Transfusion audits in 2007

Please note: for current Transfusion audits, please see Transfusion audits.

Audit of blood transfusion policy, procedures and administration practice

Blood and blood components are administered by a range of staff across hospitals. Access to and knowledge of hospital protocols for blood administration is important for patient safety and organisational risk management. This audit includes both the initial specimen collection for crossmatch and subsequent administration of blood product at the bedside.

Note should be taken of the ANZSBT/RCNA Guidelines for the Administration of Blood Components 2004.

The Blood Matters Program wishes to work with hospitals to ensure that blood components are administered to patients appropriately and safely.

The Blood Matters Advisory Committee has identified the area of blood product administration policy and practice as an area for targeted desk and clinical audits in order to determine current practice across the State.

Definition of Policy and Procedure:

The policy/procedure document refers to a document that is for hospital-wide use and that is authorised in accordance with hospital clinical policy/procedure processes for such documents [eg the hospital executive or delegate is responsible for authorising the document(s)].

Instructions and data collection forms

Instructions and forms for local data collection have been forwarded to hospitals and can also be downloaded if required and are located below.

Instructions for the Audit of blood transfusion policy, procedures and administration practice (55kb, MS Word)

Form: Audit of hospital-wide policy and procedure(s) for blood transfusion (44kb, MS Word)

Form: Prospective Audit of Blood Product Administration Practice - transfusion episodes 1 to 15 (108kb, MS Word)

Form: Prospective Audit of Blood Product Administration Practice - transfusion episodes 16 to 30 (107kb, MS Word)

Data submission process

Data submission for the Protocol (policy and procedures) and Administration Practice audits is now closed, paper based audit sheets are available for self auditing purposes. Thankyou to the health services who have participated in this audit, analysis of the data has commenced and reports will be forthcoming.

Clinical Audit of Platelet Use

Platelet transfusion is indicated for the prevention and treatment of haemorrhage in patients with thrombocytopenia or platelet function defects. Previous studies have shown a wide variation in clinical practice in the transfusion of platelets.

The platelet count is the primary trigger for the use of platelets, with the risk of bleeding and the extent of bleeding also used as indicators for platelet transfusion.

Note should be taken of the National Health and Medical Research Council and Australian and New Zealand Society of Blood Transfusion guidelines for transfusion of platelets ((NH&MRC/ANZSBT, 2001).

The Blood Matters Program wishes to work with Victorian hospitals to ensure that we

1. Use blood components and products appropriately and effectively, and
2. Use alternative blood management strategies to limit the need for transfusion where clinically appropriate.

The Blood Matters Advisory Committee has identified the area of platelet use as an appropriate area for targeted clinical audit in order to determine current practice across the State.

See information sheet below for more information.

Clinical Audit of Platelet Use information sheet - 10 August 2007 (48kb, pdf)

Form: Clinical Audit of Platelet Use - 10 August 2007 (30kb, pdf)

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