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ORIGINAL ARTICLE
Year : 2022 | Volume
: 11
| Issue : 3 | Page : 150-157
Investigation into changes in blood transfusion indicators and returning blood products along with the cause of returning and cost calculation
Farhad Madani1, Javad Fath Gharib Bidgoli2, Seyed Amir Hassan Matini3, Hossein Akbari4
1 Department of Pediatric Hematology, Kashan University of Medical Sciences, Kashan, Iran
2 Department of Pediatrics, Student Research Committee, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
3 Department of Clinical Pathology, Kashan University of Medical Sciences, Kashan, Iran
4 Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
Correspondence Address:
Javad Fath Gharib Bidgoli
Department of Pediatrics, Student Research Committee, Faculty of Medicine, Kashan University of Medical Sciences, Kashan
Iran
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/atr.atr_26_22
Background and Objectives: Blood is a valuable source, and the wastage of blood products could impose severe impacts on healthcare. This study investigates the changes in blood transfusion indices and blood product transfusion from 2018 to 2019 in public hospitals affiliated to Kashan University of Medical Sciences. Materials and Methods: This descriptive cross-sectional study was carried out using a researcher-made checklist across five public hospitals in Kashan, Iran. The amount of cross-match/transfusion, transfusion index (TI), and T% (transfusion probability) indices were calculated and analyzed. Results: In 2018, we ordered a total of 19741 blood product units, among which 18,723 units (94.8%) were transfused. In addition, we ordered a total of 15,323 units of blood products in 2019, and 14,223 units (92.8%) were transfused. The CT ratio was 1.04 in 2018 and 1.06 in 2019, with a 2% increase. The transfused probability (T %) percentage in the studied public hospitals in 2018 was 38.04%, whereas the rate was 36.7% in 2019, with a 3.5% decline. In 2018, the TI in the studied hospitals was 0.96 and decreased to 0.85 (11%) in 2019. Moreover, the TI was higher than 0.5 in hospitals, except for Shahid Rajaei Hospital. Based on the results, the cost of blood products was 74459499405 Rials ($ 690526) in 2018 and 79073079143 Rials ($ 612115) in 2019, with a 6% increase. Conclusions: Blood order and transfusion enjoyed good conditions in public hospitals affiliated to Kashan University of Medical Sciences, though the blood order pattern was unfavorable in Shahid Rajaei Hospital.
Keywords: Blood products, blood transfusion index, hospital
Since the early 20th century, blood transfusion has been widely used in medical practice to treat hemorrhage and anemia in traumatic and nontraumatic patients. It has also been used in medical practice to treat hemorrhage and anemia. Despite limited blood availability, high costs, and serious risks associated with transfusion, blood transfusion is still excessively used.[1] Excessive blood ordering often causes serious problems for blood bankers, especially in resource-limited settings. Maximal ordering of blood products by physicians has been reported in several developing countries.[2] Type and cross-match are routine protocols in Asian countries, especially in Iran. However, screen protocols and electronic types are more common in western countries.[3] Routine protocols in Iran may cause blood product unavailability for other individuals through increased costs of blood supply, inaccessibility for an emergency, inappropriate distribution of blood units, and increased workload for blood bank staff.[4],[5]
Moreover, studies showed that many factors lead to the wastage of blood components, such as broken seals, broken bags returned after 30 min, expired units, clotted blood, or miscellaneous reasons, which are primarily due to a lack of proper knowledge and awareness.[6] One of the main causes of wastage of blood components in Iran is returning blood products after 30 min, through which the component warms up, and the risk of bacterial proliferation increases over time.[7],[8] Furthermore, blood transfusion causes variable costs according to different reasons in treatment expenditures.[9] These costs include testing and preparing suitable components for transfusion, delivering blood components to hospitals, applying to the recipient, monitoring patient for adverse outcomes, treating transfusion-induced reactions, disposing of blood components as medical waste, and filing all mandatory information.[10]
Therefore, considering the importance of blood transfusion and the lack of enough studies in this domain, especially in Iran, we investigate changes in blood transfusion indices and blood products which were transfused and returned. To this end, we can take a step further to reduce the costs associated with transfusions and blood loss and return. In severe trauma cases, there may be certain problems with blood products. Thus, the bank should have adequate supply to respond to requests. Orders should be established according to needs and regulations. This problem is fundamental in massive transfusions in emergencies and trauma.
Materials and MethodsTarget group
This retrospective study was conducted in Kashan Hospitals (Shahid Beheshti, Matini, Naghavi, Kargarnejad, Seyed Al-Shohada, and Shahid Rajaei) from November 2018 to May 2020. We searched through filed documents of blood banks in all hospitals to collect data. In this study, we recorded blood transfusion indices, blood product consumption and returning, and the reasons for returning blood products. Inclusion criteria consisted of all application forms and returning blood products from the blood bank of public hospitals affiliated to Kashan University of Medical Sciences. We excluded incomplete or distorted forms of request, injection, returning blood products, and the cases in which the reasons for returning blood products were not mentioned. Such faulty data were not trustable and were thus excluded.
Study design
The study received ethics approval from the Ethics Committee of Kashan University of Medical Sciences (IR.KAUMS.MEDNT.REC.1399.086).
We obtained written permission from the research deputy of the medical school and referred to hospitals affiliated to Kashan University of Medical Sciences. After receiving confirmation to attend the blood bank and medical records unit of these hospitals, we reviewed the medical files. The recipients' data included age, sex, nationality, and the service department that ordered the cross-match. The number of requested and consumed units, ABO/Rh grouping of the transfused blood product and patient, and the type of requested blood product (packed red blood cells, fresh-frozen plasma [FFP], platelets) were considered.
We separately reviewed blood transfusion indices, blood product consumption and return, and the reasons for returning blood products in case of product types and the respective hospital. Then, the ratio of cross-match to blood injection, percentage of injection probability, and injection index were calculated and compared based on the following formulas.[11]
In the next step, the costs of injected blood products and patients' cross-match were recorded through hospital admissions and finance units. The cost was calculated and compared using the following formula in terms of price (Rials and Dollars) and percentage:
Cost of blood transfusion and blood products in the IBTO Kashan Center + cost of blood transfusion and blood products and returning blood products in all hospitals - total costs of technical and professional fees in all hospitals = total cost of blood transfusion and blood products.
Sample size
The data were collected from the blood banks of hospitals in 2018 and 2019. In 2018, the total number of 19,741 units of blood products fulfilled the inclusion criteria. In 2019, a total of 15,323 units of blood products were ordered.
Data collection
The data were collected using a checklist that was developed based on a thorough review of the literature from different sources and included relevant information. The checklist contained sections on blood transfusion-related information and associated factors. The questions and statements were grouped and arranged according to our particular objectives. Using a structured pretested checklist, we collected the records on the ward for transfusion, the unit of requested blood, the type of requested blood component, the unit of blood cross-matched, and units of used blood after cross-match by reviewing the recipients' cards and laboratory blood bank logbooks. The details, including a hematological profile of the patient, the number of expired units (outdated) before utilization, the number of transfused blood components, and the department issuing the request, were noted.
Data analysis
The data were analyzed and reported only for patients with completed information. Deformed or defected documents were excluded due to reliability concerns. All indices were calculated (transfusion index [TI], transfusion probability, and cross-match/transfusion [C/T]) by means of the data. Statistical analysis was done using SPSS version 22 software (SPSS Inc., Chicago, IL, USA). A Kolmogorov–Smirnov test was used to evaluate the normal distribution of quantitative parameters. A Paired t-test was used for variables with normal distribution. On the other hand, Wilcoxon tests were used for variables without normal distribution. The categorical data were presented in terms of frequencies and percentages. The C/T, T%, and TI were calculated as follows:
ResultsIn public hospitals affiliated to Kashan University of Medical Sciences in 2018, a total of 19741 units of blood products were ordered, among which 18723 units (94.8%) were transfused. In 2019, 14,223 units (92.8%) were transfused out of 15323 units of ordered blood products. The findings also show that the demand and consumption of blood products from 2018 to 2019 decreased by 22 and 24%, respectively [Table 1].
Table 1: Frequency distribution of blood products requested, transfused (injected), and returned in public hospitals affiliated to Kashan University of Medical SciencesMoreover, in 2018, 96.4% of the ordered PC were transfused, which was 94.4% in 2019. In addition, in terms of FFP, PLT, and CP products, 95.9%, 92.5%, and 97.2% were used in 2018, respectively. These rates were respectively 95.1%, 89.4%, and 95.5% in 2019 [Table 1].
The highest consumption of blood products in 2018 and 2019 in Beheshti Hospital was found in 3 medical wards (2692 units) and emergency and trauma departments (1564 units), respectively. In Naghavi hospital, the highest consumption was noted in the operating room wards (20 units) and ICU (17 units). The thalassemia ward in Matini Hospital and the emergency and trauma departments in Seyed Al-Shohada Hospital had the highest consumption of blood products [Table 2].
Table 2: Frequency distribution of transfused blood products by different departments across public hospitals affiliated to Kashan University of Medical Sciences (hospital blood bank report)In the trauma and emergency wards of Shahid Beheshti hospital in 2018, 24.5% PC, 16.8% FFP, and 4.3% PLT were consumed. However, 23.6% PC, 24.7% FFP, and 10.6% PLT were injected in 2019 [Table 1].
Totally, the CT ratio in public hospitals affiliated to Kashan University of Medical Sciences was 1.04 in 2018 and 1.06 in 2019, with a 2% increase. Furthermore, the CT ratio in Rajaei hospital was much higher compared to other hospitals. The percentage of transfused probability (T %) in public hospitals in 2018 was 38.04%, which was 36.7% in 2019, with a 3.5% decrease. In addition, transfusion probability in Beheshti and Rajaei hospitals was <50% and was higher than 50% (optimal limit) in the other three hospitals. The TI in the hospitals was 0.96 in 2018, whereas the rate decreed to 0.85 (11%) in 2019. Also, the TI was higher than 0.5 (optimal limit) in other hospitals, except in Rajaei hospital, which was <0.5 [Table 3].
Table 3: Blood transfusion indices of public hospitals affiliated to Kashan University of Medical SciencesThe cost of blood products in Kashan University of Medical Sciences was 74459499405 Rials in 2018 ($ 690526) and 79073079143 Rials ($ 612115) in 2019, with a 6% increase [Table 4].
Table 4: Blood product costs in public hospitals affiliated to Kashan University of Medical Sciences Discussion The most important purpose of blood transfusion centers is to supply blood and its products, especially to traumatic patients. Handling blood supply is important as any disturbance in processing, such as lack of supply, can harm the traumatic patients. The reason is that returned blood products from other wards cannot be reused and should be put aside. On the other hand, anemia in hospitals is one of the major problems, which has often delayed or canceled many surgeries. In fact, the mismatch between blood ordering principles and the maximum blood required for a particular operation causes false deficiency, increases the age of stored blood in the blood bank in hospitals, reduces quality, imposes high laboratory costs, and increases waste due to expiration date. Therefore, blood bank specialists and hospital managers make efforts to create and implement a standard blood ordering system and correct consumption patterns.
In this study, a total of 19741 and 15323 units of blood products were ordered in 2018 and 2019, respectively. Our findings show that the demand and transfusion of blood products decreased by 22 and 24% from 2018 to 2019, respectively, which contrasts with those of Chegini et al.,[12] Akhavan Sepahi et al.,[13] Belayneh et al.,[2] and Alaoddolei et al.[14] These differences might be due to the discrepancy in hospital types, ward types, and even the departments requesting blood and its products.
In this study, the CT ratio in public hospitals was 1.04 and 1.06 in 2018 and 2019, respectively. In general, the pattern of order and transfusion of blood and its products in hospitals was appropriate in our study. Reasons for the desirability of the request and transfusion of blood products in these hospitals include regular meetings of the hemovigilance committee in hospitals, hemovigilance training workshops for physicians and nurses, and continuous training of blood bank staff. These findings are in line with the studies of Chegini et al.,[12] Anani Sarab et al.,[15] Rafiei Mehr,[16] Akhavan Sepahi et al.,[13] Trisal et al.,[17] Yangdon et al.,[18] Belayneh et al.,[2] Vrotsos et al.,[19] Rezaie et al.,[20] and Gharehbaghian et al.[21] Blood transfusion is essential for surviving patients in need, without which thousands of surgeries are impossible.[22] By contrast, in this study, there were significant differences in the clinical pattern of demand and transfusion in Shahid Rajaei Hospital (C/T ratio was 3.12 and 3.6 in 2018 and 2019, respectively). This indicates the inadequacy of demand and transfusion patterns in this specialized hospital (obstetrics and gynecology).
Another indicator of blood transfusion is the probability of the blood transfusion in a treatment protocol (% T), which is obtained by calculating the ratio of the percentage of patients who received blood products to the number of patients who were cross-matched. Acceptable values for this index are 50% and above.[23] In our study, the probability of blood transfusion in Shahid Beheshti and Shahid Rajaei Hospitals was low, which is consistent with the studies of Zewdie et al.,[24] Ibrahim et al.,[25] and Belayneh et al.,[2] However, we observed an acceptable probability of blood transfusion in Matini and Seyed Al-Shohada hospitals, which agrees with the findings of Trisal et al.[17] and Yangdon et al.[18] In this study, except for Shahid Beheshti and Shahid Rajaei hospitals, this index was acceptable in other hospitals and was 38.04 and 36.7 in all public hospitals affiliated to the university in 2018 and 2019, respectively. These values are not acceptable and indicate that most blood units for patients were not transfused, which necessitates investigating the reasons for requesting blood transfusion.
The next indicator is known as the blood TI, and values of 0.5 and above indicate the system's optimal use of the ordered blood. This index was acceptable in all hospitals, which is similar to what Anani Sarab et al.,[15] Rafiei Mehr,[16] Trisal et al.,[17] Yangdon et al.,[18] and Belayneh et al.[2] reported. Our findings in this respect contrast with Zewdie et al.' results.[24] This index was not acceptable in Shahid Rajaei Hospital, indicating that the volume of blood orders was higher than blood transfusions in this specialized center. In general, this index was acceptable in all public hospitals affiliated to the university. This index is important because over-ordering a blood product requires the cross-matched blood remain in the hospital blood bank for a long time, even until the patient is discharged. Consequently, this lengthy storage increases the amount of waste that can negatively affect blood supply, especially negative blood groups. In such cases, especially in Shahid Rajaei Hospital, it is better to use the antibody grouping and screening system rather than cross-match and blood storage. These methods increase the speed of blood preparation, especially in emergencies and trauma, in addition to economic efficiency and TI index improvement.[26]
According to the case files, the reasons for not transfusing blood and its products and their return to these hospitals were the expiration date and patients' allergic reactions to blood transfusions and products. This finding is consistent with the study of Maramazi Ghafleh et al.,[27] whereby the most common cause of blood loss was the expiration date. This could be due to blood over-requests by physicians without adequate knowledge about properly requesting blood and its products and with fear of not accessing sufficient blood during surgery and trauma.[28] In this regard, Keramati suggested that management practices in determining the level of blood storage in hospital blood banks, managing how to request blood and applying methods, such as type and screen (antibody screening), and using guidelines for maximum blood demands in Maximum Surgical Blood Ordering Schedule surgeries are very effective in blood transfusion status.[29] The importance of excessive demand for blood and its products creates a false deficiency, prolongs blood storage in the blood bank, reduces quality, imposes high laboratory costs and wastes due to expiration date, increases the likelihood of contamination due to unnecessary transfusion, and leads to increased pressure on donor statistics. Such actions are especially important in the current situation (the COVID-19 pandemic and present restrictions for blood donors across the country) as it is necessary to maintain a reasonable distance between supply and demand.[21]
Documentation defects and reports were evident in the present study in all files. In the studies of Karami et al.,[28] Friedman and Ebrahim,[30] and Gharehbaghian et al.,[21] this documentation defect was also observed and reported. Therefore, training physicians, assistants, nurses, and blood bank staff is essential to improve accurate documentation of blood returning causes and manage blood product waste. This issue has been overlooked in blood bank systems so far. Furthermore, one of the findings of this study concerned the difference between the Iranian Blood Transfusion Organization (IBTO) Kashan center and the Blood Bank of Hospitals in document registration of consuming and returning blood and its products. Therefore, we must establish an accurate daily reporting system to record these cases. To improve this issue, the role of a blood bank or hemovigilance committee is important to monitor the status of statistical reports on requests and cases of blood transfusions and ultimate strategies to improve the quality of blood transfusion.
The cost of the IBTO Kashan center was 69819.83 and 69377.11 Rials in 2018 and 2019, respectively, and the cost of blood and its products was 74459499405 Rials (690526 $) in 2018 and 79073079143 Rials in 2019 (612115 $) with a 6% increase. An important finding in our study was the increase in the cost of blood and is products from 2018 to 2019. Moreover, the cost of returning blood and its products was 2980.28 Rials in 2018 and 4117.08 Rials in 2019. In the study of Kooshesh et al.,[31] the cost of preparing each unit of blood, from blood sampling to preparation and distribution among medical centers, was about 30–40 thousand Tomans in Iran. In one medical center in the US, a study found that the base price for PC preparation was 114 $.[32] The production cost of a pack cell unit was estimated at 70 $ in Italy and 80 $ in France.[33] The cost of producing each unit of blood was estimated as 40 $ by the World Health Organization.[21] In Iran, the real costs of blood supply have not been calculated, though the Blood Transfusion Organization has estimated the costs to be 600 thousand Rials. According to a study conducted in 2002, the average current cost of producing a blood unit was about 120 thousand Rials.[34] Yazd Blood Transfusion estimated the processing cost of each blood bag as 150,000 Tomans in 2015, which reached 5 million Tomans for rare blood groups. Other costs must be added to the above amount, including cross-match, transferring, maintenance, and screening tests.[34] Due to health policies in the country, the government is committed to providing free access to blood products, and thereby some hospitals may not put enough effort into the optimal use of blood products. Indeed, hospitals consider the cost of blood transfusions to the patient in their services (technical fee and professional fee).[35]
ConclusionsBlood order and transfusion were in good condition in public hospitals affiliated to Kashan University of Medical Sciences, though the pattern of blood order was unfavorable in Shahid Rajaei Obstetrics and Gynecology Hospital. However, efforts should be made to improve the quality of blood product orders and transfusions. The most crucial ward that such improvements can influence could be emergency trauma.
Acknowledgment
The authors consider it necessary to thank the “Clinical Research Development Unit of Kashan Shahid Beheshti Hospital”.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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