she started the blood transfusion, she looked in the blood bag and she looked at wristband. Details on both were different. This blood was not for this patient. There is too much mistake done here, in the hospital in blood transfusion. And we give by mistake a blood to a …….. patient that is not his and she developed allergy and rashes because that was not his blood". This quote is from the focus group interviews

42. Recommendation

43. To deliver safer and more effective patient care, the observed inappropriate blood transfusion practices of nurses need to be corrected urgently through appropriate education and training.

44. We are immensely grateful to all study participants, the management, the concerned nursing director or associate director, all nursing staff, and the blood bank staff of both hospitals. Acknowledgements

45. In order to raise the profile of patient care, experience gained from developed countries indicates that the following issues should be addressed, sooner rather than later: Raise the profile of nursing Raise the profile of nursing Invest in research Invest in research Support professional development of nurses Support professional development of nurses Where do the UAE healthcare institutions go from here?

46. Where do nurses go from here? Nurses are accountable for their practice. They have an ethical, moral, professional, and legal responsibility of providing sound care to patients. Therefore: Identify every patient properly before each unit of blood Identify every patient properly before each unit of blood Take an active role in developing you practice Take an active role in developing you practice Remain updated Remain updated

47. Thank You Principal Investigator Hijji-B1@ulster.ac.uk

48. REFERENCES Bayraktar, N. and Erdil, F. (2000) Blood transfusion knowledge and practice among nurses in Turkey [Special Focus Issue: Hematology]. Journal of Intravenous Nursing. 23(5): 310-317. British Committee for Standards in Haematology (1999). The administration of blood and blood components and the management of transfused patients. Transfusion Medicine. 9; 227-238. Rigby, A. (2000). Statistical methods in epidemiology: Towards an understanding of the kappa coefficient. Disability and Rehabilitation. 22(8): 339-344. Royal College of Physicians (2005). National comparative audit of blood transfusion: Re- audit of bedside transfusion practice. Clinical Effectiveness & Evaluation Unit of the RCP. RCP Publications: London. Saxena, S.; Ramer, L. and Shulman, I. (2004). A comprehensive assessment program to improve blood administering practices using the FOCUS-PDCA model (2004). Transfusion. 44; 1350-1356. Shulman, I.; Lohr, K.; Derdiarian, A. and Picukaric, J. (1994). Monitoring transfusionist practices: a strategy for improving transfusion safety. Transfusion. 34(1): 11-15. Shulman, I.; Saxena, S. and Lois, R. (1999). Assessing blood administering practices. Archives of Pathology and Laboratory Medicine. 123(7): 595-598. Whitsett, C. and Robchaux, M. (2001). Assessment of blood administration procedures: problems identified by direct observation and administrative incident reporting. Transfusion. 41; 581-586.