Rev. Enferm. UFSM, v.13, e17, p.1-27, 2023
Submission: 10/13/2022 • Acceptance: 3/02/2023 • Publication: 9/05/2023
Review article
Transfusion process assessment indicators: integrative review*
Indicadores para a avaliação do processo transfusional: revisão integrativa
Indicadores para la evaluación del proceso transfusional: revisión integradora
Daiana de MattiaI
Dulcineia Ghizoni SchneiderII
Francine Lima GelbckeIII
I Federal University of Santa Catarina. Florianopolis, Santa Catarina, Brazil
*Extracted from a thesis entitled “Gerenciamento de enfermagem no processo transfusional: construção e validação de indicadores para melhoria da qualidade”, Graduate Program in Nursing, Universidade Federal de Santa Catarina, 2022.
Abstract
Objective: to identify transfusion-related indicators. Method: an integrative literature review carried out between March and May 2022, in nine sources of information from 2001 to 2021. As a search strategy, the descriptors “Quality Indicators in Health Care”, “Service Indicators”, “Basic Health Indicators”, “Hemotherapy Service”, “Blood Transfusion”, “Blood Safety” were used, with Boolean operators “AND” and “OR” in three languages, with 49 articles being analyzed. Results: a total of 53 indicators were identified, which were grouped for: blood component stock management, transfusion process production, transfusion process assessment and transfusion process support. Conclusion: the identified indicators make it possible to assess the transfusion process, although activities, such as care assessment, present few indicators, highlighting the need for studies on the subject and the construction of new indicators to support a more improved transfusion process assessment.
Descriptors: Quality Indicators, Health Care; Indicators of Health Services; Hemotherapy Service; Blood Transfusion; Blood Safety
Resumo
Objetivo: identificar os indicadores relacionados ao processo transfusional. Método: revisão integrativa de literatura realizada entre março e maio de 2022, em nove fontes de informação no período de 2001 a 2021. Como estratégia de busca, utilizaram-se os descritores "Indicadores de Qualidade em Assistência à Saúde", "Indicadores de Serviços", "Indicadores Básicos de Saúde", “Serviço de Hemoterapia", "Transfusão de Sangue", "Segurança do Sangue”, com os operadores boleanos “AND” e “OR” em três idiomas, sendo analisados 49 artigos. Resultados: foram identificados 53 indicadores, os quais se agruparam para: gestão do estoque de hemocomponentes, de produção do processo transfusional, para avaliação do processo transfusional e de suporte do processo transfusional. Conclusão: os indicadores identificados possibilitam avaliação do processo transfusional, apesar de atividades, como a avaliação do cuidado, apresentarem poucos indicadores, evidenciando a necessidade de estudos sobre a temática e construção de novos indicadores para dar sustentação à avaliação mais aprimorada do processo transfusional.
Descritores: Indicadores de Qualidade em Assistência à Saúde; Indicadores de Serviços; Serviço de Hemoterapia; Transfusão de Sangue; Segurança do Sangue
Resumen
Objetivo: identificar indicadores relacionados con el proceso de transfusión. Método: revisión integrativa de la literatura, realizada entre marzo y mayo de 2022, en nueve fuentes de información de 2001 a 2021. Como estrategia de busca, se utilizaron los descriptores “Indicadores de Calidad en la Atención de Salud”, “Indicadores de Servicio”, “Indicadores Básicos de Salud”, “Servicio de Hemoterapia”, “Transfusión de Sangre”, “Seguridad de la Sangre”, con operadores booleanos “AND” y “OR” en tres idiomas, analizando 49 artículos. Resultados: se identificaron 53 indicadores, los cuales fueron agrupados en: gestión del stock de hemocomponentes, producción del proceso transfusional, evaluación del proceso transfusional y apoyo al proceso transfusional. Conclusión: los indicadores identificados posibilitan la evaluación del proceso transfusional, aunque actividades, como la evaluación del cuidado, presenten pocos indicadores, destacando la necesidad de estudios sobre el tema y la construcción de nuevos indicadores que apoyen una evaluación más perfeccionada del proceso de transfusión.
Descriptores: Indicadores de Calidad de la Atención de Salud; Indicadores de Servicios; Servicio de Hemoterapia; Transfusión Sanguínea; Seguridad de la Sangre
Blood transfusion is a vital and life-saving process for patients with acute and chronic conditions, aiming to replace lost blood components such as red blood cells, platelets and/or clotting factors.1 This procedure is complex and comprises stages, such as medical prescription of blood components, blood sample collection, pre-transfusion tests, blood component selection, blood transfusion performance and monitoring and reporting of adverse events related to blood transfusion.2 Despite the high investment that has been taking place, it has not yet been possible to find something to replace blood. Therefore, blood transfusion and its components, so far, is necessary.3
Every year, millions of people worldwide undergo blood transfusion, which makes it one of the most used treatments in modern medicine.4-5 Although it is a widespread practice, it has associated risks, including immunological complications, immunomodulation or transfusion-transmitted infection. Many of the risks associated with human errors have been reported in blood transfusion processes, comprising approximately 85% of the total avoidable risks.1,6 Data from the European Union from 2021 indicated 35 transfusion-related deaths, which led the Serious Hazards of Transfusion (SHOT), describing that “improvement in decision-making, monitoring and professional education, addressing factors that contribute to errors, are vital to improving transfusion safety”.6 In order to improve blood safety and availability, it is recommended that facilities implement effective quality systems, including quality management, standards, good manufacturing practices, documentation, staff training and quality assessment.7
Among the tools used to monitor quality in the health field, there are indicators that allow institutions to identify areas of low performance and measure improvements.8 In the field of blood transfusion, indicator use provides important information that is not only limited to comparing blood use between countries, but also allows assessing changes in blood transfusion practice over time.9 They are measurable representations, i.e., quantitative bases of characteristics of products and processes used to control and improve the performance and quality of organizations.10 They aim to know the external customer’s perception, enable the comparative analysis of the organization’s performance, diagnose the service’s strengths and weaknesses, and comparatively assess different organizations, processes, problems and undertake improvement actions.11 Thus, this article aimed to identify the transfusion-related indicators.
This is an integrative literature review that allows the synthesis of multiple studies published in different journals, allowing relevant conclusions about a particular area.12 In this review, six stages were followed: theme identification and research question elaboration; establishment of inclusion and exclusion criteria for studies; definition of the information to be extracted from selected studies; assessment of included studies; interpretation of results; and presentation of knowledge review/synthesis.12
For the review question elaboration, the acronym PICO was used13 (P (person/problem): indicators; I (intervention): transfusion process; C (comparison): not applied; O (outcomes): transfusion process quality), obtaining as a review question: What is the scientific evidence of transfusion-related indicators?
The bibliographic survey was carried out between March and May 2022, using the Medical Literature Analysis and Retrieval System Online (MEDLINE) information sources, consulted through PubMed, Latin American and Caribbean Health Sciences Literature (LILACS), Nursing Database (BDENF), CINAHL, COCHRANE Library, EMBASE, Scopus, Web of Science, and Scientific Electronic Library Online (SciELO). The search strategy was developed in MEDLINE and applied to the specificity of each source:
(“Quality Indicators, Health Care”[Mesh] OR “Health Care Quality Indicators”[Title/Abstract] OR “Indicators of Health Services”[Title/Abstract] OR “Health Status Indicators”[Mesh] OR “Health Status Indicators”[Title/Abstract] OR “Indicators”[Title/Abstract] OR “Indicator”[Title/Abstract] OR “Health Status Index”[Title/Abstract] OR “Health Status Indexes”[Title/Abstract] OR “Health Status Indices”[Title/Abstract] OR “Health Metric”[Title/Abstract] OR “Health Metrics”[Title/Abstract] OR “Healthcare Global Trigger Tool”[Title/Abstract]) AND (“Hemotherapy Service”[Title/Abstract] OR “Blood Therapy”[Title/Abstract]OR “Hemotherapy”[Title/Abstract] OR “Hemotherapeutic”[Title/Abstract] OR “Blood Transfusion”[Mesh] OR “Blood Transfusion”[Title/Abstract] OR “Blood Safety”[Mesh] OR “Blood Safety”[Title/Abstract] OR “Blood Supply Safeties”[Title/Abstract] OR “Blood Supply Safety”[Title/Abstract] OR “Hemovigilance”[Title/Abstract]).
Article selection was carried out by two independent reviewers, who selected the studies from reading their titles and abstracts, checking duplicates and reading them in full, assessing their suitability for the review question. A third reviewer was available in case there was any disagreement. Considering the eligibility criteria, analysis was composed of 49 articles, which were subjected to a new reading, seeking to extract relevant information, considering the study review question. To organize the collected data, a synoptic table was prepared in a Microsoft Excel® spreadsheet containing the following items: source, author(s), title, year, journal, study site, objective, study design, methodological approach, transfusion process indicators. Data analysis included pre-analysis, material exploration and treatment of results, inference and interpretation.16
A total of 5,010 studies were found, and 49 were selected to compose the integrative review. Figure 1 illustrates the study search and selection process.
Figure 1 – Article search and selection process, Florianópolis/SC, Brazil, 2022
As for the design, 38 had a quantitative approach (cross-sectional, experimental, intervention and cohort); six were qualitative (descriptive and methodological); and five were quantitative and qualitative (descriptive and methodological).
Regarding the site of selected articles, it was found that most were developed in the United States of America (n=11), followed by India (n=6), Spain (n=4), Saudi Arabia (n=2), Canada (n=3), Netherlands (n=3), France (n=2), United Kingdom (n=2). The other countries, such as Brazil, presented only one study.
Chart 1 presents the studies included in the integrative literature review according to year, country, objective, methodological approach, study design, sample, setting and results.
Chart 1 – Characterization of included studies that address transfusion-related indicators, Florianópolis/SC, Brazil, 2022
|
country |
Objective |
Method/Sample |
Results |
|
2001/ United Kingdom17 |
Produce nationally tested audit tools, influence the content of national guidelines and allow the definition of performance indicators for the clinical transfusion process. |
Cross-sectional study. 50 hospitals |
More than 20% of participating hospitals did not have Hospital Transfusion Committees. Audits of transfusion practice demonstrated considerable variation in the performance of standard procedures regarding blood administration and little change in practice between the two audits. |
|
2001/ Finland18 |
Verify whether automatically stored blood transfusion data could be used as a source of indicators for transfusion practice assessment. |
Methodological study.
|
Key indicators include the percentage of patients transfused, the number of transfused units and costs across different diagnostic groups as well as transfusion rates by treatment episodes weighted by diagnostic groups. |
|
2002/ USA19 |
Determine normative ratios of matched red cell concentrate (RBC) ratios to transfused, wasted, and expired RBC units, and examine hospital blood bank practices associated with more desirable rates. |
Cross-sectional study. 1,639 public and private institutions |
The proportion of RBC matched and effectively transfused was <1.5 in the best performing participating institutions, and 1.8 to 1.9 with intermediate performance and > 2.4 with poor performance. RBC unit expiration rates were 0.1% at top performing institutions, 0.3% to 0.9% at intermediate performers, and > 3.5% at lowest performers. |
|
2002/ France20 |
Analyze information extracted from the experience of the first four years of the hemovigilance network under the control of the French Blood Agency. |
Cross-sectional study. 24,234 transfusion incident reports. |
The highest reporting rate is seen with platelet concentrates (PC), followed by RBC and fresh frozen plasma (FFP). Bacterial contamination appeared as the main cause of morbidity and mortality. ABO incompatibilities, during RBC transfusion, remained at a constant rate and accounted for 6 fatalities. After the implementation of universal leukocyte reduction, transfusion reactions were reduced. |
|
2002/ USA21 |
Determine normative expiry and wastage rates for FFP and PC units in hospital communities and examine blood banking practices associated with more desirable rates. |
Cross-sectional study. 1,639 US public and private institutions |
The FFP and PC expiration rate ranged from 5.8% to 6.4%, and the FFP and PC loss rate ranged from 2.0% to 2.5%. Among the top performers, the FFP and PC expiration rate was < 0.6%, and the FFP and PC wastage rate was < 0.5%. In institutions with the worst performance, these rates were > 13.8% and > 6.8%, respectively. |
|
2005/ USA22 |
Determine whether the amount and time of blood collection are independent risk factors for in-hospital mortality, need for Intensive Care Unit (ICU) care, and increased length of stay in the ICU. |
Retrospective cohort study. 275 trauma patients who received at least one unit of RBC. |
Patients who received older blood had a longer ICU stay, possibly reflecting a higher level of organ dysfunction. However, these patients did not have a higher mortality rate or a greater need for ICU care. |
|
2008/ Italy23 |
Identify and assess the indicators of completeness and adequacy of FFP orders and the blood component’s therapeutic efficacy. |
Observational study. 221 FFP requests answered at regional Immunotransfusion Services. |
In 50.7% of cases, data completeness in individual requests was good. There was indication and adequate dosage in 31.5% and 62.7% of requests. Comparison of pre- and post-transfusion laboratory data showed significant correction of pathological values only for the International Normalized Ratio. |
|
2009/ USA24 |
Present the implementation of a project with blood transfusion process redesign, from the requirement of two blood samples to verify the blood type of a patient before blood transfusion. |
Intervention study. Errors in patient identification and/or sample labeling. |
With the implementation of the new policy, the risk of issuing the wrong blood unit due to errors in patient identification/sample labeling, at the time of collection, decreased, but the response time for requesting blood components increased. |
|
2010/ USA25 |
Eliminate the disposal of RBC shipped in temperature validated containers and reduce RBC waste by 50%. |
Intervention study. RBC disposed of in a hospital center. |
Overall RBC disposal decreased from 4.4% to 2% (approximately 4,300 RBC per year), saving approximately $800,000 over the four-year study period. |
|
2011/ Spain26 |
Investigate the impact of three national blood transfusion indicators specifically designed for critical care on appropriate blood transfusion indications. |
Cross-sectional study. 1,808 patients admitted to the ICU. |
13% of RBC transfusions were performed outside the established protocols. Most RBC (95%) were prescribed for a hemoglobin (Hb) threshold < 9g/dL, and there was a significant improvement in compliance with PC transfusion guidelines (36% to 52%). However, non-compliance with guidelines for FFP transfusions remained high and stable. |
|
2011/ Saudi Arabia27 |
Determine whether the accreditation process has a positive impact on patient safety and quality of care. |
Cross-sectional study. 119 performance indicators collected at King Abdul-Aziz University Hospital in Saudi Arabia. |
Indicators considered sensitive to accreditation were: 4 indicators of perioperative mortality and neonatal mortality rates; 16 from healthcare-associated infections; 1 due to blood utilization; 2 related to surgeries and invasive procedures; 2 related to cardiopulmonary resuscitation; 2 related to pressure injury. |
|
2012/ USA28 |
Determine the prevalence of Hb greater than 10.0 g/dL in patients who received RBC transfusions in hospitals served by the Community Blood Center of Greater Kansas City. |
Cross-sectional study. Patients with Hb level >10.0g/dl, transfused with RBC. |
In total, 47% of patients had Hb levels at discharge >10g/dL. The average Hb trigger for transfusion was 7.3 g/dL; the mean post-transfusion Hb level was 9.3 g/dL; and the mean Hb level at discharge was 9.2 g/dL. Overall, 76% of transfusions were of an even number of RBC units. |
|
2013/ Netherlands29 |
Assess whether the reported transfusion reactions rate is correlated with the transfusion chain safety in a hospital. |
Cross-sectional study. Transfusion reactions reported by 103 Dutch hospitals. |
Of the 103 hospitals, 101 had complete data for some years and 93 for all five years. In all, 72 reported at least one incorrectly transfused blood component. |
|
2013/ USA30 |
Investigate RBC emission response time for operating rooms and examine the current status of RBC emission response time benchmarks in other blood banks as well as anesthesiologists’ RBC emission response time expectations. |
Cross-sectional study. 416 adult elective surgical cases with requests for 4 or fewer RBC units at Vanderbilt University Medical Center (VUMC) and Stanford University Medical Center (SUMC). |
Mean response times for RBC emission at the 2 institutions were 3.8 minutes at VUMC and 7.2 minutes in SUMC. Only 3 of the 24 institutions surveyed actively monitored the issue time. The internal policies established for time of issuance were 15 and 20 minutes at VUMC and SUMC, respectively, for RBC cross requests for patients with complete diagnostic test. |
|
2014/ Malaysia31 |
Describe about the development of indicators, quality and clinical audits, quality assessment programs and hemovigilance program. |
Descriptive study.
|
Monitoring provides information, identifies weaknesses and deficiencies that can be assessed to implement corrective actions and appropriate interventions. The hospital transfusion committee plays an important role in implementing a monitoring system in the hospital. |
|
2014/ USA32 |
Create a reproducible metric that allows a risk-adjusted assessment of blood component use, taking into account patients’ diagnosis and surgical procedures. |
Cross-sectional study. Electronic medical records of 37,403 surgical patients admitted to Johns Hopkins Hospital. |
It was observed that, according to patients’ diagnosis, the surgical procedure, and its severity, transfusion needs were directly correlated to RBC, FFP, PC transfusions. |
|
2014/ Saudi Arabia33 |
Raise the degree of compliance of the anesthesia team with the new policies and procedures for anesthetized surgical patients for blood transfusion administration. |
Cross-sectional study. 1,142 audit files from a large teaching hospital and a reference in tertiary care. |
The degree of compliance in carrying out the pre-request steps for blood collection criteria, request for blood criteria, blood products verification procedures, post-transfusion procedure was 100%. |
|
2015/ Pakistan34 |
Assess the frequency of receipt of fully completed blood transfusion reaction forms followed by the required samples. |
Cross-sectional study. 106 transfusion reaction forms received during a year at the Aga Khan University blood bank. |
During the study period, 17,880 RBC, 13,200 PC, 13,620 FFP and 2,256 cryoprecipitates were transfused and 106 transfusion reactions (0.23%) were reported. Of these, non-hemolytic febrile reaction was the most common (47%), mostly caused by RBC transfusion. |
|
2015/ Netherlands35 |
Assess compliance with the 2011 Dutch Blood Transfusion Guideline recommendations. |
Cross-sectional study. All Dutch hospitals in the operating years 2011 and 2012. |
Most hospitals had a transfusion committee with a representative and 23% met the recommended minimum. Compliance with the pre-transfusion hemoglobin threshold for RBC transfusion was achieved by 90% of hospitals in more than 80% of transfusions; 58% of hospitals measured pre-transfusion platelet counts in more than 80% of PC transfusions; and 87% of hospitals complied with traceability of blood components in more than 95% of transfusions. |
|
2015/ Iran36 |
Assess the status of requests for blood products and transfusion practice in surgical patients. |
Cross-sectional study. 377 records of hospitalized patients, from April to December 2013, at Al-Zahra and 17th Shahrivar hospitals in Rasht, northern Iran. |
In Al-Zahra, the transfusion rate was 0.27; the probability of transfusion was 12.8%; the ratio of matched RBC to transfused RBC was 7.38. Laparoscopic surgery had the worst indicator in terms of waste. At the 17th Shahrivar hospital, the transfusion rate was 0.09; the probability of transfusion was 8.82%; the ratio of matched RBC to transfused RBC was 12.5. Appendectomy presented the worst indicators. |
|
2015/ USA37 |
Determine whether comparison of institutional benchmarks with similar types of hospitals can be used as a surrogate means of assessing hospital compliance with evidence-based transfusion guidelines. |
Methodological study. 892 patients undergoing colorectal surgery in a hospital. |
The transfusion rate for colorectal surgery was 16.3%, higher than the national average. When broken down by type and size, the study hospital had a similar blood transfusion rate compared to academic hospitals, but a significantly higher rate than community hospitals, regardless of patient volume. |
|
2015/ Egypt38 |
Investigate the frequency of auto and alloantibodies in patients with beta thalassemia in Alexandria, Egypt. |
Cross-sectional study. 40 patients with beta thalassemia who received a regular blood transfusion in Alexandria, Egypt. |
The direct antiglobulin test was positive in 45% of patients. Alloantibodies were detected in 42.5%, such as anti-D (4.76%), anti-c (4.76%), anti-K (4.76%), anti-Kpa (9.52 %), anti-Kpb (19.05%), anti-Lua (9.52%), anti-Lub (19.05%) and anti-Bg(a) (4.76%). A total of 23.81% of alloantibodies were not identified. |
|
2015/ Canada39 |
Describe the benchmarking program implementation. |
Cross-sectional study. 160 hospitals in the province of Ontario. |
Key elements of the successful benchmarking strategy included dynamic targets, a comprehensive and evidence-based implementation strategy, continuous information sharing, and a robust data system to track information. |
|
2015/ Netherlands40 |
Describe a method to develop a new set of actionable quality indicators and response checklist for the Dutch ICU. |
Methodological study. 8 intensivists, participants of the National Assessment of Intensive Care registry, with the Dutch ICU as a setting. |
From the study, 7 indicators emerged: protocol for blood transfusions; percentage of patients who received RBC transfusion; RBC units transfused; percentage of lost blood products; transfusion delay; percentage of patients who received FFP; and number of transfused FFP units. |
|
2015/ United Kingdom41 |
Outline plans to harness the power of digital information to support the implementation of best practices in transfusion medicine and Patient Blood Management (PBM) |
Retrospective study. UK healthcare institutions. |
In transfusion, big data has been used for benchmarking, detecting transfusion-related complications, determining patterns of blood use, and scheduling blood orders for surgery. |
|
2016/ Saudi Arabia42 |
Report the two-year experience of using transfusion-related quality indicators as a tool in the hemovigilance system implementation. |
Cross-sectional study Quality indicators from King Abdulaziz University Hospital, Jeddah, Saudi Arabia. |
A total of 84 transfusion reactions were reported, most of which were allergic reactions (79.7%). Errors or incident were reported with approximately 0.3% of total samples/orders shipped. FFP wastage per expiration was 21.3% of the total FFP wastage. |
|
2016/ India43 |
study the usefulness of monitoring the central indicators of the National Accreditation Council for Hospitals and Health Professionals (CNAHP) in blood transfusion and in maintaining hemovigilance. |
Cross-sectional study. 4 CNAHP core indicators in blood transfusion from a tertiary hospital accredited by this Council. |
An improvement in quality was observed by monitoring the central indicators with a decrease in blood and blood product waste, a decrease in the average time of delivery of blood and blood products and a lower number of transfusion reactions. |
|
2016/ India44 |
Measure the impact of monitoring performance indicators and their use as a continuous quality improvement tool. |
Cross-sectional study. 7 performance indicators of a hospital-based blood bank with tertiary care. |
Workload trended upwards, which helped plan consumable purchases and manage labor. Monitoring blood use and disposal contributed to the efficient management of blood supplies. |
|
2016/ USA45 |
Create a blood order algorithm for cardiac surgery cases that would decrease the number of unnecessary matching tests. |
Cross-sectional study. 264 adult patients undergoing cardiac surgery in a hospital. |
Of the 264 patients requesting a transfusion, 98 were transfused, resulting in an overall transfusion probability of 37.12%. A total of 1.175 RBC were matched, but 370 RBC were transfused, resulting in an index of 3.17. The average number of RBC transfused per procedure was 1.4. |
|
2016/ Pennsylvania46 |
Understand the worldwide reach of RBC match and issuance testing practices and measure efficiency using a new quality indicator. |
Cross-sectional study. 52 blood transfusion services (North America, Europe, Asia, South America and Middle East). |
Data for calculating the ratio of RBC matched and RBC transfused were provided by 22 respondents, and the mean was 1.30 ± 0.34. There was no difference in matching and transfusion ratios between services using electronic or serological cross-matching techniques. |
|
2016/ Nigeria47 |
Assess routinely submitted blood transfusion requests to determine correctness, completeness, and consistency. |
Cross-sectional study. 2,084 laboratory request forms sent to the Department of Hematology (DH) and Blood Transfusion Services (BTS) at Aminu Kano University Hospital, Kano, Nigeria. |
The blood transfusion request completeness was 89.5% for DH and 81.2% for BTS. Patient identification information was 100% complete for DH, while only patient name was 100% complete for BTS. Incomplete information was found on BTS forms for physician signature (60.8%) and recipient laboratory signature (63.5%). None of the DH and 9.4% of BTS met all the quality indicator indices. |
|
2017/ Kenya48 |
Examine physicians’ ability to obtain blood components when needed in Kenya and examine hemoglobin measurement use as a guide to transfusion. |
Cross-sectional study. 14 hospitals belonging to the Clinical Information Network, a set of Kenya county referral hospitals. |
5% of admissions had requested blood transfusion. Of all requested transfusions, 82% were administered and documented, and 75% of them were administered on the same day as the request. Children who had a requested transfusion but did not receive the prescribed transfusion had a 20% mortality, compared to 12% among those transfused. |
|
2017/ Spain49 |
Check which internal quality indicators are being used in hospital transfusion services and how they are defined, and determine the impact of these indicators on the quality system management. |
Cross-sectional study. 76 hospital transfusion services located in Spain. |
Indicators were assigned to some basic categories, such as transfusion process, transfusion activity and stock management, hemovigilance, stem cell transplantation, transfusion laboratory, quality management system, blood donation, apheresis and therapeutic activities, and immunohematology of pregnancy. |
|
2017/ USA50 |
Determine what percentage of academic hospitals in the United States employ a massive transfusion protocol and learn the details of this commonly used protocol. |
Intervention study. 107 medical directors of US-accredited clinical anatomy and pathology residency programs. |
A total of 56 directors responded that they had a massive transfusion protocol in place, and 98.2% rely on it. The RBC to FFP ratio of 1:1 appeared in 69.9% of the institutions. The majority, 64.3%, provide six or more units of RBC in the first massive transfusion package. |
|
2017/ Canada51 |
Summarize current limitations in indicator-based assessment of blood bank stock efficiency and propose the creation of process maps as an ideal methodology for application to stock management research. |
Descriptive study.
|
The blood component journey from receipt of stock to final disposal is complex and is related to many internal and external influences, and indicators may be inadequate to understand the complexity of supply chain. Process maps contribute to stock analysis, and modern laboratory information systems can track almost any complex blood bank process. |
|
2017/ Denmark52 |
Reduce unnecessary exposure to RBC transfusion in patients without bleeding. |
Quantitative and qualitative Study (phase 1 - cross-sectional; phase 2 - validity; phase 3 - intervention study). Two ICUs (general and cardiothoracic) and five surgical wards (urology, abdominal, vascular, orthopedic and cardiothoracic) at the Rigshospitalet hospital in Denmark. |
At the hospital level, transfusion above the upper limit of the guideline decreased from 23 to 10%, and transfusion at or below the restrictive hemoglobin level of 7.3 g/dl increased from seven to 19%. The percentage of single-unit transfusions increased from 72 to 78%, and most transfusion rates and volumes decreased significantly. Red blood cell use decreased by 41% in surgical procedures and 28% in hospitalizations. |
|
2018/ Cuba53 |
Show the results of implementing a hemovigilance program. |
Cross-sectional study. 51 medical offices located in the municipality of Jovellanos, province of Matanzas, Cuba. |
The degree of knowledge in transfusion medicine of professionals has increased, and donor and recipient reactions decreased, also reducing the severity of reactions. Moreover, the number of transfusions performed decreased by 40.5%. |
|
2018/ India54 |
Study the response time for RBC emission and the contributory procedures that lead to a delay in the initiation of red blood cell transfusion in hospitalized patients. |
Cross-sectional study. 2,022 blood orders from a tertiary hospital blood bank in Tier III city in a northern Indian state. |
The mean time from request to start blood transfusion was 135 minutes in the study. Match and RBC emission tests accounted for approximately 47% of this delay. |
|
2018/ India55 |
Investigate RBC temperature during transfusion chain, including storage, transport and transfusion. |
Descriptive study. 100 RBC sent from the blood bank to the ICU heart surgery and the operating room at one teaching hospital located in Mashhad, Iran. |
10% of the 121,262 temperature samples recorded (for 2 min) were outside the standard range. Of these, 65, 17, 13 and 5% of the samples referred to the blood bank, operating room, transport and cardiac surgical ICU, respectively. |
|
2019/ Spain56 |
Identify critical failures in the blood transfusion process in a medium-sized urban hospital in Madrid, according to the failure modes and effects analysis scores. |
Cross-sectional study. 10 members of a multidisciplinary team of blood transfusion services and a medium-sized urban hospital. |
The failures identified were: transmitting information about the transfusion request; patient and sample identification; requested match tests; blood transfusion components; transfusion control document completion and submission; reporting of transfusion reactions. |
|
2019/ India57 |
Improve blood supply chain service levels by maximizing availability and minimizing blood waste. |
Cross-sectional study. Demand and supply data for blood components from 152 hospitals large and medium-sized businesses in Chennai, India. |
Scarcity index and total wastage index are used as indicators of performance measures. It was found that the pull system model outperforms the existing model and the zone model by achieving zero waste. |
|
2019/ Canada58 |
Describe the “AB” FFP adequacy index as a key quality indicator to document the appropriate use of “AB” FFP group for patients with unknown blood group and/or patients who require the use of AB FFP group. |
Cross-sectional study. “AB” FFP units used at Vancouver General Hospital, located in Vancouver, British Columbia, Canada. |
The “AB” FFP adequacy index showed inappropriate use in patients not belonging to the AB group, being used to prevent expiration after thawing. Comparing the pre- and post-implementation periods of this analysis, it was observed that the index improved. |
|
2020/ Serbia59 |
Provide work quality assessment showing the ratio of RBC matched for transfusion for certain areas of surgery or particular surgical indications. |
Cross-sectional study. 341 patients assisted by the Department of Pre-Transfusion Testing and Blood Distribution of the Serbian Blood Transfusion Institute. |
The ratio between matched RBC and transfused RBC was 2.25, and it was verified that there are variations between departments. For the abdominal surgery and resuscitation departments, where non-compliant RBC were requested, the index was < 2. The other departments had index > 3 for almost all therapeutic areas. |
|
2020/ India60 |
Analyze the incidence and nature of adverse events associated with blood transfusion, reported to the blood bank of a university hospital, with emphasis on corrective and preventive actions. |
Cross-sectional study. Adverse transfusion reactions reported to the Blood Bank of the Department of Pathology of a hospital, during a period of 42 months. |
A total of 189 transfusion reactions were found in patients aged between 12 and 80 years, with a predominance of females. Reactions associated with whole blood transfusion were common (50%), followed by RBC transfusion (1.4%) and PC (0.8%). Non-hemolytic febrile reactions occurred in 122 cases, followed by allergic reactions, 43, related to RBC transfusion, while hemolytic reactions showed association with whole blood transfusion. No late reactions or mortality were found. |
|
2021/ Brazil61 |
Identify weaknesses and risks in the blood transfusion process and propose using a tool called an indicator matrix to prioritize indicators with a focus on transfusion safety. |
Observational study. Bulletins and reports published by the National Health Surveillance Agency, Ministry of Health and General Coordination of Blood and Blood Products in the last 5 years. |
Indicator selection aims to improve the processes involved in the entire blood cycle, and using the tool aims to facilitate the choice of these indicators according to the scenario of each institution, from a blood therapy service to a transfusion agency. |
|
2021/ Africa62 |
Describe the pilot results of the Integrated Global Benchmarking Tool for hemovigilance function in 10 countries in sub-Saharan Africa. |
Descriptive cross-sectional study. Existing hemovigilance systems in 10 countries in sub-Saharan Africa. |
Countries showed variability in hemovigilance implementation and performance. The lowest scores were for organizational indicators and human resources, and the highest were observed for the transparency promotion mechanism and for monitoring regulatory performance indicators. |
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2021/ Italy63 |
Identify and analyze logistical risks as well as define responses to improve the traceability of blood bags, focusing on hospital wards. |
Descriptive study. Chain of blood supply that occurs within wards. |
There is a need to analyze the transfusion process from the context and mapping of processes; risk identification; analysis of transfusion process criticalities and definition of risk responses;monitoring and assessment of key performance indicators. |
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2021/ Spain64 |
Describe the maturity assessment model, the benchmarking program and the feasibility of implementing it. |
Cross-sectional study. 59 hospitals in Spain. |
A total of 181,826 blood transfusion requests were analyzed, which proves the feasibility of implementing a sustainable model to measure and compare clinical practice and PBM results in hospitals in Spain. |
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2021/ South Korea65 |
Compare the color change of the Freshzon prototype with that of two other prototypes, Safe-T-Vue 10 and Blood Temp 10, approved by the US Food and Drug Administration, for monitoring RBC temperature based on the 30-minute rule.
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Experimental study. 91 units were transfused to patients in the clinical setting at three tertiary hospitals in Seoul, Korea, from July to November 2019. |
In 83 units, the average time for color change differed between prototypes. Furthermore, 95.2% of Freshzon prototype tags changed color after 30 minutes of emission, while 96.4% of Safe-T-Vue 10 and 98.8% Blood Temp 10 changed color within 30 minutes of emission. In the 8 units stored in refrigerators, color change time between prototypes was different. |
Caption: RBC - Red Cell Concentrate; USA - United States of America; PC - Platelet Concentrates; FFP - Fresh Frozen Plasma; HLA - Human Leucocyte Antigen; ICU - Intensive Care Unit; Hb – hemoglobin; VUMC - Vanderbilt University Medical Center; SUMC - Stanford University Medical Center; PBM - Patient Blood Management; CNAHP - National Accreditation Council for Hospitals and Health Professionals; DH - Department of Hematology; BTS - Blood Transfusion Services.
From reading the body of analysis of this review, 53 transfusion-related indicators were identified. It is noteworthy that, among the studies, only one is Brazilian. These indicators were organized into four thematic segments, which are related to transfusion process management and described in Chart 2.
Chart 2 – Summary of transfusion-related indicators identified and organized according to segments, Florianópolis/SC, Brazil, 2022
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Identified indicators
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Blood component stock management indicators
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1. Distribution rate of blood components61 |
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2. Disposal rate by blood component and associated causes (expired, thawed, outside the proper temperature, > 30 minutes outside the ideal storage temperature)19,21,25,31,39-40,42-44,49,51,55,57,63,65 |
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3. Average storage time of blood components31,51,63 |
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4. Mean time between blood bag collection and transfusion22,63 |
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5. Percentage of units for which there is no record in the hospital blood bank for their final destination33,49 |
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6. Rate of blood components received without temperature recording33,63 |
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7. Daily maintenance of the strategic stock needed to meet the three-day demand61 |
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8. Number of days without strategic stock/days/month57,61 |
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9. Total number of blood components stored63 |
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Production transfusion process indicators
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10. Whole blood transfusion rate by blood component and blood group31-32,35,37,40,43, 53,61,63 |
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11. Transfusion rate of blood components per patient and hospitalized patient18,40,42,52,53,61 |
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12. RBC cross match ratio to blood transfusion per surgical procedure36,45 |
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13. Percentage of RBC transfusion according to the surgical procedure36,45 |
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14. Number of samples received by the blood bank along with the transfusion reaction form34 |
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15. Proportion of prescribed transfusions/total transfusions56 |
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16. Percentage of blood groups performed and screening for irregular antibodies identified44,49 |
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17. Rate of patients with 1 RBC transfusion52,64 |
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18. Transfusion rate of blood components by type of procedure, clinical situation and diagnosis (pregnant women, postpartum women)18,41-42,49 |
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19. Percentage between the ratio of use of FFP and RBC49 |
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20. RBC transfusion rate associated with the surgical procedure36,45 |
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21. RBC index matched and effectively transfused19,31,44,46,49,59,61 |
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Transfusion process assessment indicators |
22. Rate of incidents related to blood component distribution64 |
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23. Transfusion request rate met according to transfusion protocols23,26,28,31,33,35,37,52,61,64 |
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24. Transfusion reaction rate (overall, by type of reaction, severity, by type of blood component, associated with failure, near miss, associated with transfusion, or not) 20,23,27,29,31,33-34,37-38,41-44,49,53,55-56,60-61,63 |
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25. Surgical reservation request rate according to the institutional protocol41,61 |
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26. Rate of incidents related to request forms for blood components/exams (incomplete requests)23,33,42,47,49,63 |
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27. Rate of incidents related to sample collection24,42,49 |
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28. Rate of incidents related to pre-transfusion testing/exams31,42,49,63 |
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29. Rate of pre-transfusion electronic identification verification35 |
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30. Rate of transfused blood components according to the results of laboratory tests and patients’ clinical conditions26,28,31,35,37,52,64 |
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31. Response time from transfusion request to start of blood transfusion30,31,33,40,43-44,48-49,51,54 |
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32. Rate of transfusion feedback sent to the Transfusion Agency.63 |
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33. Return rate of non-transfused blood bags to the blood bank and record keeping35,49,63 |
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34. Rate of returned transfusion control documents56 |
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35. Rate of completion and signature of the consent form for transfusion33,49 |
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36. Rate of compliance with match guidelines during blood component selection49,58 |
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37. Short-term morbidity and mortality rate of patients undergoing blood transfusion23,31 |
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38. Blood transfusion efficacy assessment rate23 |
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39. Rate of patients undergoing transfusion whose vital signs were monitored and documented33 |
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40. Double-check registration rate in transfusion-related procedures33 |
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Transfusion process support indicators
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41. Index of blood bank staff receiving training on circuit and transfusion practice17,49,56 |
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42. Technical knowledge index regarding blood transfusion44,53,61 |
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43. Availability of computer server with instructions for blood transfusion components56 |
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44. Participation rate in proficiency test and participation in external quality control49,61 |
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45. Index of professionals from clinical units receiving circuit and transfusion training17,49,56 |
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46. Active Transfusion Committee and hemovigilance (presence, number of meetings, responsible person, number of hours devoted to hemovigilance) 17,35,61-62 |
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47. Rate of incidents related to quality management (lack of indicators, lack of data)35,49,56 |
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48. Rate of clinical units with availability of printed instructions on blood transfusion56 |
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49. Presence of protocol and policies for blood transfusions 17,40 |
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50. Assessment of transfusion costs in different Diagnosis Related Groups 18 |
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51. Assessment of massive transfusion protocol use49-50 |
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52. Rate of suggested key performance indicators for PBM monitored41 |
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53. Percentage of surgical episodes in which tranexamic acid was administered41 |
Caption: FFP – Fresh Frozen Plasma; RBC - Red Cell Concentrate; PBM - Patient Blood Management.
Blood component stock management indicators
This segment comprises the indicators related to blood component stock management, which in this study totaled nine (18%), being the “Disposal rate per blood component and associated causes (expired, thawed, out of proper temperature, > 30 minutes out of ideal storage temperature)” the most evident, as it was present in 15 (30%) articles. Another important indicator in this segment was “Average storage time of blood components”, found in 3 (6%). The other indicators emerged in one or two articles.
Production transfusion process indicators
In this segment are those related to the numbers generated in the transfusion process, which comprised 12 (24%) indicators. The “Whole blood transfusion rate by blood component and blood group” was present in 9 (18%) articles, followed by “Index of RBC matched and effectively transfused”, in 7 (14%), “Rate of blood transfusion components per patient and hospitalized patient”, in 6 (12%), “Rate of blood transfusion components by type of procedure, clinical situation and diagnosis (pregnant women, puerperal women)”, in 4 (8%). The other listed indicators were evidenced in one or two articles.
Transfusion process assessment indicators
In this segment are the indicators of transfusion process assessment, comprising 19 (38%). Among them, the “Transfusion reaction rate (overall, by type of reaction, severity, by type of blood component, associated with failure, near miss, associated with transfusion, or not)” was highlighted, being evidenced in 20 (40%) articles, followed by “Transfusion request rate met according to transfusion protocols” and “Response time from transfusion request to start of blood transfusion”, which were present in 10 (20%); “Rate of blood components transfused according to with the results of laboratory tests and patients’ clinical conditions”, in 7 (14%); “Rate of incidents related to request forms for blood components/exams (incomplete requests)”, in 6 (12%); “Rate of incidents related to pre-transfusion testing/examinations”, in 4 (8%); “Rate of incidents related to sample collection” and “Rate of return of non-transfused blood bags to the blood bank and record keeping”, in 3 (6 %) articles. The other indicators were identified in one or two articles.
Transfusion process support indicators
In this segment, there are 13 (26%) indicators related to actions to support the transfusion process, of which the following stand out: “Active Transfusion Committee and hemovigilance (presence, number of meetings, responsible person, number of hours devoted to hemovigilance)” present in 4 (8%) articles, “Index of blood bank staff receiving training on circuit and transfusion practice”, “Technical knowledge index regarding blood transfusion”, “Index of professionals from clinical units receiving circuit and transfusion training”, “Rate of incidents related to quality management (lack of indicators, lack of data)” were evidenced in 3 (6%). The other indicators were found in one or two articles.
Indicators are tools that allow us to know the situation that we want to change, establish priorities, identify objectives and translate them into goals, assess processes, plan the necessary redirections and verify the results and impacts obtained.66 Thus, they subsidize service improvements with assertive decisions and resource optimization.11
When it comes to the health area, more specifically in hemotherapy, in Brazil, it is legally necessary for hemotherapy services to adopt indicators and targets for monitoring the performance of their processes throughout the blood cycle.2 Supported by this statement, the study contributed to identifying the indicators used in the national and international literature and categorizing them according to the process that it is willing to assess.
The Indicators for managing blood component stock segment was the one that presented the least indicators, compared to the others. However, the “Disposal rate by blood component and associated causes (expired, thawed, outside the proper temperature, > 30 min outside the ideal storage temperature)” indicator was present in 30% of articles. This is due to blood components used in blood transfusion that have an expiration date and an adequate way of storage to maintain their characteristics and clinical viability.2 However, when these are not stored or handled properly, they need to be disposed of.
In the case of disposal, it is necessary to consider, in addition to the technical aspects, the financial value. According to an estimate made by the WHO, only the disposal of RBC in the countries of Latin America and the Caribbean, in 2011, represented a loss of approximately 45 million US dollars, with a respective cost of 20 million US dollars for the Brazilian state.67 This scenario encourages the need to know the factors that influence the disposal of processed blood units, with the aim of listing actions to prevent those considered potentially avoidable.68
Still on stock management, another indicator evidenced in 6% of the articles was the “Average storage time of blood components”. This indicator permeates some discussions regarding the physical and metabolic alterations that RBC may undergo with storage time, even if this occurs in the recommended way. Some studies have found that storage time may be associated with the development of red blood cell oxidative stress, metabolic deficiency, decrease in ATP and 2,3-DPG, increase in inflammatory cells, adhesion to endothelial cells, activation of the complement system, changes in coagulability and hemolysis.69-70
Although the time of RBC collection does not influence mortality, there is evidence indicating that adverse events related to red blood cell transfusion are more pronounced in susceptible patient populations, such as those in intensive care, trauma, cardiac surgery and newborns, while other patient populations do not appear to be affected by transfusion of older RBC.70-71
In the Transfusion process production indicators segment, the “Whole blood transfusion rate by blood component and blood group” was the most cited, present in 18% of articles. This incidence occurs because the numbers related to the number of transfusions performed, taking into account some variables, such as hospital size, number of beds, specialties attended, make it a necessary tool that allows the planning of work demand by blood services and guides the application of initiatives such as PBM.72 In Brazil, it serves as a monitoring tool by the National Health Regulatory System for indicators of blood component production and use.73 Moreover, another essential role of this indicator is the performance of benchmarking among other institutions, collaborating for continuous improvement of the transfusion process.74
The “RBC index matched and effectively transfused” was also representative, as data from developed countries show that 40 to 70% of units of blood prepared for transfusion are actually transfused.75 Blood reserves for surgical patients contribute to this statistic, which requires spending on supplies and human resources and prevents using these units reserved for other hospital demands, leading to the loss of blood components due to expiration date.76
Another segment that emerged in the study was “Transfusion process assessment indicators”, which presented the highest number of indicators. It can be said that this is due to the fact that it includes the main items for assessing the transfusion process quality, which have a direct impact on the care provided to the patient.
Among those that stood out the most is the “Transfusion reaction rate (overall, by type of reaction, severity, by type of blood component, associated with failure, near miss, associated with transfusion, or not)”, evidenced in 40% of articles. Transfusion reaction is defined as an adverse event associated with blood transfusion components, observed in up to 1% of all transfusions performed, which can be fatal.77 There is potential for error at every step of the transfusion process, and learning from incidents should lead to improvements in health care.6 Additionally, identifying the transfusion reaction rate is an important step in an institution’s risk management, as it enables the development of strategies to increase the transfusion process quality.78
Other indicators listed in this segment were representative, as they are part of legal aspects related to the blood transfusion process. This is the case of “Transfusion request rate met according to transfusion protocols”, “Rate of incidents related to request forms for blood components/exams (incomplete requests)” and “Rate of transfused blood components according to the results of laboratory tests and patients’ clinical conditions”. According to regulations, blood transfusion requests cannot be incomplete, erased or illegible, they need to present the diagnosis and clinical indication of the blood component, as well as be in line with institutional protocols.2
The “Response time from transfusion request to start of blood transfusion” was also frequently highlighted. This is an important quality indicator, as delays in transfusions continue to contribute to patient deaths, and communication problems were identified in 33.3% of reported cases of delays, being considered one of the contributing factors.6,79 In addition to these, indicators such as “Rate of incidents related to sample collection” and “Rate of incidents related to pre-transfusion testing/exams” were also observed, whose incidents can lead to adverse transfusion events, including acute hemolytic transfusion reactions and death.6
Sample collection and pre-transfusion tests are critical steps in the transfusion process and need to be monitored and assessed. A study carried out between 2006 and 2015 in Canada described that 42,363 sample collection errors and 14,666 sample handling errors were reported in 1,736,512 samples received by the 23 blood banks. Of these errors, 24.5% were classified as high severity, which are related to sample labeled with incorrect patient identification, no identification, wrong patient collected, incomplete/illegible label for the main patient identifiers, incorrect identification wristband/ not available. The transfusion request and sample ID do not match.80 With regard to failures in pre-transfusion tests, in 2021, in the United Kingdom, 389 events were reported, with the highest proportion of errors occurring in the stages of labeling, availability, handling and storage of components (31.4%), followed by testing (29.3%) and component selection (23.4%).6 With this, we observe the critical areas of the transfusion process and which require more care, attention and knowledge to ensure safe transfusions.
The last segment described, “Transfusion process support indicators”, included 26% of indicators, highlighting “Active Transfusion Committee and hemovigilance (presence, number of meetings, responsible person, number of hours devoted to hemovigilance)”, present in 8% of articles. This indicator is related to a WHO determination that states that hospitals need to have transfusion committees to ensure the appropriate clinical use of blood, effective staff training and clinical practice monitoring and assessment. This committee is responsible for supervising and implementing hemovigilance in the hospital, regularly reviewing results and monitoring the effectiveness of improvement measures.81
Another three indicators that were highlighted are related to the training process of teams that perform blood transfusions. The technical knowledge of professionals who are directly linked to the blood transfusion process is essential. These indicators are the subject of several publications, mainly in the field of nursing, as can be seen in some studies.nursing professionals’ knowledge is reduced in this area, and it is necessary to improve knowledge and skills to ensure good practices in blood transfusion.1,82-83
In addition to those cited, the “Incident rate related to quality management (lack of indicators, lack of data)” appeared in 6% of articles. This is due to a WHO recommendation, which determines that an effective quality management system must be implemented within each organization responsible for elements of the transfusion chain. This system should ensure consistent practice, through using written procedures and regular audits, and that there is a cycle of quality improvement that produces demonstrable results.81
There was a concentration of indicators to assess the operational and tactical scope of the transfusion process, mainly blood component stock management and production numbers, with a gap with regard to the assessment of care provided to blood recipients and transfusion safety and low production of Brazilian articles on this topic. This evidence justifies the need for studies that address this issue, especially at the national level, in order to assess the transfusion process also at the strategic level, emphasizing the care provided.
The development of this study reinforces the importance of having indicators that monitor and assess the transfusion process in order to identify the risks related to this therapy, the improvements that can be made, thus contributing to transfusion quality and safety. Furthermore, it made it possible to show that institutions seek to adopt these indicators as a way of assessing processes and adapting them to current legislation.
Given the overview of scientific production presented by this review, it was observed that using an indicator is a necessary tool to assess and monitor the transfusion process, being used by several health institutions around the world. The growing concern for improving the transfusion process quality was evidenced by the presence of a list of indicators that assess and monitor the management of blood component stocks, production numbers of the transfusion process, transfusion process stages and support actions, despite that there are few indicators related to the care provided to patients undergoing blood transfusion, indicating the need to improve studies on the subject.
In the case of the Brazilian context, which has particularities in its health system when compared to other countries, such as socioeconomic heterogeneity and access to technologies, there is a shortage of publications on the subject. It is noted the importance of using indicators for the transfusion process assessment as well as the publication of studies that address this issue, in order to disseminate best practices and contribute to benchmarking among health institutions.
1. Noor NHM, Saad NH, Khan M, Hassan MN, Ramli M, Bahar R, et al. Blood transfusion knowledge among nurses in Malaysia: a university hospital experience. Int J Environ Res Public Health. 2021;18(21):11194. doi: 10.3390/ijerph182111194
2. BRASIL. Ministério da Saúde. Portaria de consolidação nº 05, de 28 de setembro de 2017. Consolidação das normas sobre as ações e os serviços de saúde do Sistema Único de Saúde. Brasília, DF: Ministério da Saúde, 2017. Disponível em: https://www.gov.br/aids/pt-br/centrais-de-conteudo/copy_of_portarias/2021/portaria-de-consolidacao-no-5-de-28-de-setembro-de-2017. Acesso em: 17 mar. 2023.
3. Feitosa ACF, Ferreira Júnior OC. O uso de indicadores nas diversas etapas do ciclo do sangue: uso de ferramenta de seleção. J Bras Patol Med Lab. 2021;57:1-8. doi: 10.5935/1676-2444.20210049
4. Anthes E. Transfusions are one of the most overused treatments in modern medicine, at a cost of billions of dollars. Researchers are working out how to cut back. Nature. 2015;520:24-6. doi: 10.1038/520024a
5. Simancas-Racines D, Montero-Oleas N, Vernooij RWM, Avelo-Rodriguez I, Fuentes P, Gich I, et al. Quality of clinical practice guidelines about red blood cell transfusion. J Evid Based Med. 2019;12(2):113-24. doi: 10.1111/jebm.12330
6. Serious Hazards of Transfusion (SHOT). Annual SHOT Report 2021 [Internet]. London (UK): SHOT; 2022 [cited 2022 Jul 10]. Available from: https://www.shotuk.org/wp-content/uploads/myimages/SHOT-REPORT-2021-FINAL-bookmarked.pdf
7. World Health Organization (WHO). Blood safety and availability [Internet]. Genebra (CH): WHO; 2020 [cited 2022 Jul 10]. Available from: https://www.who.int/en/news-room/fact-sheets/detail/blood-safety-and-availability
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9. Zillkner-Jansen PYZ, Janssen MP, Jong AJWVT, Schipperus MR, Osselton JCW. Quality indicators for the hospital transfusion chain: a national survey conducted in 100 dutch hospitals. Vox Sang. 2015;109:287-95. doi: 10.1111/vox.12281
10. Silveira TVL, Prado Júnior PP, Siman AG, Amaro MOF. Opinião dos enfermeiros sobre a utilização dos indicadores de qualidade na assistência de enfermagem. Rev Gaúcha Enferm. 2015;36(2):82-8. doi: 10.1590/1983-1447.2015.02.47702
11. Bitencourt GR, Ferreira AFM, Amaral MHSP, Renault SMG, Silva JO, Santos KM. Uso de indicadores na avaliação do serviço de educação permanente: reflexão dos pilares da qualidade. Rev Baiana Enferm. 2021;35:e36844. doi: 10.18471/rbe.v35.36844
12. Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008;17(4):758-64. doi: 10.1590/S0104-07072008000400018
13. Sousa LMM, Marques-Vieira CMA, Severino SSP, Antunes AV. Metodologia de revisão integrativa da literatura em enfermagem. Rev Investigação Enferm [Internet]. 2017 [acesso em 2022 nov 17];21:17-26. Disponível em: http://www.sinaisvitais.pt/images/stories/Rie/RIE21.pdf#page=17
14. World Health Organization (WHO). Blood safety and clinical technology: 2000-2003 strategy. Geneva (CH): World Health Organization; 2001 [cited 2022 Feb 09]. Available from: https://apps.who.int/iris/handle/10665/66832
15. BRASIL. Ministério da Saúde. Lei nº 10.205, de 21 de março de 2001. Regulamenta o § 4o do art. 199 da Constituição Federal, relativo à coleta, processamento, estocagem, distribuição e aplicação do sangue, seus componentes e derivados, estabelece o ordenamento institucional indispensável à execução adequada dessas atividades, e dá outras providências. Brasília, DF: Ministério da Saúde, 2001. Disponível em: https://www.planalto.gov.br/ccivil_03/leis/leis_2001/l10205.htm. Acesso em: 10 jul. 2022.
16. Bardin L. Análise de Conteúdo. São Paulo: Edições 70; 2016.
17. Murphy MF, Wilkinson J, Lowe D, Pearson M. National audit of the blood transfusion process in the UK. Transfus Med. 2001;11(5):363-70. doi: 10.1046/j.1365-3148.2001.00330.x
18. Syrjälä MT, Kytöniemi I, Mikkolainen K, Ranimo J, Lauharanta J. Transfusion practice in Helsinki University Central Hospital: an analysis of diagnosis-related groups (DRG). Transfus Med. 2001;11(6):423-31. doi: 10.1046/j.1365-3148.2001.00338.x
19. Novis DA, Renner S, Friedberg R, Walsh MK, Saladino AJ. Quality Indicators of blood utilization: three college of American pathologists Q-Probes studies of 12,288,404 red blood cell units in 1639 hospitals. Arch Pathol Lab Med. 2022;126(2):150-6. doi: 10.5858/2002-126-0150-qiobu
20. Andreu G, Morel P, Forestier F, Debeir J, Rebibo D, Janvier G, et al. Hemovigilance network in France: organization and analysis of immediate transfusion incident reports from 1994 to 1998. Transfusion. 2002;42(10):1356-64. doi: 10.1046/j.1537-2995.2002.00202.x
21. Novis DA, Renner S, Friedberg RC, Walsh MK, Saladino AJ. Quality indicators of fresh frozen plasma and platelet utilization. Arch Pathol Lab Med. 2002;126(5):527-32. doi: 10.5858/2002-126-0527-QIOFFP
22. Murrell Z, Haukoos JS, Putnam B, Klein SR. The effect of older blood on mortality, need for ICU care, and the length of icu stay after major trauma. Am Surg. 2005;71(9):781-5. doi: 10.1177/000313480507100918
23. Iorio A, Basile M, Marchesini E, Palazzesi GP, Materazzi M, Marchesi M, et al. Audit of the clinical use of fresh-frozen plasma in Umbria: study design and results of the pilot phase. Blood Transfus. 2008;6(4):211-9. doi: 10.2450/2008.0042-07
24. Goodnough LT, Viele M, Fontaine MJ, Jurado C, Stone N, Quach P, et al. Implementation of a two-specimen requirement for verification of ABO/Rh for blood transfusion. Transfusion. 2009;49(7):1321-8. doi: 10.1111/j.1537-2995.2009.02157.x
25. Heitmiller ES, Hill RB, Marshall CE, Parsons BJ, Berkow LC, Barrasso CA, et al. Blood wastage reduction using Lean Sigma methodology. Transfusion. 2010;50(9):1887-96. doi: 10.1111/j.1537-2995.2010.02679.x
26. Leal-Noval SR, Arellano-Orden V, Maestre-Romero A, Muñoz-Gómez M, Fernández-Cisneros V, Ferrándiz-Millón C, et al. Impact of national transfusion indicators on appropriate blood usage in critically ill patients. Transfusion. 2011;51(9):1957-65. doi: 10.1111/j.1537-2995.2011.03091.x
27. Awa BA, De Wever A, Almazrooa A, Habib H, Al-Noury K, El Deek B, et al. The impact of accreditation on patient safety and quality of care indicators at King Abdulaziz University Hospital in Saudi Arabia. Res J Med Sci. 2011;5(1):43-51. doi: 10.3923/rjmsci.2011.43.51
28. Edwards J, Morrison C, Mohiuddin M, Tchatalbachev V, Patel C, Schwickerath VL, et al. Patient blood transfusion management: discharge hemoglobin level as a surrogate marker for red blood cell utilization appropriateness. Transfusion. 2012;52(11):2445-51. doi: 10.1111/j.1537-2995.2012.03591.x
30. Osselton JCW, Jong AJWVT, Jansen PYJ, Watering LMGV, Brand A, Bom JGV, et al. Variation between hospitals in rates of reported transfusion reactions: is a high reporting rate an indicator of safer transfusion? Vox Sang. 2013;104(2):127-34. doi: 10.1111/j.1423-0410.2012.01642.x
31. McClain CM, Hughes J, Andrews JC, Blackburn J, Sephel S, France D, et al. Blood ordering from the operating room: turnaround time as a quality indicator. Transfusion. 2013;53(1):41-8. doi: 10.1111/j.1537-2995.2012.03670.x
32. Ayob Y. Monitoring transfusion practice. ISBT Science Series. 2014;9(1):72-9. doi: 10.1111/voxs.12089
33. Stonemetz JL, Allen PX, Wasey J, Rivers RJ, Ness PM, Frank SM. Development of a risk-adjusted blood utilization metric. Transfusion. 2014;54(10 Pt 2):2716-23. doi: 10.1111/trf.12548
34. Pogaku V, Dossary SA, Bernawi HA, Sohaibani MA, Malki AA. Operative blood transfusion quality improvement audit. Anesth Essays Res. 2014;8(1):68-71. doi: 10.4103/0259-1162.128912
35. Hussain S, Moiz B, Ausat FA, Khurshid M. Monitoring and reporting transfusion reactions as a quality indicator – a clinical audit. Transfus Apher Sci. 2015;52(1):122-7. doi: 10.1016/j.transci.2014.03.012
36. Zijlker‐Jansen PY, Janssen MP, Jong AJWT, Schipperus MR, Wiersum‐Osselton JC. Quality indicators for the hospital transfusion chain: a national survey conducted in 100 dutch hospitals. Vox Sang. 2015;109(3):287-95. doi: 10.1111/vox.12281
37. Sheykhansari Charvadeh S, Darbandi B, Zahiri Sorouri Z, Baghersalimi A. Evaluating blood requests and transfusion practice in major surgical procedures. IJBC [Internet]. 2015 [cited 2022 jul 12];7(5):227-30. Available from: http://ijbc.ir/article-1-610-fa.html
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Author contributions
1 – Daiana de Mattia
Corresponding author
Nurse, Mater’s Degree - daimattia@gmail.com
Research conception and development, manuscript writing, review and approval of the final version.
2 – Dulcinea Ghizoni Schneider
Nurse, PhD - dulcineia.schneider@ufsc.br
Research conception and development, manuscript writing, review and approval of the final version.
3 – Francine Lima Gelbeck
Nurse, PhD - francine.lima@ufsc.br
Research conception and development, manuscript writing, review and approval of the final version.
Editor-in-Chief: Cristiane Cardoso de Paula
Associate Editor: Etiane de Oliveira Freitas
How to cite this article
Mattia D, Schneider DG, Gelbcke FL. Transfusion process assessment indicators: integrative review. Rev. Enferm. UFSM. 2023 [Access at: Year Month Day]; vol.13, e17: 1-27. DOI: https://doi.org/10.5902/2179769271970