The effect of an educational program on transfusion practices in a regional blood program

Medical student education in transfusion medicine: Proposal from the "European and Mediterranean initiative in transfusion medicine"

A large body of observations indicate that there is an inconsistent knowledge of Transfusion Medicine among health care professionals as well as inconsistent knowledge in all aspects of the transfusion process, from blood donation to transfusion on the ward. It is obvious to consider that appropriate education in Transfusion Medicine should be achieved in the education of specialists who will prescribe transfusion on a regular basis (hematologists, critical care specialists, anaethesiologists and others.) However,we also believe that education in Transfusion Medicine should also be delivered to almost all other medical specialists who may prescribe blood components. The variability in education of undergraduates in medical schools is universal most likely due to an absence of a predefined common platform. This paper, therefore, focuses on education at the undergraduate level and advocates coverage of the essential physiology and pathophysiology of blood as applied to blood transfusion as well as the medical and societal aspects of issues related to blood donation. It proposes incremental levels of training in Transfusion Medicine, with what is being therefore referred to as 'A', 'B', 'C' etc. curricula in ascending order of complexity; for example, 'A' and 'B' levels would involve medical, midwifery and nursing students, covering a broad base of the subject: they will be detailed in the present essay; ongoing further curricula will focus on physicians and other professionals working within the area or with responsibility for different aspects of the transfusion chain. It is intended that these courses include aspects of donor care, patient care and the appropriate use, safety and effectiveness of blood products. Next, it is advocated that curricula are addressed not only for high-income countries but also for middle- and low-income ones.

Behaviour modification interventions to optimise red blood cell transfusion practices: a systematic review and meta-analysis

OBJECTIVE

To assess the impact of behaviour modification interventions to promote restrictive red blood cell (RBC) transfusion practices.

DESIGN

Systematic review and meta-analysis.

SETTING, PARTICIPANTS, INTERVENTIONS

Seven electronic databases were searched to January 2018. Published randomised controlled trials (RCTs) or non-randomised studies examining an intervention to modify healthcare providers' RBC transfusion practice in any healthcare setting were included.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was the proportion of patients transfused. Secondary outcomes included the proportion of inappropriate transfusions, RBC units transfused per patient, in-hospital mortality, length of stay (LOS), pretransfusion haemoglobin and healthcare costs. Meta-analysis was conducted using a random-effects model and meta-regression was performed in cases of heterogeneity. Publication bias was assessed by Begg's funnel plot.

RESULTS

Eighty-four low to moderate quality studies were included: 3 were RCTs and 81 were non-randomised studies. Thirty-one studies evaluated a single intervention, 44 examined a multimodal intervention. The comparator in all studies was standard of care or historical control. In 33 non-randomised studies, use of an intervention was associated with reduced odds of transfusion (OR 0.63 (95% CI 0.56 to 0.71)), odds of inappropriate transfusion (OR 0.46 (95% CI 0.36 to 0.59)), RBC units/patient weighted mean difference (WMD: -0.50 units (95% CI -0.85 to -0.16)), LOS (WMD: -1.14 days (95% CI -2.12 to -0.16)) and pretransfusion haemoglobin (-0.28 g/dL (95% CI -0.48 to -0.08)). There was no difference in odds of mortality (OR 0.90 (95% CI 0.80 to 1.02)). Protocol/algorithm and multimodal interventions were associated with the greatest decreases in the primary outcome. There was high heterogeneity among estimates and evidence for publication bias.

CONCLUSIONS

The literature examining the impact of interventions on RBC transfusions is extensive, although most studies are non-randomised. Despite this, pooled analysis of 33 studies revealed improvement in the primary outcome. Future work needs to shift from asking, 'does it work?' to 'what works best and at what cost?'

PROSPERO REGISTRATION NUMBER

CRD42015024757.

Practices for rational use of blood components in a universitary hospital

OBJECTIVE

to produce improvements in transfusion practices through the implementation of an educational program for health professionals in a university hospital.

METHODS

this is an interventional and prospective study, with pre- and postanalysis of an educational intervention. The research was developed at the University Hospital of the Universidade Federal de Sergipe, involving participation of health professionals in the stage of training, during the month of February 2011, in addition to the monitoring of blood transfusions performed in the pre- and post-intervention periods. Transfusion practices were investigated upon request for transfusion or devolution of unused blood components. Knowledge of health professionals was assessed based on the responses to a questionnaire about transfusion practices.

RESULTS

during the educative campaign, 63 professionals were trained, including 33 nurses or nursing technicians and 30 physicians. Among the doctors, there was a statistically significant gain of 20.1% in theoretical knowledge (p=0.037). Gain in the nursing group was even higher: 30.4% (p=0.016). The comparative analysis of transfusion request forms showed a non-significant decrease from 26.7 to 19.5% (p=0.31) in all forms with incomplete information. We also observed a statistically significant improvement in relation to the filling of four items of transfusion request.

CONCLUSION

there was a significant improvement of the entire process related to blood transfusions after interventional project conducted in February 2011.

Expanding developmental and behavioral services for newborns in primary care: program design, delivery, and evaluation framework

BACKGROUND

Healthy Steps (HS) for Young Children strengthens the healthcare system as a source of developmental and behavioral support for parents. This series of papers presents a study of HS as implemented within a large health maintenance organization that tested the benefit of beginning intervention services during pregnancy with an extension program called "PrePare" (PP).

METHODS

The design was a quasi-experimental comparison of intervention families with families receiving usual care. Within the intervention, families were assigned randomly to begin receiving Healthy Steps services prenatally (PP+HS) or shortly after birth (HS). We used a systems model, PRECEDE/PROCEED, for planning, implementation, and process evaluation. Outcomes examined when the infants were aged 3 months included changes in family social support and capacity for parenting, parenting behaviors, and satisfaction and loyalty to the health plan.

RESULTS

The sample of 439 families was distributed as follows: usual care (n=136), prenatal initiation of services (PP+HS; n=151), and postnatal Healthy Steps (HS; n=152). Information about program implementation, including provider satisfaction, is provided for the early phases of the study (through age 3 months). The intervention was delivered with fidelity and with minimal disruption to the practice styles of pregnancy providers, most of whom considered the program valuable to their patients. Relative to families in the comparison group, families in the intervention group received more usual care services and more intervention-specific services.

CONCLUSIONS

The pregnancy and newborn phases of the intervention were embedded successfully within the existing healthcare delivery system. The program was considered valuable for parents by providers and parents. Participating families received more services and a greater variety of services than families in usual care. Whether these differences result in beneficial outcomes for families or the health plan are topics of the subsequent papers.

Guiding the decision to transfuse

Guiding the decision to transfuse can improve transfusion practices. Effective processes must first identify problem(s) in transfusion practice and then include the attending physician as an educational target. Process improvements that have been shown to be effective include the following: (1) briefly meeting one-on-one with physicians, (2) teaching at scheduled conferences, (3) making daily clinical rounds of patients who receive transfusion, (4) concurrently reviewing orders for transfusion before issue of the blood product, and (5) installing algorithms and guidelines in the operating room. Transfusion practices improved with these process improvements.

The transfusion audit as an educational tool

Audits of transfusion used as educational tools can improve transfusion practices. Effective audits must first identify problem(s) in transfusion practice and must then include as educational target, the attending physician. Educational methods that have been shown to the effective include: (1) meeting briefly one-on-one with physicians, (2) teaching at scheduled conferences, (3) making daily clinical rounds on patients who receive transfusion, (4) concurrent review of orders for transfusion prior to issue of the blood product and (5) installing algorithms and guidelines in the operating room. Transfusion practices improved with these educational audit methods.

The transfusion audit as a tool to improve transfusion practice: a critical appraisal

Transfusion audits have a long history and they are required by many regulatory agencies. These audits have been touted as effective in reducing unnecessary transfusions as evidenced by many published articles on the subject. Most of these studies, however, have one or more flaws in their design including the use of historical controls, disregard of the Hawthorne effect, use of multiple interventions, and publication bias. Studies differ in the baseline rate of inappropriate transfusions and have different methods of measuring these rates. There is also little data on how long the effect of implementing a transfusion audit system may last. Transfusion audits appear most successful when there is a high baseline rate of inappropriate transfusions and interventions other than the audit itself are performed. Individual institutions should critically evaluate whether or not their current system of transfusion audits is useful.

Audit and education in transfusion medicine

Because transfusions carry risks to the patient and because inappropriate transfusions are costly, interest in audits and effective education in transfusion medicine has increased over the last decade. Audits identify areas of practice that can be improved by follow-up education of the physicians who prescribe the transfusions. Successful educational approaches to follow-up on problems identified by audit include 30-min one-on-one meetings with surgeons, traditional scheduled teaching conferences, daily clinical rounds on transfused patients, prospective review of blood transfusions and installation of transfusion practice algorithms in the operating room. Other than identifying inappropriate transfusions, audit and education have also been used successfully to improve bedside blood administration practices, decrease unnecessary crossmatches and reduce outdating of donor blood. Multi-institutional audits play a useful benchmarking role. In summary, audit followed by targeted education can improve practices in transfusion medicine.