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ORIGINAL ARTICLE
Year : 2023 | Volume
: 22
| Issue : 1 | Page : 33-39
Red cell requisition and utilization pattern in a tertiary care hospital of South India
Parmatma Prasad Tripathi
Department of Transfusion Medicine and Hematology, NIMHANS, Bengaluru, Karnataka; Department of Transfusion Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh; Department of Transfusion Medicine and Immunohematology, CMC Vellore, Tamilnadu, India
Correspondence Address:
Parmatma Prasad Tripathi
Department of Transfusion Medicine and Hematology, NIMHANS, Bengaluru, Karnataka
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_141_21
Abstract
Introduction: The equilibrium between supply and demand for red blood cells is increasing unpredictably in many countries. An understanding of trends in blood usage profile and current usage can help predict future trends in demand and to put efforts to reduce use in particular areas. This study helps in analyzing the pattern of red blood cell utilization in a tertiary care hospital. Materials and Methods: This retrospective study was conducted in a blood bank, tertiary care hospital over a period of 6 months. All the requests coming to blood bank with information regarding patient's demographic details, diagnosis and indication for transfusion, type of request, blood transfused or returned were collected and reviewed. Crossmatch transfusion (CT) ratio, transfusion index (TI), and transfusion probability were also calculated. Results: A total of 10,364 patients (20,399 requests) utilized total 32,608 units of blood and its components, out of those 14,195 units of packed red cells units were utilized. March month had maximum number of requests and utilization. Most of the requests for blood were from the inpatients (wards) and were requested and utilized in the age group of 21–30 years with male predominance. Patients in the division of medicine utilized most blood. Although the division of surgery requested most of the blood, on an average, they utilized only one-third of the requested product. Overall, anemia was the most common indication for red cell utilization. In surgical group, spine surgery had a maximum CT ratio. Neurosurgery and hand surgery had the lowest TI in all specialties. Hand surgery and spine surgery had a lowest transfusion probability. Overall, utilization rate in our study was 59.8%. Conclusion: A regular review of blood unit's usage is very important to estimate the blood utilization pattern in any hospital. Profile of blood utilization will act as indicator for quality management of blood bank.
Abstract in French Résumé
Introduction: L'équilibre entre l'offre et la demande de globules rouges augmente de manière imprévisible dans de nombreux pays. Une compréhension des tendances du profil d'utilisation du sang et de l'utilisation actuelle peut aider à prédire les tendances futures de la demande et à déployer des efforts pour réduire l'utilisation dans des domaines particuliers. Cette étude aide à analyser le modèle d'utilisation des globules rouges dans un hôpital de soins tertiaires. Matériaux et méthodes: Cette étude rétrospective a été menée dans une banque de sang, l'hôpital de soins tertiaires sur une période de 6 mois. Toutes les demandes venant de la banque de sang avec des informations concernant les détails démographiques du patient, le diagnostic et l'indication de la transfusion, le type de demande, le sang transfusé ou le retour ont été collectés et examinés. Le rapport transfusion (CT) transfusion (CT), l'indice de transfusion (TI) et la probabilité de transfusion ont également été calculés. Résultats: Un total de 10 364 patients (20 399 demandes) ont utilisé 32 608 unités de sang et ses composants, sur ces 14 195 unités d'unités de globules rouges emballées ont été utilisées. Le mois de mars avait un nombre maximum de demandes et d'utilisation. La plupart des demandes de sang provenaient des patients hospitalisés (quartiers) et ont été demandés et utilisés dans le groupe d'âge de 21 à 30 ans avec une prédominance masculine. Les patients de la division de médecine ont utilisé la plupart du sang. Bien que la division de la chirurgie ait demandé la majeure partie du sang, en moyenne, ils n'ont utilisé qu'un tiers du produit demandé. Dans l'ensemble, l'anémie était l'indication la plus courante pour l'utilisation des cellules rouges. Dans le groupe chirurgical, la chirurgie de la colonne vertébrale avait un rapport CT maximum. La neurochirurgie et la chirurgie des mains avaient le TI le plus bas dans toutes les spécialités. La chirurgie des mains et la chirurgie de la colonne vertébrale avaient une probabilité de transfusion la plus faible. Dans l'ensemble, le taux d'utilisation dans notre étude était de 59,8%. Conclusion: Un examen régulier de l'utilisation de l'unité sanguine est très important pour estimer le modèle d'utilisation du sang dans n'importe quel hôpital. Le profil de l'utilisation du sang servira d'indicateur pour la gestion de la qualité de la banque sanguine.
Mots-clés: Rapport de transfusion croisée, calendrier de commande de sang chirurgical maximal, concentré de globules rouges, indice de transfusion, probabilité de transfusion
Keywords: Crossmatch transfusion ratio, maximum surgical blood order schedule, packed red blood cell, transfusion index, transfusion probability
Introduction 
Blood transfusion with hopes to benefit patients is an ancient practice and the available records, date back to the 13th century, from then and till date transfusion of blood and blood components remain an important and indispensible part of patient management. With the progress made in the field of medicine and the advent of new technology transfusion is safer than ever before, even then like all therapeutic interventions, it involves many significant and often unwanted side effects and underestimated risks. This, and the fact that blood is a very limited and precious resource and the attempts to come up with substitutes have not yielded any satisfactory results, the judicious and appropriate use of blood and its component becomes imperative. Surgical patients usually required blood transfusion for resuscitation and management, leading to over ordering of blood for elective and emergency surgeries, and it is usually common practice.[1] Different studies have started, due to increase in demand for blood units with rising transfusion associated cost and morbidity, to review appropriate utilization and usage of blood ordering practice.[2],[3] Health-care expenses including blood usage are increased and costly, due to inappropriate usage of medical technology and blood leading to additional cost to the treatment of disease.[4] Thus, indication for ordering blood must be fully justified. Hence, periodic review of blood usage is essential to assess the utilization pattern in any hospital setup. Transfusion practice audit should be conducted on individual requisition or aggregate data. This can be followed by ongoing monitoring of input areas after assessment of effectiveness of intervention. Taken together, a declining donation rate and an increase in the consumption of blood units require a novel approaches on both sides of the blood supply chain. Optimal use of blood units requires even more attention. Establishment of criteria for blood transfusion and strict adherence to such criteria may be necessary to reduce blood usage. Nationwide studies are necessary for monitoring and improving transfusion practices. By this study, results obtained may help to provide improvement opportunity and to find strategies for such improvements. The aim of this study is to determine utilization pattern of blood units with objective to study appropriate usage of blood and to calculate crossmatch transfusion ratio (CT ratio), transfusion index (TI), and Transfusion probability (%T) for large volume user departments.
Materials and Methods This retrospective observational study was conducted in the department of transfusion medicine and immunohematology (blood center), at tertiary care hospital (2781 beds-referral center) in southern India over a period of 6 months (February– November), where randomly chosen each month represented the every quarter of the year. The study was approved by the Institutional Review Board (Research and Ethics Committee) of the hospital. All the requests sent to blood center were analyzed from the various inpatient and outpatient facilities including operation rooms, intensive care units, wards, and outpatient treatment rooms. Blood request form contains all data regarding demographic details, unit ward, clinical diagnosis, indication for transfusion, date of request, date of transfusion, emergency/routine, blood group, type of blood or its product requested, type of blood or its product allotted, type of blood and its product issued, crossmatching, return of blood products. All the completed blood request forms with the above details from different departments were included in this study. Incomplete forms were excluded from this study. To collect the data, similar to blood request form EpiData format was generated for easy entries documentation and quick interpretation. In this study, daily requests for blood units that were sent to blood bank for the specified duration were reviewed and all relevant information present on request form were entered in EpiData format entry client version 2.0.3.15 software. EpiData entry client version 2.0.3.15 and EpiData manager version 2.0.5.51 under window 64 bits were used to manage and entering the data and analysis was done by SAS version 9.4. Distribution of blood requests and blood utilization were presented by departments, indications, diagnosis, blood group frequencies, CT ratio, and TI and transfusion probability. We follow blood group typing and crossmatch policy for issuing blood to all departments. Most of the operation requests were received 1 day prior of operation to blood center. After scrutinized by medical officer on duty, blood units were crossmatched according to demand and next morning issued to operation theater in bulk, where they were kept refrigerator (2°C–8°C) for whole day. All blood units in operation theater were utilized according to their need. On the same day in evening, all unutilized blood units were returned and restored in blood center. As multiple surgical departments were there with limited number of operation theater and patient input was huge, so type and screen policy could not be implemented. New variables were derived from existing variables using appropriate formula and descriptive statistics calculated wherever needed.
Crossmatch-to-transfusion ratio (C/T ratio) = Number of units crossmatched/Number of units transfused (A ratio of 2.5 and below = significant blood usage)Transfusion probability (%T) = Number of patients transfused/Number of patients crossmatched ×100 (A value of 30% and above = significant blood usage)TI = Number of units transfused/Number of patients crossmatched (A value of 0.5 or more = significant blood utilization)Utilization rate: Units transfused ×100/Units crossmatched.As data are huge, we are considering more in favor of only red cell requisition and utilization patterns in this study. Rest of the blood components utilization pattern were excluded from this study.
Results General information with reference to blood requests
A total of 9,79,023 patients were registered in our hospital during 6-month period. A total of 20,399 overall requests were received in the blood bank and resulted in a ratio of 21 requests per 1000 total patients. Red cell utilization rate per bed for inpatients was 6.3 units per bed. The largest proportion of requests was from the wards (37.3%) followed by operation theater (34.6%) (mostly routine) and OPD (10.4%). Request versus patients for hospital admitted patient was in ratio of 1:3. Maximum number (67.6%) of red cell requests was for patients in the age group of 21–60 years. Male-to-female ratio for number of requests was 1.5:1. Emergency requests comprised 15.9% and the majorities (80.7%) were received as routine requests over this period. For the purpose of the study, we segregated the requests by the source considered as broad divisions: medicine, surgery, pediatric, and obstetrics and gynecology (OG).
Blood requests and utilization pattern
Total 16,829 requests came for red cells in 6 months and maximum red cells were requested in March month and maximum red cell units were utilized in July month as shown in [Figure 1]. On average, there were 2804 requests for red blood cell and 2365 red cell units were utilized per month. 14,195 red cell units were utilized by 8584 patients in this study. Maximum requests were by medical and surgical divisions which accounted for a one-third of the red cell requests, each as shown in [Table 1]. Medical division utilized the maximum red blood cell units (49.9%) and the OG division contributed the least (6.8%). Maximum number of red cell requests and utilization was from 21 to 30 years age group as shown in [Figure 2]. Majority of the requests for red cells were for male patients. Approximately a third (30.8%) of red cell units requested was from the wards. In wards, out of 29.7% red cells crossmatched, 24.5% of red cell units were utilized. On the contrary, 45.1% of red cell units were requested for the operation room, leading to 43.8% of red cell units being crossmatched and only 16.6% of red cell units were utilized. Rests of the red cells were returned to blood bank without any utilization. For OPD, 7.2% of red cell units were utilized out of 7.4% of red cell unit crossmatched. Almost a fifth of blood units were utilized as emergency during study period as shown in [Figure 3].
Figure 3: Proportion of utilization of blood – Routine versus emergencyOverall, 23,701 red cell units were requested, 23,708 red cell units were allotted, 20,639 red cell units were issued, 5090 red cell units were returned, and total 14,195 (43.5%) red cell units were utilized during study period [Figure 4]. In medical division, hematology had generated the maximum demand of red cells and utilization (51%) followed by casualty (11.4%). In surgical division, orthopedic department requested for maximum number of red blood cells and maximum blood was utilized by orthopedics (24.9%) followed by general surgery (22.1%) and thoracic surgery (17.1%). In division of pediatrics, pediatric oncology accounted for the majority of red cell requests and utilization (28.7%) followed by neonatology (12.0%). Least blood was utilized by OG. Overall, top five departments utilized maximum red cell units in descending order during study period were hematology (25.4%), orthopedics (8.6%), general surgery (7.7%), pediatrics (6.9%), and OG (6.8%). Anemia was most common indication for utilization of blood under hematology department (40.5%) and pediatrics (8.8%). Orthopedic department (20.5%) utilized maximum blood, as indication intraoperative blood loss followed by urology (13.0%) and OG (11.4%). Similarly, Orthopedic department utilized maximum blood for indication postoperative anemia (31.3%) followed by general surgery (17.4%). The hemoglobin trigger for giving red cell concentrate transfusion at our institute was 7 g/dL. During study period, most of the patients (59.8%) from medical division had utilized red cells for anemia with hemoglobin value of <7 g/dL. The mean hemoglobin value of those patients transfused was 5.1 g/dL (range: 1.0–7 g/dL). Among the patients with Hb >10 g/dL, one-third (34.9%) were from the surgical division followed by medical division (24.3%), pediatric division (22.9%), and OG (17.6%) division. Hematology had utilized most of blood as indication anemia for hemoglobin value between 7 and 8 g/dL. The hemoglobin trigger for giving blood transfusion during intraoperative blood loss was 10 g/dL. Most of blood (73.4%) was utilized by surgical division intraoperatively for HB level <10 g/dL. The mean hemoglobin level at transfusion was 10 g/dL (range: 1–20 g/dL). Among the patients in OG, the transfusion trigger was 9 g/dL, and from pediatric patients, the mean value of hemoglobin was 8.3 g/dL (range: 2.2–20 g/dL).
Crossmatch transfusion ratio
Overall, CT ratio was 1.6 during study period. Surgical division had maximum CT ratio (2.2) and least by medical division with CT ratio of 1.2 [Table 2]. In surgical division maximum, CT ratio was from spine surgery (5.1) followed by neurosurgery [Figure 5].
Transfusion index
TI was 2.1 for medical division followed by pediatric division (1.2). Surgery (1.0) and OG (1.0) had similar values. In surgical division, least TI was from hand surgery (0.2), neurosurgery (0.4), and from spine surgery (0.4) in specialties.
Transfusion probability
Hematology (98%) and general medicine (89%) had maximum transfusion probability among large blood volume user. In surgical division, spine surgery and hand surgery had least transfusion probability and general surgery had maximum transfusion probability.
Utilization rate
Blood utilization rate in our study was 59.8% that means 60% of blood was utilized out of the number of red cell units' crossmatched. Medical division (78.1%) had maximum utilization rate and surgical division had least utilization rate (43.8%) during study period.
Discussion The goal of quality assurance in blood bank is to ensure the provision of safe and quality assured blood to the patients. Rational use of blood is intended to ensure that blood is used like a lifesaving, therefore, it is necessary for every blood bank, besides ensuring quality of this life saving product, to monitor, assess, and evaluate the existing trends, any misuse and appropriateness of blood ordering.[5] Studies have reported the marked decline in overuse and inappropriate usage of blood after educational campaign to clinicians after such reviews.[6],[7] Usually, retrospective audits are very efficient in finding out the areas where there is a need to change transfusion practice. When red cells were considered, the clinical demand to utilization ratio in our study was 59.8% which was comparable to other studies (13.6% to 23.14%).[8] Vibhute et al. showed an improved utilization rate from 23.14% to 74.74% after implementation of maximum surgical blood order schedule (MSBOS).[8] The trend of utilization increases with increasing age which was against our observation, where largest proportion of the transfusions was from 21 to 30 years. Two different data from by Beguin et al. and Cobain et al. showed increasing trends of transfusion with increasing age in both medical and surgical group.[9],[10],[11] Our study data were not comparable in terms of age-related transfusion with other western studies trend, but comparable with Indian data.[12] This seems to depend up population demographic trend of the region studied and the prevalence of conditions that require transfusion. Utilization rate was higher among males (60.2%) in our study which is comparable to other studies.[13],[14] Wards followed by operation theater represent large blood consumers. Patients who present themselves to the outpatients are admitted based on their state of morbidity, and usually, only the patients who require supportive therapy and close monitoring or interventional procedures are admitted to in-patient care, leading to maximum utilization from wards. The request for use in the operation rooms is based on patient's preoperative and the anticipated surgical blood loss, leading to less utilization. Although there were one-third emergency requests only, due to lack of required information, blood bank is sometimes not able to respond appropriately to urgent transfusion requirements. There is also a possibility of misuse of emergency facility and unnecessary stress on the blood bank system due to excessive attention to comply with assured turn-around-time of 20 min for such requests. Red cell requests were more in number, reflecting the demand of blood in a tertiary care center. Major requesting departments for red cell utilization were medicine and surgery divisions (predominately). Surgical departments were requesting more blood with less utilization. Moreover, because of less utilization, it will put extra burden in terms of cost, technician time, unnecessary crossmatch, reagents wastage, and create an artificial shortage to red cell units and significant effect in terms of unavailability of red cell units for other patients. To fulfill this apparent blood shortage, more blood donations are sought and for that more blood donors should be recruited which is in effect an additional demand on the organizational services. Crawford-Sykes et al. (West Indies)[15] showed lower transfusion rate in neurosurgical patients (13.2%) with 8.6% transfused intraoperatively and 7.9% postoperatively, which is comparable with our study. Further, orthopedic department utilized only 8.6% of total RBC which is less comparative to other studies.[16] Cardiothoracic surgery also utilized large portion of blood comparable with other studies. Comparable analyses for increased number of CABG surgery suggest increased demand for significant rise for RBCs units.[17] 10% to 15% of the total blood supply of donor blood usually consumed in cardiothoracic surgery during perioperative hemorrhage.[18] About 33% of total blood was utilized for intraoperative blood loss as recommended in major surgeries such as hip, knee, and spine surgery.[19],[20],[21],[22] Perioperative blood conservation can be achieved by introduction of methods such as preoperative anemia treatment, stoppage of anticoagulants preoperatively, improvement of surgical techniques, lower hemoglobin threshold for transfusion, and using pharmacological approach to lower the need for blood. For minimizing inappropriate transfusions, restrictive strategies will assume greater significance because as a precious product, and high cost for zero risk as demandable by public, law courts, and the media.[23] Friedman et al.[3] and various studies over different parts of countries showed overordering in 40% to 70% of the patients transfused. In elective surgery, only 30% of crossmatched blood was used.[1] In one study from north India, 59.0% of crossmatched was unutilized which is comparable with our study (40.1%).[23] However, crossmatch unutilized blood percentage is very low as compared to other studies conducted in Nepal (86.4%), Egypt (74.8%), Nigeria (69.7%), and in India (76.8%).[1] Due to over assumption of preoperative blood requirements, many of the problems are faced by blood bank management including blood aging and outdating, particular groups and phenotype availability, extra costs, and unnecessary laboratory works.[21],[22] Overall, CT ratio (1.6) was very low in our study, as compared to other study by Jayaranee et al. with CT ratio of 5.1.[24] Different C/T ratio from different studies in developing countries was India (2.5), Nigeria (2.2), Malaysia (5.0), and Egypt (3.9).[1] However, surgical departments alone had high CT ratios comparable to other studies. Our CT ratios for surgical departments were comparable with the study from Singh et al. (3.7:1) with blood usage of 26.8% in colorectal resections.[25] In these situations, only “group and save” protocol is required. Optimal crossmatching and MSBOS protocol should be used in surgical patients requiring transfusion. Similar trends were seen with %T in wards, signified appropriate blood usage in our study. Surgical departments had much lower %T, as compared to study by Belayneh et al. (47%).[1] %T from a tertiary center of Indian study was (11.1% to 25%) and from Egypt showed probability of 36.9%.[1] That means, there were over ordering and more number of blood units is crossmatched for patients as compared to number of patients transfused. TI of our study was significant and comparable to studies from Indian tertiary hospital and Egypt hospital.[1] Surgical department had low TI comparable with the study by Subramanian et al. with TI <0.5 for neurosurgical and orthopedic surgeries.[23] Over ordering of blood should be minimized and should be revised with the help of MSBOS for each procedure and clinical department.[25] There is a paucity of randomized clinical trials, due to that there are no evidence-based protocols for red cell transfusions. Introduction of transfusion guidelines which are evidence based will increase the chance of blood utilization appropriately.
Limitations
This being a retrospective study, availability of data was restricted to the blood bank forms mostly. This accounts for a certain amount of missing dataWe could not see the patient and verify laboratory resultsThere is not much of literature specifically addressing the issue of supply, demand, and utilization, especially from India. Hence, comparisons are limited. Conclusion Blood is a precious and scarce resource and as health-care becomes accessible to more of the population, the demand will increase in our country. This retrospective study provides information on blood usage in our tertiary care hospital. Medical wards have maximum supply of blood and utilization followed by surgical group. However, surgical group had slightly more red cell request than medical group as compared to red cell utilization which is almost half of medical group. Surgical group has a highest CT ratio. Hand research and spine surgery have a lowest transfusion probability and hematology has the highest transfusion probability. Surgery and obstetrics and gynecology have a lowest TI, and medicine has a highest transfusion index. Overall, CT ratios for operation theater were high. This shows nonsatisfactory transfusion practice that will lead to potential increase in cost of care and stress on the inventory as well as increased workload on the transfusion service. Cyclical auditing and regular responses are also vital to improve the blood utilization practices. A functional hospital transfusion culture should be motivated for clinicians to consider the possibility of transfusion in their patients well before the actual demand arises and to scheme an effort to use blood resources most efficiently. It indicates the trend of utilization of blood units and is applicable for quality management of transfusion practice, cost analysis, and local and regional blood donation programs planning. Formulation and strictly following the transfusion guidelines and introduction of MSBOS will help to improve the transfusion practice and appropriate usage of blood resources. Plans for improving blood utilization include timely and properly preoperative assessment of risk, increment of baseline hemoglobin, anticipation of potential transfusion problems, minimizing blood loss during perioperative period, point of care testing, blood salvage techniques, transfusion guidelines, target therapy, and massive transfusion protocols. Awareness of these elements encourages a safe and cost-effective transfusion practice.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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