|Year : 2021 | Volume
| Issue : 2 | Page : 178-182
Reappraisal of quality indicators in the blood center of a tertiary care teaching hospital - Are we ready for accreditation?
Gargi Mukherjee1, Parijat Pramanik2, Dipmala Das3, Asitava Deb Roy1
1 Department of Pathology, IQ City Medical College, Durgapur, West Bengal, India
2 Department of MBBS Intern, IQ City Medical College, Durgapur, West Bengal, India
3 Department of Microbiology, IQ City Medical College, Durgapur, West Bengal, India
|Date of Submission||15-Jul-2021|
|Date of Decision||17-Sep-2021|
|Date of Acceptance||20-Sep-2021|
|Date of Web Publication||30-Nov-2021|
Dr. Asitava Deb Roy
Department of Pathology, IQ City Medical College, Durgapur, West Bengal
Source of Support: None, Conflict of Interest: None
Background and Objectives: Ensuring quality in transfusion services has become an essential part of the hospital quality management system to provide safe blood supply to the patients. To assess the overall quality performance of our blood center, this study was conducted to evaluate the five mandatory quality indicators (QI) put forward by the National Accreditation Board for Hospitals and Healthcare Providers (NABH) and make recommendations, if any, for improvement of the same. Methods: The five mandatory QIs (defined by NABH) were observed and monitored monthly for a period of 1 year from April 2019 to March 2020, information was gathered in a structured manner, root causes for any deviation were analyzed, and specific corrective and preventive actions were taken. Results: The overall performance was found to be satisfactory with the mean transfusion-transmitted infection % being 1.82%, mean transfusion reaction rate 0.30%, and mean wastage rate 13.5%. The turnaround time was maintained at 28.5 min for emergency cases and 141.38 min for routine. There was no case of component quality control failure during the study period. Conclusion: The study observed that by strictly following the quality parameters put forward by NABH, processes can be controlled in a manner that errors are avoided or kept at minimum. This, in turn, shall help in attaining higher levels of performance. The study concluded by putting forward few important recommendations.
Keywords: National accreditation board for hospitals and health-care providers, quality indicators, quality management system, transfusion service
|How to cite this article:|
Mukherjee G, Pramanik P, Das D, Roy AD. Reappraisal of quality indicators in the blood center of a tertiary care teaching hospital - Are we ready for accreditation?. Glob J Transfus Med 2021;6:178-82
|How to cite this URL:|
Mukherjee G, Pramanik P, Das D, Roy AD. Reappraisal of quality indicators in the blood center of a tertiary care teaching hospital - Are we ready for accreditation?. Glob J Transfus Med [serial online] 2021 [cited 2022 Jan 18];6:178-82. Available from: https://www.gjtmonline.com/text.asp?2021/6/2/178/331621
| Introduction|| |
Over the last few years, the quest for safe blood supply has led to tremendous growth in the science and practices of transfusion medicine. To ensure and establish a zero-risk blood transfusion, endeavors were made to enhance the level of quality of the transfusion service. In doing so, a need was felt for concrete proof, to measure the quality of transfusion services. This led to the introduction of quality indicators (QIs) in blood banking system.
QIs are a quality management system (QMS) tool that is instituted in an organization with intent on providing needed proof of the level of quality as well as utilizing information gained to seek improving the quality of performance in the organization.
Eleven QIs have been defined by National Accreditation Board for Hospital and Healthcare Providers (NABH) as tools for quality improvement in the blood transfusion service (BTS). Further, out of these eleven, first five indicators have been mandated for accredited blood bank to monitor and report quarterly to NABH.
The primary objective of the services in transfusion medicine is to promote high standards of quality in all aspects of patient care. BTS can reach the highest level of efficiency through implementation of QMS in all phases of blood collection, processing, and storage. QIs are performance measures designed to monitor and evaluate the quality of transfusion process.
Aims and objectives
This study was conducted to assess the quality performance as well as to check the preparedness of the blood center of a tertiary care teaching hospital going to be accredited by the NABH and make recommendations, if any, for improvement of the same.
| Materials and Methods|| |
This is a retrospective study conducted in a tertiary care teaching hospital where the first five mandatory QIs (defined by NABH) were recorded on a monthly basis over a period of 1 year, from April 2019 to March 2020. The information was gathered in a structured manner and then assessed. Root causes were analyzed and specified corrective and preventive actions were taken.
All the necessary information regarding the parameters were collected on a monthly basis from all the wards, intensive care units, operation theatres and from the blood storage unit itself by the blood center technicians with the help of the clinical personnel. The whole process was supervised by the in-charge of blood storage unit.
The QIs under consideration were (derived by various formulae according to the NABH guidelines):
- Percentage of transfusion-transmitted infection (TTI%) was derived by taking combined TTI cases (HIV + HBV + HCV+Syphilis+MP) and dividing it by total number of donors in that particular month and then taking its percentage by multiplying with 100
TTI% = combined TTI cases (HIV + HBV+ HCV+Syphilis+MP) ×100/Total No. of donors
- Percentage of adverse transfusion reactions was derived by dividing the number of adverse transfusion reactions by the total number of blood or component units transfused in that particular month and multiplying by 100
Percentage of adverse transfusion reactions = number of adverse transfusion reactions × 100/total number of blood or component units issued
- Percentage of outdated whole blood or concentrated red blood cells (RBCs) (wastage rate) was derived by dividing the number of whole blood or concentrated RBC discarded due to outdating by the total number of whole blood and concentrated RBC collected or prepared and multiplying it by 100
- Percentage of outdated whole blood or concentrated RBC (wastage rate) = number of whole blood and concentrated RBC discarded due to outdating × 100/total number of whole blood or concentrated RBC collected or prepared turnaround time (TAT) was calculated by taking the sum of the time taken and dividing it by the total number of times whole blood or RBC issued. Time taken was calculated from the time the request or sample received in the blood bank till the blood was cross matched or reserved and made available for transfusion
TAT = Sum of the time taken/the total number of times whole blood or RBC issued
- Percentage of component quality control (QC) failures (for each component) was calculated by taking the number of a particular component QC failures and dividing it by the total number of that component tested and multiplying it with 100.
Percentage of component QC failures (for each component) = Number of a particular component QC failures × 100/total number of that component tested.
| Results|| |
The results of these five QI were calculated monthly for a period of 1 year, from April 2019 to March 2020 and arranged in an organized manner as shown in [Table 1] and [Table 2]. Each indicator was also analyzed by using different diagrams and the trends were observed. It was found that percentage of TTI was highest in the month of September 2019 which was 4.36 and lowest in the month of November 2019 was 0.33. The mean TTI% was 1.83.
The mean transfusion reaction rate in patients was 0.30 with the maximum value of 0.9 in the month of July 2019 and there is no transfusion reaction at all in the month of August, October 2019 and February and March 2020. Furthermore, no adverse reaction in donors was noted during the entire study period.
The mean wastage rate (percentage of outdated whole blood or concentrated RBC) was 13.5%. Maximum wastage of 21.74% occurred in the month of October 2019 whereas minimum wastage rate was 7.2% in March 2020.
TAT was noted <30 min for emergency cases in most of the months with the mean of 28.5 min. However, for routine cases, the mean TAT was noted to be 141.38 min [Table 2].
The most positive finding was that the packet RBC (PRBC) QC failure and fresh frozen plasma QC failure were completely nil throughout the whole study period.
| Discussion|| |
The transfusion of blood components is a complex procedure that not only requires a donor and a recipient but also health-care workers working at different levels within the institution. Therefore, it is very important to have a very stringent quality assurance program in place to ensure a safe and effective transfusion service.
At our center, we have been trying to prepare ourselves for the accreditation process by monitoring the QIs as per NABH standards. This has helped in achieving a certain standard of transfusion services in the past 1 year. With regular academic activities and hands-on trainings, it has become easier for every staff to identify, assess, and report any outlier. This ultimately helps in analyzing the root causes of these outliers so that appropriate and timely corrective and preventive actions can be taken.
Most of the studies on QIs published worldwide are based on the monitoring of crossmatch: transfusion (CT) ratio, the rate of RBC expiration, and the rate of RBC wastage. These parameters usually give an idea regarding “usage of blood” only. A similar study by Novis et al. evaluates the various practices in 1639 institutions across the USA. The authors have analyzed the CT ratio, RBC unit expiration rate, and RBC wastage rates in different institutions. However, to have an overall idea regarding the QC of blood banking process, we decided to evaluate our performance on the basis of the five mandatory QIs as per NABH.
In our study, we found that overall TTI % was 1.82%. Among the five TTI tested in our blood center, Hepatitis B was found to be most seroprevalent followed by HIV. Similar finding was reported in the study done by Fernandes et al. (2010) and Hariharan et al. (2019), but the TTI prevalence in both these studies was lower that of the index study (0.6%). Another study by Zulfikar et al. (2012) also showed prevalence to be 0.82% and Varshney and Gupta. (2017) 0.93%. A possible cause for a higher TTI % in this study was thought to be absence of a dedicated donor counselor in our blood center and also use of a technology (electrochemiluminescence) with higher sensitivity for screening viral markers. As a measure for preventive and corrective action, a donor counselor was appointed immediately to have a stringent donor recruitment process.
TAT for routine cases found in our study (141.38 min) was less than the data obtained by a similar study by Gupta et al. (153 min) and slightly higher than that reported by Varshney and Gupta. (135.82 min). However, overall TAT for emergency cases (28.50 min) was comparable to the study done by Ramanathan and Usha. (30.3 min) and the one done by Varshney and Gupta. which reported TAT for emergency cases as 29.87 min. A thorough analysis of the root cause for delay (>30 min) in the TAT for emergency cases in the month of June and September 2019 revealed that the blood center was running with only 50% of the usual manpower on these 2 months because of some unprecedented leaves of the technical staff. A similar delay, although not very significant, was also reflected in routine cases during these 2 months. Therefore, as corrective and preventive action, the technical supervisor was advised to manage manpower effectively and appropriately such that it does not hamper the workflow of the blood center. Furthermore, the technical staff were trained to act with a sense of urgency in cases of emergency blood requests to maintain TAT. As such, no specific recommendations for turn-around-time have been established and very few studies are available to compare.
Another major quality parameter, i.e., the mean adverse transfusion reaction rate was 0.30 with the maximum value of 0.85 in the month of July 2019.This was slightly higher than the values obtained by studies reported by Bhattacharya et al. (0.18%), Chakravarty-Vartak et al. (0.16%) and Hariharan et al. (0.14%). However, the positive point was that during the study period, there were no incidences of adverse transfusion reactions in the month of August 2019, October 2019, February 2020, and March 2020. It was observed that majority of the cases were caused by allergic reactions and febrile nonhemolytic transfusion reactions (90%). The use of newer technologies such as leuko-reduction, regular reporting of all adverse events by enrolling in the National Haemovigilance Programme of India, and continuous training of medical and paramedical staff regarding collection, processing and storage of blood was initiated to bring down the rate of adverse transfusion reactions.
The mean wastage rate (percentage of outdated whole blood or concentrated RBC) was 13.5%. Maximum wastage of 21.74% occurred in the month of October 2019 whereas minimum wastage rate was 7.2% in March 2020. A study by Hariharan et al. (2019) found a similar wastage rate for whole blood and PRBC (15.93%). Similar results were also obtained by Suresh et al. (2015), Kaur et al. (2016), and Varshney and Gupta. where the most common cause of wastage of blood units was TTI positivity. In the index study, however, the most common cause of wastage was due to expiry of blood units because of nonutilization followed by TTI reactivity, low volume collection, and over-collection. These results are in accordance with a similar study conducted by the author (Roy et al., 2015) on wastage rate of blood and components. Few other causes for wastage of blood units include breakage or leakage of blood bags while processing and storage of blood, bacterial contamination, and hemolysis. As a preventive measure, regular audits were planned by setting up a Hospital Transfusion Committee, adopting and strictly implementing the (first in first out) policy for blood issue. A maximum surgical blood order schedule was also prepared after discussion with the operating clinicians and the Hospital Transfusion Committee to avoid unnecessary wastage of blood and components.
The study observed that by strict vigilance and enforcement of the quality parameters put forward by NABH, processes can be controlled in a manner that errors are avoided or kept at minimum. This, in turn, shall help in attaining higher levels of performance in terms of quality.
| Conclusion|| |
The study concluded by putting forward few important recommendations:
- A properly conducted donor interview by a trained personnel and notification of permanently deferred donors will help in reducing the percentage of TTI reactive donors
- Mandatory enrolment in the National Haemovigilance Programme of India will help in proper documentation of adverse transfusion reactions. Alongside, the technical staff should also be continuously trained in collection and processing of blood and components
- A structured implementation of blood transfusion policies will help in reducing the rate of discard of blood bags due to expiry. Since whole blood has got only limited indications these days, whole blood collection should be kept to minimum to prevent expiry due to nonutilization. Interlinking and networking with other blood centers to outsource the components when required may also help in proper utilization of the products and thus prevent wastage
- Adequate and properly trained manpower should be available to issue blood and components by adhering to the TAT as per policy of the institution
- Every hospital should have a hospital transfusion committee to monitor the rational use of blood and components and review the blood management system.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization WHO. Quality Systems for Blood Safety: Introductory Module Guidelines and Principles for Safe Blood Transfusion Practice Geneva. WHO: Geneva; 2002. p. 65-75.
Devi KM, Sharma AB, Singh LD, Vijayanta K, Lalhriatpuii ST, Singh AM. Quality indicators of blood utilization in the tertiary care center in the north-eastern India. IOSR J Dent Med Sci 2014;13:50-2.
Accreditation Standards on Blood Banks / Blood Centres and Transfusion Services. National Accreditation Board for Hospitals and Healthcare Providers. 3rd
ed. India: Quality Council of India; 2016.
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 2002;126:150-6.
Fernandes H, D'souza PF, D'souza PM. Prevalence of transfusion transmitted infections in voluntary and replacement donors. Indian J Hematol Blood Transfus 2010;26:89-91.
Hariharan A, Chandrasekar M, Ramachandran T, Yuvarajan S, Lavanya RS. Quality indicators of blood utilisation in a tertiary care hospital in the Southern India – A step towards blood safety. Natl J Basic Med Sci 2019;9:168-74.
Zulfikar A, Umaru M, Shreesha K. Seroprevalence of transfusion transmitted infections among blood donors in Mangalore. Med Innov 2012;1:24-7.
Varshney L, Gupta S. Quality indicators performance tools of blood transfusion services. J Evol Med Dent Sci 2017;6:6348-52.
Gupta A, Gupta C. Role of national accreditation board of hospitals and healthcare providers (NABH) core indicators monitoring in quality and safety of blood transfusion. Asian J Transfus Sci 2016;10:37-41.
] [Full text]
Ramanathan T, Usha KC. Turn around time (TAT) for emergency blood issue: A quality indicator. 39th
ISBTI annual conference, TRANSCON 2014, Patiala. Asian J Transfus Sci 2015;9:1144.
Bhattacharya P, Marwaha N, Dhawan HK, Roy P, Sharma RR. Transfusion-related adverse events at the tertiary care center in North India: An institutional hemovigilance effort. Asian J Transfus Sci 2011;5:164-70.
] [Full text]
Chakravarty-Vartak U, Shewale R, Vartak S, Faizal F, Majethia N. Adverse reactions of blood transfusion: A study in a tertiary care hospital. Int J Sci Study 2016;4:90-4.
Suresh B, Babu SK, Arun R, Chandramouli P, Jothibai DS. Reasons for discarding whole blood and its components in a tertiary care teaching hospital blood bank in South India. J Clin Sci Res 2015;4:213-9. [Full text]
Kaur P, Kaur R, Masih V, Jindal A. Incidence and causes of wastage of blood and blood components in a blood bank of tertiary care hospital: A retrospective study. IOSR-JDMS 2016;15:108-10.
Roy AD, Pal A. Evaluation of 'Wastage Rate' of blood and components – An important quality indicator in blood banks. Br J Med Med Res 2015;8:348-52.
[Table 1], [Table 2]