Context This project was done in a district general hospital in Scarborough, Northern Yorkshire, England. The team members were internal medicine trainees and we collaborated with the transfusion practitioners and lab personnel in order to obtain data relevant to this project.

Issue/Challenge Blood is a precious resource. It has been observed that in recent years especially with relative easier availability of blood products, there is a tendency for clinicians to over-prescribe blood products.

National guidelines recommend the usage of single unit red cell transfusions for those not actively bleeding and consideration of alternatives. Patients should be reassessed clinically and with further blood count to determine need for further transfusion.

Assessment of issue and analysis of its causes

A retrospective audit was conducted in the Acute Medical Unit of Scarborough Hospital between 1st of January to 1st of May 2022 to explore local transfusion practice and its adherence to recommended guidelines.

Information was obtained from paper, electronic and blood transfusion records regarding transfusion indications, number of units requested and issued, pre-and post transfusion haemoglobin, evidence of clinical reassessment post transfusion, baseline haematinics and its replacement. Our exclusion criteria were actively bleeding patients, surgical patients, and transfusion-dependent patients.

Impact 49 transfusion episodes were identified, 17 of which were analysed after applying the exclusion criteria above. The mean age of the patients audited was 75 and included 47% (8) males and 53% (9) females. 82% (14) of the transfusion episodes were single unit. 100% (17) had a post transfusion Hb done in 24 hours, 24% (4) had evidence of a clinical reassessment performed post transfusion and 24% (4) had evidence of both a clinical reassessment and blood count checked post transfusion.76% (13) of patients had baseline haematinics done. 69% (9) of these patients were iron deficient, with 67% (6) receiving appropriate replacement.

There is evidence of good practice ie. usage of single unit blood transfusion, however there is scope for improvement in multiple areas especially in haematinic workup and clinical reassessment post transfusion.

Improvement in these areas will be greatly beneficial to patients as transfusions are not without its risks. Furthermore, implementing a single unit blood transfusion policy is projected to be significantly cost-saving for the local trust involved.

Intervention The decision to transfuse often lies with a senior clinical decision maker. Implementing a single unit transfusion policy for stable patients and enforcing good transfusion practice often calls out for improvement and even a change of old habits. Good leadership in this regard with foresight of the many benefits of this will go a long way in improving practice in this regard.

Involvement of stakeholders, such as patients, carers or family members:

As this is a retrospective audit, they were involved indirectly in data collection.

Key Messages The decision to transfuse a patient should be based on the individual’s clinical needs and as clinicians we should be mindful that transfusion is not without its risks. There is a need to balance the need of treating anemia, and avoiding unnecessary transfusion, with its associated costs and potential harms. Let us be reminded of the Hippocratic Oath: ‘I will prescribe regimens for the good of my patients according to my ability and my judgment and will do no harm or injustice to them’.

Lessons learnt Blood transfusion practice is a very large topic and just sampling a small amount of patients provided a wealth of data. If I had the opportunity to start again, I would involve a larger amount of patients over a longer period of time.

Barriers to this project was mainly in data collection as we were reliant on lab personnel due to the lack of access on our part to laboratory IT systems.

Measurement of improvement After undertaking the improvement steps, it is proposed to reaudit over a similar length of time the same parameters and analyse for improvement.

Strategy for improvement Interventions undertaken include staff education in the form of teaching sessions. Other improvements planned include distribution of posters and dissemination of information via email and social media.