This presentation includes parts of unpublished, preliminary results of a larger study. The contents of this presentation may not be quoted or used in.

This presentation includes parts of unpublished, This presentation includes parts of unpublished, preliminary results of a larger study.preliminary results of a larger study.

The contents of this presentation may not be The contents of this presentation may not be quoted or used in any form without prior written quoted or used in any form without prior written

permission of the Principal Investigator. permission of the Principal Investigator.

ImportantImportant

This activity was accredited for 1.5 This activity was accredited for 1.5 CME hours for nurses by the General CME hours for nurses by the General Authority of Health Services Authority of Health Services (GAHS) (GAHS) for the Emirate of Abu Dhabi.for the Emirate of Abu Dhabi. Unique ID #: 280307Q4BH

Nurses’ Nurses’ Practice of Blood Transfusion. Results of the Practice of Blood Transfusion. Results of the First Observational Research Study in the United First Observational Research Study in the United

Arab EmiratesArab Emirates

Belal M. HijjiBelal M. Hijji11, Kader Parahoo, Kader Parahoo11, Mohammad M. Hossain, Mohammad M. Hossain22, , Owen BarrOwen Barr11, Shirley Murray, Shirley Murray33

11School of Nursing, Faculty of Life & Health Sciences, School of Nursing, Faculty of Life & Health Sciences, University of Ulster, UKUniversity of Ulster, UK

22Institute of Medicine, Universiti Brunei DarussalamInstitute of Medicine, Universiti Brunei Darussalam

33Royal Group of Hospitals, Belfast, UKRoyal Group of Hospitals, Belfast, UK

Learning objectivesLearning objectives

Upon completion of this activity, participants should be able to:Upon completion of this activity, participants should be able to:

• Describe the importance of preparing the patient before blood • Describe the importance of preparing the patient before blood collectioncollection• Identify the steps required for proper identification of patient • Identify the steps required for proper identification of patient prior to initiating a transfusionprior to initiating a transfusion• Recognise traditional practices, not grounded in evidence, that • Recognise traditional practices, not grounded in evidence, that would increase the risk for patient suffering an acute transfusion would increase the risk for patient suffering an acute transfusion reactionreaction• Identify the type of information to be disclosed to patient • Identify the type of information to be disclosed to patient (relative) prior to transfusion(relative) prior to transfusion• Recognise the importance of recording vital signs prior to, and • Recognise the importance of recording vital signs prior to, and at 15 minutes after, initiating a transfusionat 15 minutes after, initiating a transfusion• Recognise the importance of adhering to recommendations • Recognise the importance of adhering to recommendations aiming at minimising the risk for bacterial contaminationaiming at minimising the risk for bacterial contamination

BackgroundBackground

Nurses play a crucial role in the administration of Nurses play a crucial role in the administration of bloodblood/ blood components/ blood components

Their skills and relevant practices are important Their skills and relevant practices are important determinants of the safety and effectiveness of determinants of the safety and effectiveness of

transfusionstransfusions

Published information about nurses' blood Published information about nurses' blood transfusion practices in the Gulf region, in general, transfusion practices in the Gulf region, in general,

and in the UAEand in the UAE, in particular,, in particular, is lacking is lacking

To fill this information gap and other gaps To fill this information gap and other gaps identified in the literature, this study was identified in the literature, this study was undertaken in Abu Dhabi Emirate, UAEundertaken in Abu Dhabi Emirate, UAE

Literature reviewLiterature review

Six published observational studies located Six published observational studies located worldwideworldwide

Turkey (Bayraktar and Erdil, 2000)Turkey (Bayraktar and Erdil, 2000) UK (Royal College of Physicians, 2005)UK (Royal College of Physicians, 2005) America (Shulman America (Shulman et alet al. 1994 & 1999; . 1994 & 1999; Whitsett & Robichaux, 2001; Saxena Whitsett & Robichaux, 2001; Saxena et al.et al. 2004).2004).

AimAim

Principal aimPrincipal aim

To observe and document nurses’ actual blood To observe and document nurses’ actual blood transfusion practicestransfusion practices

Specific questionsSpecific questions

Are nurses’ blood transfusion practices based on Are nurses’ blood transfusion practices based on recommendations?recommendations?

Are essential procedures done as recommended?Are essential procedures done as recommended?Are unnecessary procedures performed?Are unnecessary procedures performed?

If there are any practice deficitsIf there are any practice deficitsWhat are these?What are these?

Are these likely to jeopardize patient safety and well-Are these likely to jeopardize patient safety and well-being?being?

MethodsMethods

Data presented here were collected as part of a Data presented here were collected as part of a larger study of nurses’ knowledge and practice larger study of nurses’ knowledge and practice

related to blood transfusionrelated to blood transfusion

Data were collected in early 2005Data were collected in early 2005

2 medium-sized, public, general hospitals in Abu 2 medium-sized, public, general hospitals in Abu Dhabi Emirate, UAEDhabi Emirate, UAE

3 wards were selected in each hospital3 wards were selected in each hospital

Study settingsStudy settings

Altogether 140 registered nurses in 6 selected Altogether 140 registered nurses in 6 selected wards in both study hospitalswards in both study hospitals

Study populationStudy population

Study sampleStudy sample

50 nurses selected randomly from the study 50 nurses selected randomly from the study populationpopulation

Non-participant observation by the PINon-participant observation by the PI

Observation methodObservation method

A structured observation schedule was usedA structured observation schedule was used

Based on the schedule in Turkish developed by Based on the schedule in Turkish developed by Bayraktar and Erdil (2000)Bayraktar and Erdil (2000)

Translated into EnglishTranslated into English Modified and expanded based on British Modified and expanded based on British

Committee for Standards in Haematology (BCSH) Committee for Standards in Haematology (BCSH) 1999 guidelines, experts’ advice, local practices1999 guidelines, experts’ advice, local practices

The observation scheduleThe observation schedule

Had 4 sections (slides 19, 20, 21)Other important variables were included

Observation form related to nurses’ blood Observation form related to nurses’ blood transfusion practices (18)transfusion practices (18)

Activities related to transfusionActivities related to transfusion ApplieAppliedd

NNAA

RemarksRemarks

A. In ward before collecting bloodA. In ward before collecting bloodYes NoYes No

1. Venous access is available1. Venous access is available

2. The nurse checked patency of line2. The nurse checked patency of line

with the appropriate solutionwith the appropriate solution

B. In the blood bankB. In the blood bank

1. The nurse brought a documentation1. The nurse brought a documentation

containing patient details containing patient details

2. The nurse performed checks in the2. The nurse performed checks in the

blood bank blood bank

3. Used a special blood transport box 3. Used a special blood transport box

Observation form related to nurses’ blood Observation form related to nurses’ blood transfusion practicestransfusion practices (18) (18)

C. In the C. In the Ward Ward Before TransfusionBefore Transfusion AppliedApplied

YesYes NoNoNANA RemarksRemarks

1. Blood 1. Blood commencedcommenced within within 3030 min min. post collection. post collection

2. Wrapped the blood pack with linen/ blanket2. Wrapped the blood pack with linen/ blanket3. 3. Two nurses performed checks at nurses' stationTwo nurses performed checks at nurses' station

4. 4. Wore disposable non-sterile glovesWore disposable non-sterile gloves 5. Provided relevant information to patient5. Provided relevant information to patient

66. . Appropriateness of patient identificationAppropriateness of patient identification6.1 6.1 Asked the patient to state his/her nameAsked the patient to state his/her name6.2 6.2 Asked the patient to state his/her DOBAsked the patient to state his/her DOB

6.3 6.3 Checked the patient ID bandChecked the patient ID band

6.4 6.4 Compared together patient's IDCompared together patient's ID, , blood bagblood bag, , blood bank blood bank form form and prescription chartand prescription chart

7. R7. Recorded ecorded baseline baseline pulse, BP and temperaturepulse, BP and temperature

8. Used set with proper filter size8. Used set with proper filter size

Observation form related to nurses’ blood Observation form related to nurses’ blood transfusion practicestransfusion practices (18) (18)

Activities related to transfusionActivities related to transfusion ApplieAppliedd

Yes Yes NoNo

NANA RemarkRemark

D. After initiating the transfusionD. After initiating the transfusion

1.1. Regulating the blood transfusion Regulating the blood transfusion flow rateflow rate

1.1 Transfused (25-30 ml) for the first 1.1 Transfused (25-30 ml) for the first 15 minutes (adult)15 minutes (adult)

1.2 Transfused (1/10) of the total 1.2 Transfused (1/10) of the total volume for the first 15 minutes volume for the first 15 minutes (pediatric)(pediatric)

1.3 Regulated the transfusion rate to 1.3 Regulated the transfusion rate to complete as ordered or within 4 complete as ordered or within 4 hours post collectionhours post collection

2. Observation of patient for reaction 2. Observation of patient for reaction symptomssymptoms

2.1 Physical monitoring for the first 10-2.1 Physical monitoring for the first 10-15 min.15 min.

2.2 Recorded temp and pulse 15 2.2 Recorded temp and pulse 15 minutes post initiationminutes post initiation

Validity and reliability of the observation schedule

Transfusion experts from the UK established Transfusion experts from the UK established content validity.content validity.

Three pilot studies using 12 nurses.Three pilot studies using 12 nurses. Inter-observer reliability: Perfect (kappa = 1) Inter-observer reliability: Perfect (kappa = 1)

for most items. Where kappa was poor, item for most items. Where kappa was poor, item removed. Kappa calculations as removed. Kappa calculations as recommended by Rigby (2000).recommended by Rigby (2000).

Anonymity assuranceAnonymity assurance

Official ApprovalsOfficial ApprovalsMinistry of Health research ethics committee, UAEMinistry of Health research ethics committee, UAE

Hospital A research ethics committeeHospital A research ethics committeeHospital B administrationHospital B administration

Confidentiality assuranceConfidentiality assurance

Ethical issuesEthical issues

Voluntary informed consent was obtained from all Voluntary informed consent was obtained from all study participants study participants including those who participated including those who participated

in the pilot studiesin the pilot studies

Data collectionData collection

Each selected nurse was observed once.Each selected nurse was observed once. Recognising when a request of blood has been Recognising when a request of blood has been

made was facilitated by the researcher personal made was facilitated by the researcher personal follow up, ward nurses, and/ or blood bank staff. follow up, ward nurses, and/ or blood bank staff.

Assessment began 10 minutes before blood Assessment began 10 minutes before blood collection until 15 minutes post initiation.collection until 15 minutes post initiation.

Performance or non-performance of each Performance or non-performance of each observable activity was recorded. Field notes observable activity was recorded. Field notes taken- vitaltaken- vital

Non measurable activities were also recordedNon measurable activities were also recorded

Practice scores were summed for each nursePractice scores were summed for each nurse

Data analysisData analysis

Descriptive statisticsDescriptive statisticsFrequencies, percentages, medians, and inter-quartile rangesFrequencies, percentages, medians, and inter-quartile ranges

Inferential statisticsInferential statisticsChi squared testChi squared test

The ‘median test’ was used to test for statistical The ‘median test’ was used to test for statistical significance in the difference between the median significance in the difference between the median

practice scores of nurses in the 2 hospitalspractice scores of nurses in the 2 hospitals

ResultsResults

49 of the 50 selected nurses participated resulting 49 of the 50 selected nurses participated resulting in a response rate of 98%in a response rate of 98%

The nurses’ length of ward experience and their The nurses’ length of ward experience and their blood transfusion practices are shown in the tables blood transfusion practices are shown in the tables

on the next 5 slideson the next 5 slides

For some practices, the ‘n’ was not 49 due to For some practices, the ‘n’ was not 49 due to inapplicability or missing datainapplicability or missing data

Nurses’ length of ward experienceNurses’ length of ward experience

0

5

10

15

20

25

30

< I yr 1-5years

> 5-10yrs

>10-15 yrs

> 20yrs

Range of wardexperience

PracticePractice No.No. %%

Venous access availableVenous access available

4949 1010

00

Checking patency of IV lineChecking patency of IV line

33 66

Using blood transport boxUsing blood transport box

00 00

PracticePractice No.No. %%

Covering bag with linen / blanket Covering bag with linen / blanket (belief)(belief)Remote checks at nurses’ stationRemote checks at nurses’ station

773030

14146363

Starting blood within 30 min post-Starting blood within 30 min post-collection collection

2828 5757

Giving information to patient / Giving information to patient / relative:relative:

1. Reasons/ benefits of transfusion 1. Reasons/ benefits of transfusion 00 00

2. Risks of transfusion2. Risks of transfusion 00 00

3. Reaction symptoms3. Reaction symptoms 1313 3535

Wearing gloves (surgical and Wearing gloves (surgical and disposable)disposable)

4747 9696

PracticePractice No.No. %%Blood pressure recordingBlood pressure recording 1616 55

00Pulse recordingPulse recording 1818 55

66Temperature recordingTemperature recording 2929 66

22Asking patient to state nameAsking patient to state name 33 88

Asking patient to state DOB Asking patient to state DOB 00 00Number of patients wearing ID bandsNumber of patients wearing ID bands 3232 77

00Checking patient's ID band Checking patient's ID band 2121 44

33

Comparing bracelet with blood bag Comparing bracelet with blood bag 1414 2299

Comparing together bracelet, bloodComparing together bracelet, bloodbag, request form, and drug chart bag, request form, and drug chart

22 44

PracticePractice No.No. %%

Using administration set with appropriate Using administration set with appropriate filter size filter size 4545 9292

Transfusion rate 25-30 ml in the 1st 15 Transfusion rate 25-30 ml in the 1st 15 minutes (adult)minutes (adult) 2525 7676

Transfusion rate 1/10 of total volume 1st 15 Transfusion rate 1/10 of total volume 1st 15 minutes (child)minutes (child) 1313 8181

Physical attendance 1Physical attendance 1st st 10-15 minutes post 10-15 minutes post initiation initiation 1818 3737

Transfusion regulation at 15 minutes post Transfusion regulation at 15 minutes post initiation, or:initiation, or:Completing within 4 hours post collectionCompleting within 4 hours post collection

22

2323

44

5050

Pulse recording 15 minutes post initiationPulse recording 15 minutes post initiation 1212 3838

Temperature recording 15 minutes post Temperature recording 15 minutes post initiationinitiation

1616 3434

Risk of acquiring bacterial infectionsRisk of acquiring bacterial infections

Initiation of transfusion Initiation of transfusion after collectionafter collection

# # NursesNurses

%% Completion time after Completion time after commencement [1]commencement [1]

Completion time after Completion time after collectioncollection

<= 4 h<= 4 h >4 h >4 h <=4.5 h >4.5 h <=4.5 h >4.5 h [2][2]

Within 10 min.Within 10 min. 44 88 44 00 44 0 0

Within >10 -30 min.Within >10 -30 min. 2424 4949 202033

2020 3 3

> 30 min. > 30 min. [3][3] 2121 4343 151544

1111 8 8

TotalTotal 4949 100100 3939 77 3535 11 11

[1] Completion time was not documented for three units[2] Range between 4 hours 37 minutes and 6 hours 30 minutes (mean 5 hours 18 min.)[3] Range between 35 – 138 minutes, mean 54 minutes

Nurses’ blood transfusion practice scoresNurses’ blood transfusion practice scores

42

2922

18 18

6

0

5

10

15

20

25

30

0-10 11-20 21-30 31-40 41-50 51-60 61-70

Scores (% )

Num

ber

of n

urse

s

HospitalHospital RangeRange MedianMedian2525thth

percentilepercentile7575thth

percentilepercentile

AA 4 to 134 to 13 6.56.5 55 88

BB 3 to 133 to 13 1010 88 1212

Nurses blood transfusion practice scores Nurses blood transfusion practice scores by hospital. Median score was 8. Maximum by hospital. Median score was 8. Maximum

possible score was 21possible score was 21

Median test of practice scoreMedian test of practice score

Hospital AHospital A Hospital BHospital B TotalTotal

> median > median 5 (25%)5 (25%) 15 (75%)15 (75%) 20 (41%)20 (41%)

<= median <= median 1919 1010 2929

TotalTotal 2424 2525 4949

XX22 = 7.77, df = 1, p <0.01 = 7.77, df = 1, p <0.01

ConclusionsConclusions

Specific questionsSpecific questions

Are nurses’ blood transfusion practices based Are nurses’ blood transfusion practices based on on recommendations?recommendations?

Are essential procedures done as Are essential procedures done as recommended?recommended?

Low practice scores indicate practice deficitsLow practice scores indicate practice deficitsAre unnecessary procedures performed?Are unnecessary procedures performed?

YesYesWrapping the blood pack with linen / blanketWrapping the blood pack with linen / blanketRemote identity check at the nurses’ stationRemote identity check at the nurses’ station

Specific questionsSpecific questions

If there are any practice deficitsIf there are any practice deficitsWhat are these?What are these?

Practices related to proper identification of the Practices related to proper identification of the patientpatient

Practices that could increase the risk of bacterial Practices that could increase the risk of bacterial contamination of the bloodcontamination of the blood

Are these likely to jeopardize patient safety and Are these likely to jeopardize patient safety and well-being?well-being?

YesYes

The OutcomeThe Outcome

""There is one mistake done in the hospital here. In …….There is one mistake done in the hospital here. In …….ward one member of staff was admitted; one of the staffward one member of staff was admitted; one of the staffwent to collect the blood. She collected a unit for anotherwent to collect the blood. She collected a unit for anotherpatient and she gave to our staff. When she started thepatient and she gave to our staff. When she started theblood transfusion, she looked in the blood bag and sheblood transfusion, she looked in the blood bag and shelooked at wristband. Details on both were different.looked at wristband. Details on both were different. ThisThisblood was not for this patient.blood was not for this patient. There is too much mistakeThere is too much mistakedone here, in the hospital in blood transfusion. And we givedone here, in the hospital in blood transfusion. And we giveby mistake a blood to a …….. patiby mistake a blood to a …….. patieent that is not his andnt that is not his andshe developed allergy and rashes because that wasshe developed allergy and rashes because that was not hisnot his

bloodblood""..

This quote is from the focus group interviewsThis quote is from the focus group interviews

RecommendationRecommendation

To deliver safer and more effective patient care, To deliver safer and more effective patient care, the observed inappropriate blood transfusion the observed inappropriate blood transfusion

practices of nurses need to be corrected practices of nurses need to be corrected urgently through appropriate education and urgently through appropriate education and

training.training.

We are immensely grateful to all study We are immensely grateful to all study participants, the management, the concerned participants, the management, the concerned

nursing director or associate director, all nursing nursing director or associate director, all nursing staff, and the blood bank staff of both hospitals.staff, and the blood bank staff of both hospitals.

AcknowledgementsAcknowledgements

In order to raise the profile of patient care, In order to raise the profile of patient care, experience gained from developed countries experience gained from developed countries indicates that the following issues should be indicates that the following issues should be addressed, sooner rather than later:addressed, sooner rather than later: Raise the profile of nursingRaise the profile of nursing Invest in researchInvest in research Support professional development of nursesSupport professional development of nurses

Where do the UAE Where do the UAE healthcare institutions go healthcare institutions go

from here?from here?

Where do nurses go from Where do nurses go from here?here?

Nurses are accountable for their practice. They have an Nurses are accountable for their practice. They have an ethical, moral, professional, and legal responsibility of ethical, moral, professional, and legal responsibility of providing sound care to patients.providing sound care to patients.Therefore:Therefore: Identify every patient properly before each unit of blood Identify every patient properly before each unit of blood Take an active role in developing you practiceTake an active role in developing you practice Remain updated Remain updated

Thank YouThank YouPrincipal InvestigatorPrincipal Investigator

[email protected]@ulster.ac.uk

REFERENCES

Bayraktar, N. and Erdil, F. (2000) Blood transfusion knowledge and practice among nurses in Turkey [Special Focus Issue: Hematology]. Journal of Intravenous Nursing. 23(5): 310-317.British Committee for Standards in Haematology (1999). The administration of blood and blood components and the management of transfused patients. Transfusion Medicine. 9; 227-238.Rigby, A. (2000). Statistical methods in epidemiology: Towards an understanding of the kappa coefficient. Disability and Rehabilitation. 22(8): 339-344. Royal College of Physicians (2005). National comparative audit of blood transfusion: Re-audit of bedside transfusion practice. Clinical Effectiveness & Evaluation Unit of the RCP. RCP Publications: London. Saxena, S.; Ramer, L. and Shulman, I. (2004). A comprehensive assessment program to improve blood administering practices using the FOCUS-PDCA model (2004). Transfusion. 44; 1350-1356.Shulman, I.; Lohr, K.; Derdiarian, A. and Picukaric, J. (1994). Monitoring transfusionist practices: a strategy for improving transfusion safety. Transfusion. 34(1): 11-15.Shulman, I.; Saxena, S. and Lois, R. (1999). Assessing blood administering practices. Archives of Pathology and Laboratory Medicine. 123(7): 595-598. Whitsett, C. and Robchaux, M. (2001). Assessment of blood administration procedures: problems identified by direct observation and administrative incident reporting. Transfusion. 41; 581-586.