Follows a directive from the Medicines and Therapeutics committee MTC Moyo to review the appropriateness of clinical transfusion and transfusion reactions amidst the shortages of blood resources in Moyo and West Nile region and Uganda according to the Uganda Blood Transfusion Service UBTS

1. Clinical Transfusion Appropriateness
Audit: Moyo General Hospital
Andrew Jokene MBChB, MPH
Francis K. Kidega DPharm, BPharm, MPS, MPH
June 2021

3. Contents
 Introduction and Background
 Aim
 Methods
 Results
 Discussion
 Conclusion
 Recommendation
 References

4. Introduction and Background
 There are evidences of inappropriate blood transfusion (BT)
practices in many Ugandan hospitals
 Despite challenges of increased demands, reduced donor
pool and resources constraints
 Lack of standardization of blood transfusion processes, No
hospital transfusion committee or transfusion policy

5. BT is used as part of anaemia treatment (de Graaf et
al., 2009)
BT is a balance between benefiting the patient by
improving oxygenation and risk of complications
(Ministry of Health, 2016 p.540)

7. Uganda Blood Transfusion Service (UBTS)
 Uganda Blood Transfusion Service (UBTS) coordinates all blood transfusion
and safety activities in Uganda
 Decentralization of services to all regional blood banks including;
 Nakasero Blood Bank (headquarter)
 Arua regional blood bank (Moyo Hospital mainly collects blood from here)
 Fort-portal, Gulu, Kitovu, Mbale, Mbarara, Jinja, Soroti
 Other blood collection centers - Lira, Hoima, Kabale, and Rukungiri

8. UBTS

9. Aim
Audit follows a directive from the Medicines and
Therapeutic Committee (MTC) of Moyo General
Hospital
Review of the appropriateness of blood transfusion
at Moyo General Hospital
Review of transfusion reactions in 2020

10. Methods
 Retrospective review of inpatient BT records and Lab records
 Medical, Maternity and Surgical wards BT reviewed for April,
May, June 2020
 Inpatient files collected from records and the wards in May
2021
 Data managed and analysed using PSPP version 0.10.4-
g50f7b7 statistical software package and Microsoft Office
Excel
 The appropriateness of blood transfusion were assessed using
the Uganda Clinical Guidelines 2016, and ICD-10

11. Results

12. Results
 57 patients actually received BT in the period of April to June 2020 in the
three wards (Table 1) out of 1119 total admissions, 5% of admitted
patients received BT
Table 1: Distribution of transfused patients by wards from April to June
(N=57)
ward Frequency Percent Valid Percent Cum Percent
Maternity 25 43.86 43.86 43.86
Medical 28 49.12 49.12 92.98
Surgical 4 7.02 7.02 100.00
Total 57 100.0 100.0

13. Results
Table 2: Patient category
Variable Frequency Percent Valid PercentCum Percent
Emergency 47 82.46 82.46 82.46
Elective 10 17.54 17.54 100.00
Total 57 100.0 100.0
Majority of patients
(82%) received BT as
emergency while 17.5%
were electively
transfused

14. Table 3: Distribution of blood transfusion by diagnosis and C/T
Ratio in 2020 (N=57)
Diagnosis No.
Patients
% No. Units
prescribed
No. cross
matches (C)
No.
transfusions
(%) (T)
C/T Ratio
Bleeding 25 43.8 37 59 40 (44.4%) 1.5
Severe anaemia of
unknown cause
6 10.5 7 14 9 (10%) 1.5
Surgery 5 8.8 6 9 7 (7.8%) 1.3
HIV/AIDS 4 7 5 5 6 (6.7%)) 0.8
Cancer 4 7 6 7 8 (8.9%) 0.9
Organ disorders CLD,
CKD
3 5.3 3 7 5 (5.6%) 1.4
Anaemia in pregnancy 3 5.3 3 4 3 (3.3%) 1.3
TSS 3 5.3 3 5 6 (6.7%) 0.8
Sickle cell disease 2 3.5 1 3 2 (2.2%) 1.5
PTB/EPTB 2 3.5 3 9 4 (4.4%) 2.2
Total 57 100 74 122 90 (100%) 1.3

15. Results
 90 units of blood were transfused to 57 patients from medical ward (49%),
Maternity ward (43.8%), and surgical ward (7%) at Moyo General Hospital
(Tables 1 and 3)
 Overall C/T Ratio 1.3 in 2020 which indicates optimum usage of blood.
 Bleeding accounted for the highest proportion of BT (44.4%); followed by
anaemia of unknown causes (10%) and Cancer 8.9%
 The most common infectious cause of blood transfusion was HIV/AIDs
(6.7%).
 The C/T Ratio indicates efficiency of usage of blood, a ratio between total
cross-matched units of blood and transfused units. C/T ratio of less than 2
is desired (Obi et al., 2020 cited in Karaca et al., 2020).

16. Results
in April, 33 units of
blood were prescribed
but 40 units were
transfused while in May,
15 units were
prescribed but 20 units
were transfused and in
June 30 units of blood
was transfused yet 26
units was prescribed
33
15
26
40
20
30
0
5
10
15
20
25
30
35
40
45
April May June
NUMBER
OF
UNITS
Blood utilization in 2020
Units prescribed Units transfused

17. Results
The median pre-
transfusion Hb was 5.0
g/dL and the
interquartile range was
2.55 (Tukey’s Hinges 4.1-
6.5)
Table 4b: Median Pre-transfusion Haemoglobin (Hb) level
Statistic Std. Error
PreTransfusio
nHb
Mean 5.92 .38
95% Confidence
Interval for Mean
Lower
Bound
5.16
Upper
Bound
6.68
Median 5.00
Minimum 1.60
Maximum 15.10
Range 13.50
Interquartile Range 2.55

18. Clinical Review and
impaired Oxygenation
Table 5: Clinical review after 1 unit (N=57)
Value Label Frequency Percent
Valid
Percent
Cum
Percent
Yes 44 77.19 77.19 77.19
No 13 22.81 22.81 100.00
Total 57 100.0 100.0
• 77% clinically reviewed by
clinicians after the first
unit of BT while about 23%
not reviewed after single
unit (Table 5)
• More than half of patients
transfused (56%) had
impaired oxygenation
prior to blood transfusion
while 43.8% had no
features of impaired
oxygen delivery.
Table 6: Impaired oxygenation signs/symptoms
Value Label
Frequenc
y
Percent
Valid
Percent
Cum
Perce
nt
yes 32 56.14 56.14 56.14
No 25 43.86 43.86
100.0
0
Total 57 100.0 100.0

19. Documentation
Audit
• Figure 2 above shows,
majority of blood transfusion
in May 2020 (84.6%) followed
documented prescription by
doctors followed by 84% in
April and 79% prescription in
June 2020 while 100% of the
transfused patients consented
for BT in May 2020 and 88%
and 79% consented in April
and June respectively. In
majority of cases, rationale for
BT was given by the clinicians
(79%, 77% and 76%
respectively).
84.0 84.6
79.0
0.0 0.0 0.0 0.0 0.0 0.0
88.0
100.0
79.0
0.0 0.0 0.0 0.0 0.0 0.0
0.0
76.0 77.0 79.0
0.0 0.0 0.0 0.0 0.0 0.0
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
percentage
month
Fig 2: Compliance with Medical
Documentation
PRESCRIPTION CONSENT DOCUMENTED INDICATION PROVIDED

20. Documentation Audit
76
53.8 57.9
8 15.3 10.5
24 23
36.8
APRIL MAY JUNE
Percentage
Month
Figure 3: Compliance with Nursing
Documentation 2020
Time commenced indicated
Time concluded indicated
Signed
0%
10%
20%
30%
40%
50%
8%
3.5%
50%
4% 0% 0%
Completeness of
observations
Complete obs at baseline
Complete obs at completion

21. Transfusion Reactions
Table 8: Transfusion Reaction
Documentation
Value
Label
Freque
ncy
Percen
t
Valid
Percent
Cum
Percent
yes 1 1.75 1.75 1.75
No 56 98.25 98.25 100.00
Total 57 100.0 100.0
Majority of patients
did not have
documented
evidence of
transfusion
reactions. Less than
2% transfusion
reactions occurred

22. Discussion

23. Discussion
90 units of blood were transfused to 57
patients in the 3 wards audited (Tables 1
and 3)

24. UCG 2016
 In UCG 2016, BT is recommended for;
 any symptomatic anemia and with Hb<8g/dL in a non-
bleeding adult
 In pregnancy <36 weeks: Hb</= 5g/dL; pregnancy> 36 weeks:
Hb</= 6g/dL (Ministry of Health, 2016 p. 544)
 In paediatric patients, Hb </= 6g/dL with complications and
 Hb </= 4g/dL regardless of the clinical condition of the
patient

25. The appropriateness of blood transfusion
in 2020
• Patient diagnosis and C/T Ratio in 2020
• Blood utilization at Moyo General Hospital in 2020
• Clinical review and oxygen impairment

26. Patient diagnosis and C/T Ratio in 2020
majority of patients were transfused blood as
emergency management as compared to
elective blood transfusions (Table 2)
Various indications of BT given in table 3,

27. Commonest causes;
bleeding (44.4%) mainly from obstetrical and
gynaecological haemorrhages and Upper GI bleeding
with C/T ratio of 1.5
anaemia of unknown causes (10%) with C/T ratio 1.5
common infectious causes of BT; HIV/AIDs (6.7%)

28. Malaria reported to be the highest infectious cause
of blood transfusion with C/T ratio 1.1 in paediatrics
in a RRH in Uganda (Natukunda, Schonewille &
Sibinga, 2010)
Hb check (CBC) preceded all the first units of BT

29. Median transfusion Hb trigger was 5.0 g/dL, is the
recommended clinical practice
Quick haemoglobin checking is very necessary to
confirm severe anaemia in order to guide the
clinicians’ decisions on whether or not to prescribe
blood transfusion (Opoka et al., 2018).

30. Blood utilization at Moyo General Hospital in
2020
the number of units of blood prescribed (74 units) in
that period were lower than the number of units of
blood transfused (90 units) or cross-matched units
(122 units) (see figure 1 and table 3).
unnecessary requests for blood affects the blood
stock in the blood bank as the blood cross-matched
normally loses a certain shelf life (Kavaklioglu, Dagci
and Oren, 2017 cited in Karaca et al., 2020)

31. inappropriate blood transfusions denies the
opportunities for the truly anaemic patients to
receive blood and also exposes patients to risks
associated with BT (Lackritz, 1998 cited in Opoka et
al., 2018; Ministry of Health, 2016; Shari et al., 2017
cited in Opoka et al., 2018).

32. Clinical review and oxygen impairment
 A significant percentage (23%) of patients were transfused several units of
blood without clinical assessment after the first unit (Table 5)
 Successive transfusion of 2 or more units of blood is associated with the
risk of fluid overload and pulmonary oedema especially in non-bleeding
patients and the elderly
 Single unit recommended to raise Hb above trigger level and relieve
hypoxia according to clinical guidelines and International Society of Blood
Transfusion
 56% had features of impaired oxygenation while 44% had no hypoxia
signs/symptoms, possibly BT was triggered by low Hb or bleeding
 Single unit policy also saves resources

33. Documentation Audit
 No specific consent forms for BT found as patients usually consented for
treatment including BT
 Some patients did not consent for treatment (Figure 2)
 Some patients were transfused without prescription or documentation by
doctors, this is not recommended (Figure 2)
 Evidence of incomplete documentation of transfusion process by nurses
 no continuous observation of patients and recording of outcome
 Time when BT commenced often indicated but time for completion not
indicated and patient chart not signed
 Continuous observation during BT recommended to ensure normal
process and prompt response in case of transfusion reactions (de Graaf et
al., 2009; Ministry of Health, 2016)

34. Transfusion reactions
 No proper documentation of transfusion reactions
 Evidence of incomplete baseline obs, during and post-
transfusion vital observations made it hard to interpret certain
transfusion reactions
 Less than 2% of transfused patients had evidence of
transfusion reactions
 Observation that some transfusion reactions usually managed
in the wards without reporting to the lab or clinicians

35. Conclusion
 Overall C/T ratio of 1.3 and the pre-transfusion Hb trigger shows efficient
blood use
 All patients had pre-transfusion Hb level checked which is good practice
 Some patients are transfused several times without the Hb level checking
post-BT and without prescription by the clinicians or clinical review
 The pre-transfusion Hb trigger was within the recommended range
 There are issues of incomplete documentation and no continuous vital
observations during BT

36. Recommendations
 Need for blood transfusion policy at Moyo General Hospital
 Need to introduce single-unit transfusion policy
 Clinicians need to do further investigations for underlying cause of
anemia
 Trainings in best practice of clinical transfusion; clinicians, nurses,
lab
 Need for proper blood transfusion forms and accessible hospital
transfusion guidelines/checklist for clinical transfusion at bedside

37. References
 Ministry of Health (2018) Medicines and Therapeutic Committees Manual 2018.
Wandegeya: Ministry of health Pharmacy Department.
 de Graaf, J.D., Kajja, I., Bimenya, G.S., and Postma, M.J. and Smit Sibinga, C. Th.
(2009) Bedside practice of blood transfusion in a large teaching hospital in Uganda:
An observational study. Asian Journal of Transfusion Science [Online]. 3(2): 60-65.
Available at:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2920473/#!po=91.3793 [Accessed:
18-6-21].
 Karaca, B., Namdaroglu, S., Ari, A. and Bagriacik, N. (2020) Crossmatch to
Transfusion Ratio as a New Quality Indicator in Blood Banking. Journal of
Haematology & Transfusion. 7(1): 1085.
 Opoka, R.O. et al. (2018) High Rate of inappropriate blood transfusions in the
management of children with severe anaemia in Ugandan hospitals. BMC Health
Services Research. [First published online 18 July 2018]. Available at:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6052584/#__ffn_sectitle [Accessed:
6-5-21]