Quality assurance of clinical transfusion practice by implementation of the privilege of blood prescription and computerized prospective audit of blood requests.

Guidelines, algorithms and recommendations have been issued in the attempt to ensure appropriateness of transfusion practice, but the results are less than satisfactory, mainly due to the difficulty to turn paper procedures into actual practice. In our hospital we have tried to overcome this difficulty through the implementation of a quality assurance programme which includes giving the privilege of nonurgent blood prescription to a limited number of physicians and a computerized prospective audit of blood requests. The latter is performed through verification of the compliance of blood requests, which are designed to include a patient's laboratory and clinical data, with hospital guidelines for the proper use of blood. In the 12 months since implementation of the computerized prospective audit the transfusion service has evaluated 7884 requests. Of these, 63.4% (n = 4998) were for red blood cells, 21.1% (n = 1664) for platelets and 15.5% (n = 1222) for fresh frozen plasma. The prospective audit showed that 96.8% and 98.1% of requests for red units and platelets were appropriate, respectively. Conversely, approximately 27% of plasma requests did not comply with guidelines, mainly because the evidence of coagulopathy was missing. However, inappropriateness of plasma requests for elective general surgery decreased from 39% at the onset of the programme to 14% in the last trimester considered. Moreover, the evaluation by retrospective audit of the proportion of patients transfused with both red blood cells and plasma in the perioperative period out of those transfused with red blood cells only, as an indicator of unwanted reconstitution of whole blood, showed that this proportion decreased from 47.6% (320/672) in the 12 months before implementation of computerized audit to 37.8% (244/646) in the following 12 months (difference = -9.8%, 95% confidence interval of the difference from -4.5% to -15.1%; P < 0.005 by chi 2 test). Our initial experience, together with the present system, shows that (1) the restriction of nonurgent blood prescription to a group of clinicians more educated in transfusion medicine than average clinicians practicing in a large multispecialty hospital is feasible; (2) prospective audit is a useful tool for assuring the quality of blood requesting.

Single-donor platelet concentrates stored in synthetic medium. In vitro and in vivo studies.

Single-donor platelet concentrates (PC) were prepared in 80-120 ml plasma and stored in two polyolefin bags after addition of 250 ml plasmalyte, a simple, glucose-free synthetic medium that was previously used for platelet storage; when compared to PC stored in plasma, PC stored in plasmalyte, showed similar platelet quality, morphology and function after 5 days of storage. In vivo increments observed after transfusion of PC stored for 5 days in plasmalyte were similar to those observed after transfusion of 1-2 day old PC stored in plasma. Moreover, transfusion of 5-day old PC stored in plasmalyte was associated with correction of prolonged bleeding times in all 3 of the 3 patients evaluated. It is concluded that plasmalyte seems to be promising as a medium for single-donor PC storage.

Prospective evaluation of posttransfusion hepatitis.

The incidence of posttransfusion hepatitis (PTH) was determined prospectively at our institution. An active surveillance program of transfused surgical patients was set up; alanine aminotransferase (ALT) levels were determined before transfusion and at monthly intervals for 6 months after transfusion. Patients with confirmed ALT values greater than 2.5 times the upper reference values were referred to the out-patient clinics for diagnosis. Of 4051 surgical patients who underwent transfusion between January 1986 and December 1989, 2459 (60.7%) were enrolled in the surveillance program, and 1018 (25.1%) completed the follow-up; 238 patients received autologous blood only and were used as controls. No PTH was observed in the control patients, and the incidence of the disease in patients receiving homologous blood was 10.97 percent in 1986, 6.58 percent in 1987, 5.55 percent in 1988, and 4.29 percent in 1989; the decreasing trend is significant (p = 0.018).

Prevalence of hepatitis C virus antibodies in Italian blood donors. The Italian Cooperative Group.

11,117 blood donors from 24 blood transfusion services evenly distributed throughout the various Italian regions were tested for the presence of hepatitis C virus (HCV) antibodies in the serum and serum alanine aminotransferase (ALT) level. The results are as follows: (1) anti-HCV seroprevalence in Italy was 0.87% with a difference between Northern and Southern regions (0.68 vs. 1.37%) and between younger and older subjects (0.62 vs. 1.21%); (2) prevalence of elevated ALT levels was 4.74% without a North-South effect (except than for markedly elevated ALT levels); (3) anti-HCV seroprevalence was higher in subjects with elevated ALT (5.0%), with a North-South effect (2.2 vs. 9.9%) and particularly high (19.2%) in subjects with markedly elevated ALT; (4) ALT levels were elevated in 26.2% of anti-HCV positive subjects, with a North-South effect (14 vs. 40.5%).

Quality assessment of transfusion practice in elective surgery.

A program of quality assurance (QA) was adopted to improve blood transfusion practice in elective surgery at a large urban hospital. For this purpose, a cooperative multidisciplinary group was formed, key indicators were identified, and an organization was set up. Data collected by this organization in the 1-year period needed for implementation of the program indicated that blood misuse was common practice. In fact, overrequest, overtransfusion, excessive reconstitution of whole blood (i.e., concurrent transfusion of red cells and fresh-frozen plasma), and underuse of predeposit were found in all ten surgical departments of the hospital. In a pilot study, data were collected from one surgical department during and after the implementation phase of the QA program; comparison of these data showed a postimplementation reduction of about two thirds in overtransfusion, whereas overrequest, reconstitution of whole blood, and predeposit rates remained unchanged. These results prompted continuation of the program in order to reach a definitive evaluation of its effectiveness.