PROJECT PLAN: the useCross match to transfused ratio as performance indicator

Application of Cross match /Transfuse blood units ratio as performance indicator for blood conservation in AWH

QUALITY IMPROVEMENT PROJECT

3 years study

Blood Usage review Committee

Application of C/T ratio as performance indicator for blood conservation in AWH

Project Plan ( FOCUS -  PDCA METHODOLOGY

 

•         Background

 

•         FIND A PROBLEM

•         ORGANIZE A TEAM

•         UNDERSTAND THE PROBLEM

•         Currant situation

•         SELET THE IMPROVEMT

 

•         PLAN THE IMPROVEMT

•         DO THE IMPROVEMT

•         CHECK THE RESULTS

•         ACT ON HOLD THE GAIN

Background

 

•         Blood transfusion is often a life-saving measure.

 

•         In the era of numerous blood-transmitted diseases and known complications , it is limited to patients who really require blood replacement therapy.

 

•         In elective surgery, blood transfusion is quite uncommon and most of the cross-matched blood is not used.

•         Blood Usage Review Committee has been formulated through the hospital’s Quality Department in September 2004.

 

•         The committee comprises a representative from each departments.

 

•         All issues related to clinical use of blood need to be dealt with in this committee.

FIND A PROBLEM

•         This project was initiated to determine ways to reduce unnecessary demands on blood supply, as blood bank AWH raised the point that the majority of (cross – matched blood units) were left unused.

Organize a team

•         Blood Usage Review Committee members.

Work together to look into this problem.

 

•         They nominated a sub-team  ;

- Dr Kareema ( In charge of Blood Bank AWH)

- Mrs. Asma and then Miss Faheema( Senior lab Tech. )

- Mrs. Merlyn ( Quality coordinator)

 

 

 

 

 

Clarify – The current process

( 2 blood units’ policy)

 

•         The sub-team found that the trend is.. (cross-match.. ..minimum 2 units of blood for all patients need to go to theater need it or not)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Clarify – The current process

 

 

 

 

 

 

 

 

Understand the source of the problem

 

•         There was no Hospital Blood Transfusion Policy.

•         Blood Usage was liberal.

•         No defined audit system.

 

 

 

 

Select – The improvement

•         Improvement will only be achieved by communicate the problem with the hospital’s clinical bodies.

 

•         Through Blood Usage Review Committee’s members.

 

 

 

 

Plan the improvement

A blood utilization policy was to be  prepared by the BURC committee and to get  approved by AWH quality council, and to get  implemented.

 

We chose cross-matched to transfused ratio as a performance indicator.

 

Retrospective monitoring of 2004.

          (pre-policy implementation)

 

4.     Monitor the improvement in 2005 and 2006.

         (post-plicy implementation)

Do – The improvement

Blood transfusion policy prepared and

   ( implementation in May 2005)

 

2.  Maximum Surgical Blood  Order Schedule, *MSBOS was prepared by Surgical  Paediatric and Obs&Gyn departments.

(*It is the maximum number of units transfused for each procedure by a known surgical department)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Promotion for Group & Save ( blood group and antibody screening then save the serum), instead of cross-match order.

 

4. Presentations & Educational sessions conducted by each of committee member to his/her respective department.

 

5.  Cross – matched blood units to Transfused units (C/T ratio) monitored.

    C/T ratio used as performance indicator to measure rational blood order in AWH.

 

Check the results

•         Pre-implementation period (2004) ;

 

Total number of cross-matched units was 24260.

 

Total number of transfused units was1552.

 

Transfused units were 6% of cross-matched units.

 

Cross-matched / Transfused ratio was 16 / 1

 

•         Post-implementation period (2005);

 

Total number of cross-matched units was 5497.

 

Total number of transfused units was 1149.

 

Transfused units were 21% of cross-matched units.

 

Cross-matched / Transfused ratio was 5 / 1

 

•         Post-implementation period ( 2006);

Total number of cross-matched units was 4390.

 

Total number of transfused units was 1166.

 

Transfused units were 26.5% of cross-matched units.

 

Cross-matched / Transfused ratio was 3.7/ 1.

 

•         C/T ratio has been reduced from;

 16/1 in 2004

 5 /1 in 2005

 3.7 /1 in 2006.

 

•         Cross-matched units number shows compared to 2004;

     77% reduction in 2005.

     82% reduction  in 2006.

 

 

 

 

This shows that admission to the hospital is on the rise so no argument can be made that C/T ratio is less because of less admission.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

We reached the goal in early 2007.

 Our aim was to reach it by the end of the same year.

 

 

 

 

 

 

 

Act – To hold the gain

•         Project succeeded in showing that blood transfusion orders were irrational.

 

•         Blood Transfusion policy implementation succeeded in tremendously minimizing blood ordering pattern.

 

•         C/T ratio needs to come down to 2 /1 by the end 2007, but fortunately we reached it by beginning of the same year.

 

•         Blood usage review committee needs to start  Audit system on blood transfusion orders, to match order with MSBOS. 

•         C/T ratio monitoring should be an on going process.

 

 

•         Continues educational/orientation  programs for  Medical staff  needs to be in action.

 

 

•         Results were unachievable without  Medical staff compliance.

 

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