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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 18-22

Audit of blood bank services with emphasis on loss of workforce


1 LLRM Medical College; Teerthanker Mahaveer Medical College, Meerut, Uttar Pradesh, India
2 SN Medical College, Agra, Uttar Pradesh, India

Date of Submission04-Dec-2020
Date of Decision11-Jan-2021
Date of Acceptance29-Jul-2021
Date of Web Publication18-Oct-2022

Correspondence Address:
Monika Rathi
LLRM Medical College, Meerut, Uttar Pradesh, India. Teerthanker Mahaveer Medical College, Meerut, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_166_20

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  Abstract 


Purpose: The goal of blood bank audit is to continuously improve services to the patients by reducing rework, wastage, and inappropriate care. This can be done by establishing certain quality indicators. The rate of discarded blood and its components due to wastage, expiry, and transfusion-transmitted infection are one of such indicator. Design: Retrospective data on the number of whole blood, components prepared, and discarded were collected from the blood bank information system and analyzed. Results: During the study period, the total number of blood and components prepared were 3922. Out of which, a total of 226 units (5.76%) were discarded. In order to alleviate the shortage of blood, we should do intermittent auditing, quality monitoring, thorough evaluation and training of staff, proper management of the resources, and workforce.

Keywords: Audit, blood bank, discard, expiry, financial loss, workforce loss, quality indicators, transfusion-transmitted infection, wastage


How to cite this article:
Rathi M, Chauhan N. Audit of blood bank services with emphasis on loss of workforce. CHRISMED J Health Res 2022;9:18-22

How to cite this URL:
Rathi M, Chauhan N. Audit of blood bank services with emphasis on loss of workforce. CHRISMED J Health Res [serial online] 2022 [cited 2022 Nov 30];9:18-22. Available from: https://www.cjhr.org/text.asp?2022/9/1/18/358815




  Introduction Top


Blood is an integral part of managing critical patients.[1] Thus, in today's era, every nation devotes considerable resources to collection, processing, and distribution of blood and its components.

Despite this, shortage of blood and its components keep on prevailing, especially in developing countries. Hence, alleviating the shortage of blood and its components are the need of the hour to save financial losses and to utilize the human resources up to the best extent possible.[2]

The efficiency of blood transfusion system (BTS) depends on certain quality indicators which reflect the efficiency of the system. These indicators include proper and rationale use of blood and blood products, timely delivery of proper quantity of quality product, efficient storage, transportation, transfusion, promotion of blood collection from low risk voluntary donors, reduction of discard rate due to inefficient collection, processing, and expiry, etc.[3]

Thus, the aim of this study is to analyze some of these quality indicators including the rate, reasons of discard of whole blood and its components, and so that corrective action can be taken in future.


  Materials and Methods Top


This is a retrospective study involving the analysis of rate and reasons of discarded blood and its components from April 2012 to April 2013.

The reasons of discard of whole blood and its components were categorized as follows:

  1. Inappropriate blood collection and processing (Wasted units): It includes blood and its components wasted as a result of inappropriate blood collection and component processing as they do not meet the specification that has been specified and defined these nonconformant products are not issued out to hospitals or patients or show signs of abnormal physical appearance such as underweight, overweight, plasma and platelets with red blood cell (RBC) contamination, haemolysis, leakage, clotted, lipemia, discoloration before its expiration date[3],[4],[5]
  2. Expired units: A unit (blood and its component) that was discarded because its lifespan exceeded that allowable for transfusion. (synonym: Outdated unit)[6]
  3. Units discarded due to transfusion-transmitted infection (TTI): The whole blood and components were screened for HIV, HBV, and HCV by enzyme-linked immunosorbent assay kits.


Screening for syphilis was carried out using ultra rapid test strip. Similarly, malaria antigen screening was done by the rapid test kit.

Rate of discarded blood and blood components

The rate of discard is derived when the number of whole blood, packed RBCs, and platelets, fresh-frozen plasma (FFP) discarded are divided by the number of whole blood, packed RBC's and, platelets, FFP prepared, respectively, multiplied by 100.[7]

Whole blood and blood components were discarded according to the guidelines and principles for safe blood transfusion practice (World Health Organization),[1] guidelines for the BTS in the UK[8] and AABB.[9]


  Results Top


The total number of donation done during the study period was 2918. The total number of whole blood collected in the study period was 2011, and the number of blood collected for the preparation of components was 907.

[Table 1] shows that out of the total 3921 units, percentage distribution of whole blood accounted to the maximum (51.27%), followed by FFP (23.13%) and packed RBC's (23.13%), followed by platelets (2.47%).
Table 1: Discard rate of blood and components

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The overall rate of discard of blood and components was 5.76%.

Among components, discard rate was maximum for platelet (6.18%), followed by whole blood (6.11%), followed by packed RBCs (5.40%), followed by FFP (5.29%).

[Table 2] shows that the discard rate due to handling errors came out to be 0.61% (discard rate = no. of units discarded/no. of units prepared × 100) and discard due to handling errors constituted only 10.62% to the total discards (226 units).
Table 2: Reasons of discarded blood and components due to handling errors

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At our center, only whole blood and FFP were discarded due to handling errors. The causes of discard of whole blood included underweight, followed by hemolysis, followed by leakage.

Among the causes of FFP discard, the widest category was due to leakage.

[Table 3] shows that discard due to expiry constituted, the second most common category after TTIs with a discard rate of 0.84% (discard rate = no. of units discarded/no. of units prepared × 100) constituting 14.60% to the total discards (226 units).
Table 3: Discarded blood due to expiry

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Here, the expiry was maximum for whole blood (48.48% of the total expired units), followed by packed RBC's (33.33%), followed by platelet (18.18%).

Not a single FFP was discarded due to expiry. The reason for this could be the long shelf life of FFP's and outshipping of FFP's to reliance.

[Table 4] shows that out of total discards, the maximum number of discards was due to TTI with a discard rate of 4.31% (discard rate = no. of units discarded/no. of units prepared × 100) and discards due to TTI contributed 74.78% to the total discards (226 units).
Table 4: Number of units discarded due to transfusion-transmitted infections

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Discard due to TTI was seen maximum in whole blood followed by packed RBC's and FFPs.

The discard rate for HIV, Hep B, Hep C, venereal disease research laboratory (VDRL) came out to be 0.10%, 2.24%, 1.65%, 0.3%, and zero, respectively.

Among discard due to TTIs, Hep B virus constituted the most common cause of discard (52.66% of discards due to TTI), followed by Hep C virus (37.87%), followed by VDRL (7.1%), followed by HIV (2.36%). None of the unit was discarded due to malaria.

[Table 5] shows that discard rate was the highest for TTI (4.31%), followed by discards due to expiry (0.84%), followed by discards was due to inappropriate collection and processing (0.61%).
Table 5: Discard rates due to various causes

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It was observed that out of the total 226 discards, discards due to TTI, discards due to expiry and discards due to inappropriate collection and processing contributed 74.78%, 14.60%, and 10.62%, respectively, to the total discards.

[Figure 1] shows that the highest percentage of discard was seen in July 2012 and the lowest in March 2012.
Figure 1: That the highest percentage of discard was seen in July 2012 and the lowest in March 2012

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  Discussion Top


During the study period, the total number of whole blood and components prepared were 2011 and 1911, respectively. Out of these units, a total of 226 units (5.76%) were discarded.

Among components, discard rate was maximum for platelet (6.18%), followed by whole blood (6.11%), followed by packed RBCs (5.40%), followed by FFP (5.29%).

We classified the reasons of discard as

  • Discards due to inappropriate collection and processing (underweight, overweight, leakage, hemolysis, RBC contamination, etc.)
  • Discard due to the expiry of unit
  • Discard due to TTI.


Thus, discard rate was the highest for TTI (4.31%), followed by discards due to expiry (0.84%), followed by discards was due to inappropriate collection and processing (0.61%).

Further, it was observed that TTIs contributed 74.78% to the total discards.

The discard rate for HIV, Hep B, Hep C, VDRL, and malaria came out to be 0.10%, 2.24%, 1.65%, 0.3%, and zero, respectively.

Pallavi et al.[10] conducted a 5-year study and reported the incidence of HIV, hep B, Hep C, VDRL as 0.44%, 1.27%, 0.23%, and 0.28%, respectively.

Kaur et al.[11] conducted a 5-year study and reported the incidence of HIV, hep B, Hep C, VDRL as 0.6%, 1.7%, 0.8%, and 0.7%, respectively.

Discard due to TTI is concordant with the study of Pallavi et al.

This highest rate of discard due to TTI despite meticulous screening and questionnaire by the experienced staff again emphasizes that retention of voluntary donor is the need of the hour as voluntary donation is low at our center. This can be done by camps and educating the staff and the donors.

The second most common cause of discarded blood and its components was expiry. It contributed 14.60% to the total 226 units discarded with a discard rate of 0.84%. Among this category, the highest rate due to expiry was seen in platelets (6.18%), followed by packed RBC'S (1.21%), followed by whole blood (0.79%), and none of the FFP was discarded due to expiry.

Novis et al.[6],[12] conducted a 3-year period Q probe studies during which the combined aggregate rates of RBC containing units, FFP, and platelet discarded due to expiry were 12.3%–20.2%, 6.4%, and 5.8%, respectively, in the first two studies and 2%–2.3%, 2.5%, and 8.2%, respectively, in their third study.

Our observations are concordant with the findings of the third study of Novis et al.

The lowest reason of FFP discard may be due to its high shelf life and outshipping of FFP to reliance.

Again we conclude from this that we should increase the manufacture of components. Whole blood request by clinicians is more prevalent at our place, which is a wrong practise, so we are trying to educate the clinicians in this regard.

Further whole blood expiry can be reduced by analyzing the most common blood groups requested and the least common blood groups requested in this region and then maintaining the stock accordingly if multiple donors are available.

The least number of discards was due to inappropriate collection and processing contributing 10.62% to the total discards with a discard rate of 0.61%. The discard rate in this category of discard was the highest for FFP (1.10%), followed by whole blood (0.69%) and was zero for platelets and packed RBC's.

Among this group, the reasons of discard included underweight bag (50%), leakage (41.66%), and hemolysed bag (8.33%).

Morish et al.[3] did a study in 2007 at national blood center Kualalumpar and found out that the total number of discarded whole blood units and its components due to inappropriate collection and handling errors were 2.3%. Platelet concentrate recorded the highest of discard at 6% followed by whole blood at 3.7%, FFP at 2.5%. Our discard rates are comparable with their study. They also reported that RBC contamination of platelet and FFP was the major cause of discard (40%).Other causes included leakage (26%), lipemia (25%), and underweight bags (4%).

In our study, underweight bags are the most common cause of discard. However, leakage constitutes the second most common cause in both the studies.

At our center, we are using automated blood mixing machines.

Underweight bags at our center were due to several reasons including the discontinuation of donation because of donor's reactions and the blood flow from small vein during phlebotomy and the duration of the donation exceeds 15 min.

Selecting a good donor, training, and monitoring the staffs will help to reduce cases of the underweight blood units.[3]

The second most common cause of discard was leakage.

The integrity of plastic bags is essential, and precautions should be taken to prevent leakages.[8]

The bag may be damaged during the centrifugation. This happens when the bag is forced to a sharp interior bottom/wall junction or corner, resulting in the bag material being stretched too far, causing a tear.[13]

The defect and leakage at any part of the plastic blood bags can be detected by visual inspection during the processing, after pressure in a plasma extractor, before freezing, and after thawing.[14]

The FFP should be stored in cardboard or polystyrene protective containers that minimize the risk of breakage of brittle frozen product during storage, handling, and transportation.[13],[14]

Another approach to decrease the leakage and contamination immediately before immersion of the frozen blood bags in the water bath is that the whole container should be placed in a sterile plastic bag.

In our study, all platelets concentrate component were prepared PRP method. After centrifugation, there are critical steps that can cause red cells contamination of plasma and platelets. Our trained staff took extreme precaution in these steps. The centrifuge bags were carefully removed from the centrifuge buckets and were reposted in blood extractor, gentle pressure was applied to the bag to slowly separate the layers of components into satellite bags.[15]

Another source of contamination of the PRP is the tendency of the bags' content to swirl during rotor deceleration in an effort to keep its angular momentum causing RBCs and white blood cells to be mixed with plasma.[16] Extreme precautions were taken at these steps to avoid mixing. This could be the reason why none of the component was discarded due to RBC contamination.

Novis et al.[6],[12] conducted a 3-year period Q probe study during which the first two studies were conducted in hospitals of all bed sizes, the combined aggregate rates of RBC containing units, FFP, and platelets discarded due to collection were 1%, 2%, and 2.3%, respectively. Third study done by Novis et al. showed the rates of RBC containing units, FFP and platelets discarded due to collection was 0.6%, 4.4%, and 1.4%, respectively.

Despite constituting the least number of discards, this group is important as this provides us an insight about the deviations from the established standards during the collection and processing. Hence, these deviations should be recognized as opportunities to provide better services and staff should be encouraged to report deviations, mistakes without fear of retribution.[17] Hence, we conclude that discard of blood bags not only results in financial losses, loss of workforce but it also hampers the blood services. These losses can be minimized by continuous audits and proper management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization WHO. Quality Systems for Blood Safety: Introductory Module Guidelines and Principles for Safe Blood Transfusion Practice. Geneva: World Health Organization WHO; 2002. p. 65-75.  Back to cited text no. 1
    
2.
Pitocco C, Sexton TR. Alleviating blood shortages in a resource-constrained environment. Transfusion 2005;45:1118-26.  Back to cited text no. 2
    
3.
Morish M, Ayob Y, Naim N, Salman H, Muhamad NA, Yusoff NM. Quality indicators for discarding blood in the National Blood Center, Kuala Lumpur. Asian J Transfus Sci 2012;6:19-23.  Back to cited text no. 3
  [Full text]  
4.
Cobain TJ. Fresh blood product manufacture, issue, and use: A chain of diminishing returns? Transfus Med Rev 2004;18:279-92.  Back to cited text no. 4
    
5.
Procedure for Disposal of Unsuitable Blood and/or Blood Components. Document: PDN/CP/Work Instruction-16; 2004. p. 1.  Back to cited text no. 5
    
6.
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.  Back to cited text no. 6
    
7.
Veihola M. Technical Efficiency of Blood Component Preparation in Blood Centres of 10 European Countries, Academic Dissertation. Finland: Department of Public Health, Faculty of Medicine University of Helsinki; 2008. p. 5.  Back to cited text no. 7
    
8.
Guidelines for the Blood Transfusion Services in the United Kingdom. 7th ed. 2005. p. 18-77.  Back to cited text no. 8
    
9.
American Association of Blood Banks AABB; American's Blood Centres; American Red Cross. Circular of Information for the Use of Human Blood and Blood Components. Bethesda; 2002. p. 10-40.  Back to cited text no. 9
    
10.
Pallavi P, Ganesh CK, Jayashree K, Manjunath GV. Seroprevalence and trends in transfusion transmitted infections among blood donors in a university hospital blood bank: A 5 year study. Indian J Hematol Blood Transfus 2011;27:1-6.  Back to cited text no. 10
    
11.
Kaur G, Basu S, Kaur R, Kaur P, Garg S. Patterns of infections among blood donors in a tertiary care centre: A retrospective study. Natl Med J India 2010;23:147-9.  Back to cited text no. 11
    
12.
Novis DA, Renner S, Friedberg R, Walsh MK, Saladino AJ. Quality indicators of fresh frozen plasma and platelet utilization three college of American pathologists Q-probes studies of 8 981 796 units of fresh frozen plasma and platelets in 1639 hospitals. Arch Pathol Lab Med 2002;126:527-31.  Back to cited text no. 12
    
13.
Guide to the Preparation, Use and Quality Assurance of Blood Component. 12th ed. Council of Europe Publishing; 2006. p. 242-8.  Back to cited text no. 13
    
14.
Fullerton CA. Rotor Bucket liner US Beckman Instruments, INC Patent; 1984. Available from: http://www.freepatentsonline.com/4439177.html.  Back to cited text no. 14
    
15.
Hardwick J. Blood processing: “Introduction to blood transfusion technology”. ISBT Sci Series 2008;3:148-76.  Back to cited text no. 15
    
16.
Automated System and Method for Blood Components Separation and Processing; 2008. Available from: http://www.freshpatents.com/Automated-system-and-method-for-blood-components-separation-and-processingdt20081009ptan20080248938.php.  Back to cited text no. 16
    
17.
Benjamin RJ. Quality Improvement and Control. In: Blood Banking and Transfusion Medicine: Basic principles and Practice. Churchill Livingstone; 2003. p. 115-20.  Back to cited text no. 17
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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