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 Table of Contents  
ORIGINAL RESEARCH REPORT
Year : 2019  |  Volume : 16  |  Issue : 4  |  Page : 125-132

Do we meet up with the standard blood demand, usage, and availability levels in State Specialist Hospital, Akure, Ondo State, Nigeria?


1 Department of Hematology and Virology, State Specialist Hospital, Akure, Ondo State, Nigeria
2 Department of Clinical Pharmacology and Therapeutics, University of Medical Sciences, Ondo City, Ondo State, Nigeria
3 Department of Radiology, Trauma Surgical Centre, University of Medical Sciences, Ondo City, Ondo State, Nigeria
4 Department of Internal Medicine, Kidney Care Centre, University of Medical Sciences, Ondo City, Ondo State, Nigeria

Date of Web Publication22-Oct-2019

Correspondence Address:
Dr. Patrick Olanrewaju Osho
Department of Hematology and Virology, State Specialist Hospital, Akure, Ondo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_26_19

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  Abstract 

Aim: The aim of this study is to determine the extent of blood usage during blood transfusion procedures with evaluation of blood transfusion prescription practices in view of optimal and efficient utilization of blood transfusion services (BTSs). Materials and Methods: We prospectively analyzed all the blood orders between May 2015 and April 2017 from the Blood Bank of Hematology Laboratory in State Specialist Hospital, Akure, Ondo State, Nigeria. The indices used were in compliance with the international blood transfusion clinical practice guidelines. Results: Out of 1536 blood units ordered and crossmatched in this study, 62.57% units were transfused to patients and 37.43% were not transfused. This indicates judicious blood usage during transfusion procedure to saving lives. The overall blood transfusion indices for crossmatch-to-transfusion ratio (C/T), transfusion probability (%T), and transfusion index (TI) were 1.60, 62.57, and 1.00, respectively. This implied that blood at the point of utilization within the hospital, enjoyed a favorable status of blood prescription practice compare to the standard reference values (that is, C/T ratio ≤2.5, %T ≥30, and TI ≥0.5) in most of the departments under study. Departments such as Obstetrics and Gynecology (CT = 2.45, %T = 25.45, TI = 0.41) and General Theater (C/T = 3.8, %T = 16.44, TI = 0.26) exhibited inappropriate order of excessive crossmatched blood by junior medical officers which may be subsequently canceled by senior colleagues on later review of the patients were common. Conclusion: This study showed a reliable and efficient clinical practice in the management of BTSs from the point of order to the point of need which amount to a more appropriate, prudent, and conserved utilization of blood products, resources, and services.

Keywords: Crossmatch-to-transfusion ratio, shortage/wastage level, transfusion index, transfusion probability


How to cite this article:
Osho PO, Oluwole MT, Fasipe OJ, Osho SE, Koledoye VO, Oni OI, Akinbodewa A. Do we meet up with the standard blood demand, usage, and availability levels in State Specialist Hospital, Akure, Ondo State, Nigeria?. J Clin Sci 2019;16:125-32

How to cite this URL:
Osho PO, Oluwole MT, Fasipe OJ, Osho SE, Koledoye VO, Oni OI, Akinbodewa A. Do we meet up with the standard blood demand, usage, and availability levels in State Specialist Hospital, Akure, Ondo State, Nigeria?. J Clin Sci [serial online] 2019 [cited 2019 Nov 13];16:125-32. Available from: http://www.jcsjournal.org/text.asp?2019/16/4/125/269716


  Introduction Top


Blood transfusion is the administration of donated blood products with the intention to replace lost blood, increase the flow rate of cardiac output, boost blood elements, and to replace missing clotting factors and immune system elements. It is indicated in the treatment of various medical and surgical conditions to save lives during emergency or elective circumstances, which include trauma/accidents, bleeding disorders, major surgeries, chemotherapy, inherited/acquired hematological diseases, and malignancies.[1],[2],[3],[4],[5] A well-organized Blood Transfusion Service (BTS) is a vital component of any health-care delivery system. For quality, safety, and efficacy of blood and blood products, well-equipped blood centers with adequate infrastructure and trained workforce are essential requirements.[6],[7],[8],[9],[10] The evolution of BTSs was one of the most important medical advances derived from World War I. The use of stored or bank blood began during World War 1 (1914–1918), but the first large-scale blood bank was not created until 1937, in Chicago.[11],[12],[13] The Canadian surgeon (Major L. B Robertson) serving in Canadian Army Medical Corps in the First World War was responsible for introducing transfusion in the management of war casualties to the British Army. Blood transfusion was generally accepted as the treatment of choice for severe blood loss by the end of the war.[14],[15],[16],[17] Millions of lives are saved each year through blood transfusion, yet the quality and safety of blood transfusion are still the concern, especially in the developing countries.[18],[19],[20],[21],[22]

To maximize usage for each unit of whole blood, it is separated into three different therapeutic applications as red blood cells (RBC), platelets, and plasma. The estimated national need for blood in Nigeria is about 1.4–1.7 million;[20],[22],[23],[24],[25] unfortunately, less blood is collected by the Nigerian National BTSs (NBTS), and of these, only 10% are from voluntary nonremunerated blood donors.[23],[26],[27],[28],[29],[30] According to several studies, approximately, half of all RBC units are used for surgical indications in the surgery departments and the other half for other medical indications in other departments.[31],[32],[33],[34],[35],[36] Today, blood transfusion indices such as crossmatch-to-transfusion ratio (C/T), blood transfusion index (TI), and blood transfusion probability (%T) can be used for proper assessment of blood demand and use in various hospital wards. C/T is the ratio of crossmatched blood units to transfused units. The Scottish Intercollegiate Guidelines Network recommended C/T ratio for evaluating blood demand and consumption for transfusion practices not be more than 2.5. Blood TI is the ratio of transfused blood units to patients with prepared crossmatched blood. A blood TI value of 0.5 or more is indicative of efficient blood usage, and it signifies that appropriate numbers of blood units are transfused. The blood %T is the ratio of the number of patients receiving blood to the number of patients with prepared crossmatched blood in percentage. The probability of blood transfusion for a given department is denoted by %T and was suggested by Mead et al. Values more than 30% show significant probability of blood usage.[37],[38],[39],[40],[41],[42] Excessive demand for blood is a common problem in hospitals, which causes such problems as inappropriate distribution of blood products among different units/departments, rising cost of preparation, and also increasing workload of preservation. The rising demand is for the fear of running out during surgery (irrespective of use or otherwise) or due to lack of a clear blood ordering pattern that ultimately leads to blood shortages and worsening of overall storage. It can be argued that blood ordering is done at will in most hospitals.[43],[44],[45],[46],[47] Since the introduction of blood transfusion into clinical practice, its appropriate use has been the subject for debate among several medical experts.[48],[49],[50],[51],[52],[53]

The aim of this study is to investigate blood demand via prescription practice and evaluation of its usage in view of optimal utilization of crossmatched blood service in different sections of hospital. To assess extent of wastage/shortage and ensure appropriate use in compliance with the international blood transfusion clinical practice guidelines.[18],[22],[24],[54],[55] The study will also assess factors responsible for the blood prescription and utilization practice, determine the blood group mostly being requested, and to evaluate the hospital department whose demand is on the high side in the State Specialist Hospital, Akure, Ondo State, Nigeria.


  Materials and Methods Top


Study area

This prospective study was conducted for the duration of 2-year period from May 2015 to April 2017 at the Hematology and Blood Transfusion Medicine Unit of State Specialist Hospital, Akure, Ondo State, Nigeria. The hospital receives medical, surgical, and dental referrals from within and outside the state.

Study population

The study participants were 1246 hospitalized patients who for some medical or surgical reasons needed blood transfusion and blood samples were collected from both patients (recipients) and donors.

Sampling design

This was a prospective study, in which data were retrieved from the laboratory information system and hard copies register technique of donated blood and transfused patients. In this study, recipient's names, age, gender, barcode number, blood group, and the amount of blood type were properly documented. Overall, a total of 1536 records were included in the study.

Laboratory assays

Routine screening of potential donors' blood samples was conducted daily. All donors blood were grouped (typed), screened, and the blood level estimated by packed cell volume (PCV). Three milliliters of venous blood were aseptically collected from each study participant into potassium ethylene diamine tetraacetate (EDTA) anticoagulant container. PCVs were done using hematocrit machine and hematocrit reader to ascertain adequacy of the blood level in percentage. Next is the determination of blood type using manufactured antisera to identify the presence or absence of inherited antigenic substances on the surface of the RBCs, through agglutination reaction. These blood samples were later centrifuged at 1500 rpm and the extracted plasma used for the screening of transfusion-transmissible infections (TTIs) such as HIV I and II, hepatitis B surface antigen (HbsAg), hepatitis c virus (HCV), and syphilis using serological method to determine the presence or absence of transfusion-transmissible pathogens. These potential donors' blood samples were certified nonreactive or reactive according to the manufacturers' procedure. These potential donors whose blood samples were certified nonreactive to these TTIs were bled and tagged for storage. The reactive donors were referred to clinic for management. The collected plasma specimens were also transported frozen within 12 h with the aid of iceboxes from Akure to the NBTS Centre, Ado Ekiti, and kept frozen at −20°C until the point of serological assays for further testing by the fourth-generation enzyme-linked immunosorbent assay (ELISA) method.

Blood re-screening techniques

In partnership with Ondo State BTSs and NBTS Southwest Zonal Center, Ibadan, Oyo State, and NBTS Ado Ekiti, Ekiti State, blood units were rescreened using the second algorithm (combo-Antigen and antibody), fourth-generation ELISA technique with STATFAX-2600 washer and STATFAX-2100 reader (Awareness Technology); Biorad Genscreen Ultra HIV Ag-Ab were used for HIV I and II screening, Bio-rad Monolisa HBsAg ULTRA were used for HBsAg screening, while HCV and syphilis were screened using Dia-Pro Diagnostic Bioprobes. After rescreening confirmation, the NBTS returns the nonreactive blood units with results of all units sent to them.

Crossmatch routine

Transfusion prescription orders are subjected to emergency and full crossmatched on recipient serum with donor's red cell from the blood bag tagged for compatibility and safety of life. The tagged and labeled blood in reserve for indexed recipient did not stay for more than 72 h (3 days), after which it would reenter the Blood Bank Inventory.

Data collection methods

We collected data on all blood inventories into the blood bank anonymously from May 2015 to April 2017. All blood prescriptions and their sources were noted according to the clinical departments (wards/units). These include male medical wards, female medical wards, children ward, special intensive care unit, female surgical ward, male surgical wards; Obstetrics and Gynecology, Accident and Emergency, etc., The number of transfusion orders, the number of units requested, and the number of units that were collected within 72 h were properly noted.

Statistical analysis

Data were statistically analyzed using Microsoft Excel 2007 (released 2006; Microsoft Inc., USA) and Statistical Package for the Social Sciences (SPSS) version 17 (released 2008; SPSS Inc., USA). Frequencies were calculated for all variables to assess the statistical significance of difference in blood utilization between different departments (wards/units). The standard compliance indices used to assess the appropriateness of blood ordering and utilization services during this study include C/T, blood TI, blood %T, shortage calculation, and total blood units ordered/1000 population during a particular period of time. The data obtained were computed by simple proportion (frequency, percentages, and ratios) using the following formulas below:

C/T equals to the ratio of crossmatched blood units to transfused units. The Scottish Intercollegiate Guidelines Network recommended C/T ratio for evaluating blood demand and consumption for transfusion practices not be more than 2.5.



Blood TI equals to ratio of transfused blood units to patients with prepared crossmatched blood. Regarding TI, a value of 0.5 or more is indicative of efficient blood usage, and it signifies that appropriate numbers of blood units are transfused.



Blood %T equals to ratio of the number of patients receiving blood to the number of patients with prepared crossmatched blood in percentage. The probability of blood transfusion for a given department is denoted by %T and was suggested by Mead et al. (1980). Values more than 30% show significant probability of blood usage.



Blood transfusion indices such as C/T ratio (ratio of number of crossmatched blood units to transfused units), TI index (blood TI), and %T (blood %T) can be used for proper assessment of blood demand and consumption in various hospital wards.

Shortage referred to an order not filled by NBTS as the specific blood product was not available as of the time of request.



OR



Total blood units ordered = Unit undelivered + Unit delivered

Shortage = Undelivered - (cancelled + filled + rejected)

Tranfused = (Unit delivered - returned) + re-issued

Actual shortage = Shortage – re-issued

The blood demand and supply was calculated as:



Ethical considerations

This study was conducted in compliance with the Declaration on the Right of the Patient.[46] Furthermore, the approval was sought and received from the Health Research Ethical Committee of the Ondo State Ministry of Health, Akure, Nigeria.


  Results Top


[Table 1] showed the frequency distribution for the patients' blood group and rhesus types. It can be observed that the O-positive blood type conveyed the highest percentage of 52.01%, followed by 20.63% for A-positive blood type, B-positive blood type with 19.90%, AB-positive patients with 2.65%, O-negative blood type with 2.81%, while B-negative, A-negative, and AB-negative blood type having 1.04%, 0.88%, and 0.08%, respectively, in the tabulation.
Table 1: Frequency distribution for the patients' blood group and rhesus types

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[Table 2] showed the frequency distribution for transfused and nontransfused bloods. Regarding these crossmatched bloods, a total of 62.57% were transfused, while the remaining 37.43% were not transfused.
Table 2: Frequency distribution for transfused and nontransfused bloods

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[Table 3] showed the age group distribution for the patients' who were transfused during the time period under consideration. This revealed that most of the blood transfusions were done in the age range of 31–40 (26.08%) and the least transfusion was done in the age range of 91–100 years (1.36%).
Table 3: Frequency and percentage distribution of patients age

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[Table 4] showed that in State Specialist Hospitals, Akure, the overall C/T index was 1.60, overall %T was 62.57%, and overall TI was 1.00. The highest C/T ratio was linked to general theater (C/T = 3.80, %T = 16.44, and TI = 0.26). In other words, the number of ordered blood units by this department was nearly four times the transfused units. The lowest C/T was related to hematology/virology unit (C/T = 0.65, %T = 96.00 and TI = 1.53).
Table 4: Blood transfusion indices in various wards of State Specialist Hospitals, Akure

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[Table 5] showed the blood demand, supply, and usage. The actual shortage, shortage calculation, and total blood collection units/1000 population from May 2015 to April 2016 were 12 units, 1.86% and 0.28 units/1000 population, respectively.
Table 5: Blood demand, supply, and usage

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  Discussion Top


The purpose of this study was to obtain data on blood order (demand) and usage in State Specialist Hospital, Akure, Ondo State, Nigeria for the purpose of appropriate health planning and management of transfusion services. Our study did not evaluate blood ordering pattern in specific surgical and medical indications. It is however helpful to have a high index of suspicion of likely anemia transfusion therapy. This will help in reducing the high C/T ratio and improve on the rather low clinical utilization of ordered blood. The optimal practice of transfusion therapy depends on three factors: availability of blood donors, efficient clinical practice, and societal forces. Availability of suitable and willing donors has an effect on the availability of blood components: efficient clinical practice influences the amount of needed blood and societal forces (resources, legislation) affect both. The optimum efficiency of transfusion practices and services are also location related and changes over time.

This study demonstrated that most of the blood transfusions were done for the age range of 31–40 years olds (26.08%), while the least transfusions were done for the age range of 91–100 years (1.36%). In low-income countries, up to 65% of blood transfusions are given to children under 5 years of age, whereas in high-income countries, the most frequently transfused patient age group is over 65 years, accounting for up to 76% of all transfusions;[55] making our finding in this study to be at discordance with this trend. This discordance could be partly linked to the difference in socioeconomic status and bone marrow failure/inefficiency at the extreme ages of life between the developing and developed nations which has a direct impact on their populace standard of living conditions. Blood donation rate in high-income countries is 39.2 donations/1000 population; 12.6 donations in middle-income and 4.0 donations in low-income countries.[55] Around 107 million units of blood donations are collected globally every year.[55] Nearly, 50% of these blood donations are collected in high-income countries, home to 15% of the world's population.[55]

As observed, “blood group O” has continuously sustained its predominance, and this was the reason for labeling the carriers of this blood group O as “Universal Donor.” This group was followed in preponderance by blood group A and B in that order with blood group AB constituting the least in terms of frequency distribution pattern. Thus, the old appellation of carriers of this group as “Universal Recipients” was still confirmed in this study. Comparatively, although blood group O was also predominant and prevalent in other regions.[11],[47],[48] This trend (i.e., blood group A coming next in distribution to that of blood group O) was also observed from results obtained in other parts of the world including among Black Afro-Americans in the United States of America.[49] In another study carried out in Mauritania, it was observed that blood group O had the highest frequency followed by A and least frequency was AB, and there was no significant variation in the frequencies between blood group A and B.[50] Whether this was a coincidence or has a predefined genealogical objective remains an issue, especially since the pattern has remained constant in virtually all the epidemiological studies carried out over the years in the Southwestern region of Nigeria.[51],[52] One of the major findings of this study was that Rhesus D-positive patients have the highest percentage while Rhesus D-negative patients have the lowest percentage across the study. This is consistent with the findings of previous studies conducted in Elele in Nigeria,[51],[53] which showed that the incidence of Rhesus negativity in all the studies conducted in Nigeria was found to be low, between 1.69% and 5.5% as similar to 0.08%–2.8% obtained in this study.

Blood transfusion no doubt, has saved millions of lives worldwide. However, it is reported that recipients stand the risk of becoming infected with bloodborne diseases through transfusion of infected blood and blood products.[56]

Blood transfusion undoubtedly has a major role in reviving patients undergoing surgery and those at the verge of death for medical conditions. However, growing demand for storing blood and blood products has led to reduced shelf life of blood bags stored, increased workload, and ultimately, increased financial burden for patients and blood banks.

The use of C/T ratio was first suggested by Boral and Henry.[57] Subsequently, a number of authors used C/T ratio for evaluating blood transfusion practices. The results of the present study demonstrated that, C/T ratio varied widely across the departments under study from 0.65 at Hematology/Virology Department to 3.80 at the General Theater Department. This was somewhat similar to that reported in a Nigerian study but to a lesser extent where the C/T ratio values ranged from 1.60 in Obstetrics and Gynecology Department to 3.30 in Orthopedics, Accident and Emergency Departments.[24] The excessive ordering of blood by General Theater Department is more often guided by their prevention habits and hospital routines rather than actual clinical needs. This attitude is defended by the simple excuse that, it provides a safety measure in the event of excessive unexpected blood loss during surgery in the General Theater Department. Notwithstanding, there are varying C/T ratios from one unit to another unit within our institution. The C/T ratio in the Accident and Emergency Unit of our hospital was 0.76 compared to the other departmental points of care within the institution. This C/T ratio of 0.76 in this study for the Accident and Emergency Unit was very low when compared to the values obtained in previous studies done in other centers which were relatively high. These relatively high values of C/T ratios experienced may be explained by the panic response to a bleeding patient with an attempt at transfusion of donor blood even when full and comprehensive examination has not be concluded. This panic response is further reinforced by the rowdy environment experienced in most Accident and Emergency Unit; often due to mass critical event, from road traffic accidents, gunshot injuries in victims of armed robbery attacks, or even communal conflict.

Concerning TI, a value of 0.5 or more is indicative of efficient blood usage and signifies the appropriateness of numbers of units transfused.[58] The TI reported in the current study as an overall value (1.00) and the values of the different departments under the study are considered appropriate except for the Department of General Theater (0.26) and Obstetrics and Gynecology (0.41) Department that exhibit deviation from the blood supply standards and the routine activities of wrong blood orders in these departments.

This result was similar to the study conducted in an Indian tertiary care hospital where TI ranged from 0.36 to 0.15.[59] The results of these studies show that various factors can affect values of C/T ratio and TI indices such as type of disease, type of blood product required, type of surgery, and hospital ward/department/unit.

The %T for a given department/unit was suggested by Mead et al. in 1980.[42] A value of more than or equal to 30% has been recommended to be appropriate and signifies accuracy in the numbers of blood units crossmatched. According to what is recommended in the reference literatures, the %T values reported in the current study for the different departments under this study were considered appropriate except for the Department of General Theater (16.44%), and the Department of Obstetrics and Gynecology (25.45%). This finding from our own study was higher than the study conducted in an Indian tertiary care hospital where the %T was between the range of 11.1%–25%.[59]

The level of blood shortage was suggested by Sridhar et al.,[54] using blood Supply and demand approach. The World Health Organization recommended standard for blood collection is between 10 units to 20 units/1000 populations per year; which is used to reduce wastage and account for appropriate stock management. A total population of 3.7 million people lives in Ondo State according to 2006 National Population Census, which resulted into 1034 units of total blood being collected in the State Specialist Hospital, Akure, between May 2015 and April 2016. The 0.28 units collected/1000 populations resulted in 1.86% shortage. This is far lesser than the study conducted in Guyana NBTS. At Georgetown, Guyana, a population of 750,000 people in 2007 resulted into 5475 units total blood collected, which account for 7.3 units collected/1000 population resulted in an 8.7% shortage.[25],[54],[55] The impact of cost containment should be of paramount importance in an underresourced blood bank in terms of human capital and fund. This is acutely critical in blood shortage situation where there is no budget either at local hospital level or even at the Ministry of Health Level.[25],[55] This indicates appropriate clinical prudency and efficiency in the management of crossmatch blood orders on the basis of actual need which result in a more efficient utilization of blood products to conduct BTSs.


  Conclusion Top


This study showed a reliable and efficient clinical practice in the management of BTSs from the point of order to the point of need which amount to a more appropriate and conserves utilization of blood products, resources, and services. The continuous increase in blood need within the hospital facility calls for the amendment of practice guidelines to avoid blood supply shortage. One simple way of improving the quality of routine blood use is to target blood orders to the patients that need them urgently. If blood ordering is carried out according to proper practice guidelines, the inappropriate distribution of blood among various wards/units, rising costs of blood preparation, and also increased blood bank workload can be prevented.

Recommendations

Although patient's disease condition affects the level of blood order, ordering at will among physicians in different departments/units of our hospital is clear because many doctors prescribing blood are unaware of recommended published guidelines for transfusion practices and still adhere to historical practice and not evidence-based practice. Thus, the issue can be properly addressed through the establishment of National Blood Regulation Act, Hospital Blood Transfusion Committee, Standard Blood Ordering Form, proper blood transfusion ordering guidelines, establishment of blood maintenance and monitoring system, and changes in blood ordering and transfusion patterns. In addition, practical and continuous medical education training programs in relation to blood ordering and transfusion services in every hospital system are paramount in addressing the issue of blood shortage. We recommend that decisions to order for blood transfusion be taken in accordance to accurate clinical and laboratory indicators.

Acknowledgment

We would like to thank the staff of Blood Bank Services, Akure Specialist Hospital, Ondo State, Nigeria, for their immense assistance during the course of this study. Their support was of paramount importance to the completion of this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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