Application of Cross match /Transfuse blood units ratio as performance indicator for blood conservation in AWH
QUALITY IMPROVEMENT PROJECT
3 years study
Blood Usage review Committee
Application of C/T ratio as performance indicator for blood conservation in AWH
Project Plan ( FOCUS - PDCA METHODOLOGY
• Background
• FIND A PROBLEM
• ORGANIZE A TEAM
• UNDERSTAND THE PROBLEM
• Currant situation
• SELET THE IMPROVEMT
• PLAN THE IMPROVEMT
• DO THE IMPROVEMT
• CHECK THE RESULTS
• ACT ON HOLD THE GAIN
Background
• Blood transfusion is often a life-saving measure.
• In the era of numerous blood-transmitted diseases and known complications , it is limited to patients who really require blood replacement therapy.
• In elective surgery, blood transfusion is quite uncommon and most of the cross-matched blood is not used.
• Blood Usage Review Committee has been formulated through the hospital’s Quality Department in September 2004.
• The committee comprises a representative from each departments.
• All issues related to clinical use of blood need to be dealt with in this committee.
FIND A PROBLEM
• This project was initiated to determine ways to reduce unnecessary demands on blood supply, as blood bank AWH raised the point that the majority of (cross – matched blood units) were left unused.
Organize a team
• Blood Usage Review Committee members.
Work together to look into this problem.
• They nominated a sub-team ;
- Dr Kareema ( In charge of Blood Bank AWH)
- Mrs. Asma and then Miss Faheema( Senior lab Tech. )
- Mrs. Merlyn ( Quality coordinator)
Clarify – The current process
( 2 blood units’ policy)
• The sub-team found that the trend is.. (cross-match.. ..minimum 2 units of blood for all patients need to go to theater need it or not)
Clarify – The current process
Understand the source of the problem
• There was no Hospital Blood Transfusion Policy.
• Blood Usage was liberal.
• No defined audit system.
Select – The improvement
• Improvement will only be achieved by communicate the problem with the hospital’s clinical bodies.
• Through Blood Usage Review Committee’s members.
Plan the improvement
A blood utilization policy was to be prepared by the BURC committee and to get approved by AWH quality council, and to get implemented.
We chose cross-matched to transfused ratio as a performance indicator.
Retrospective monitoring of 2004.
(pre-policy implementation)
4. Monitor the improvement in 2005 and 2006.
(post-plicy implementation)
Do – The improvement
Blood transfusion policy prepared and
( implementation in May 2005)
2. Maximum Surgical Blood Order Schedule, *MSBOS was prepared by Surgical Paediatric and Obs&Gyn departments.
(*It is the maximum number of units transfused for each procedure by a known surgical department)
Promotion for Group & Save ( blood group and antibody screening then save the serum), instead of cross-match order.
4. Presentations & Educational sessions conducted by each of committee member to his/her respective department.
5. Cross – matched blood units to Transfused units (C/T ratio) monitored.
C/T ratio used as performance indicator to measure rational blood order in AWH.
Check the results
• Pre-implementation period (2004) ;
Total number of cross-matched units was 24260.
Total number of transfused units was1552.
Transfused units were 6% of cross-matched units.
Cross-matched / Transfused ratio was 16 / 1
• Post-implementation period (2005);
Total number of cross-matched units was 5497.
Total number of transfused units was 1149.
Transfused units were 21% of cross-matched units.
Cross-matched / Transfused ratio was 5 / 1
• Post-implementation period ( 2006);
Total number of cross-matched units was 4390.
Total number of transfused units was 1166.
Transfused units were 26.5% of cross-matched units.
Cross-matched / Transfused ratio was 3.7/ 1.
• C/T ratio has been reduced from;
16/1 in 2004
5 /1 in 2005
3.7 /1 in 2006.
• Cross-matched units number shows compared to 2004;
77% reduction in 2005.
82% reduction in 2006.
This shows that admission to the hospital is on the rise so no argument can be made that C/T ratio is less because of less admission.
We reached the goal in early 2007.
Our aim was to reach it by the end of the same year.
Act – To hold the gain
• Project succeeded in showing that blood transfusion orders were irrational.
• Blood Transfusion policy implementation succeeded in tremendously minimizing blood ordering pattern.
• C/T ratio needs to come down to 2 /1 by the end 2007, but fortunately we reached it by beginning of the same year.
• Blood usage review committee needs to start Audit system on blood transfusion orders, to match order with MSBOS.
• C/T ratio monitoring should be an on going process.
• Continues educational/orientation programs for Medical staff needs to be in action.
• Results were unachievable without Medical staff compliance.
Credit:ivythesis.typepad.com
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