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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 34  |  Issue : 2  |  Page : 123-129

Quality assessment of blood bank performance in Benha University Hospitals


1 Department,of Public Health &, Community Medicine, Faculty of Medicine, Benha University, Benha, Egypt
2 Ports and Borders Health Department, Ministry of Health, Kuwait City, Kuwait

Date of Submission22-Apr-2016
Date of Acceptance27-Feb-2017
Date of Web Publication20-Nov-2017

Correspondence Address:
Abdulqader M Taher
Ports and Borders Health Department, Ministry of Health, Kuwait City, 13001
Kuwait
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bmfj.bmfj_29_16

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  Abstract 


Background Blood transfusion is an essential therapeutic intervention, and we may all need blood in emergency situations and some of us need regular transfusions. Therefore, it is important to assess the quality of blood bank performance to assure better provision of healthcare.
Aim of the study The aim of this study was to assess the quality of performance of the blood bank at Benha University Hospitals.
Materials and methods This was an observational study carried out to identify defects in blood bank processes and assess the knowledge of staff members about performance standards. The present study was carried out for 6 months from November 2012 up to April 2013. This study was performed at the blood bank of Benha University Hospitals in Benha city, Kalyobia governorate, Egypt.
Results Regarding venipuncture site, the total score was 20 for 10 checked items. The studied sample had a mean score of 17.14 out of 20 with a SD of 1.88. The highest percentages of the items showed good disinfection patterns and infection control, as 89.3% of the staff washed their hands properly before preparation, 92.9% wore new gloves. All the staff disinfected the venipuncture site with alcohol swabs, with 17.9% doing it in a circular manner and 75.0% doing it from the center outwards. 89.3% of them reported that they do not touch the venipuncture site after disinfection, and 78.6% of the staff changed gloves between donors. Regarding bag procedure performance, we assessed using 12 checklists of items that included assessing expiry date of the bag with relevant donor number, donation date, blood expiry date, and label sample tube, and all previous items proved to be performed properly.
Conclusion and recommendation Continuous monitoring through standard quality indicators of a quality management system will improve blood transfusion services. Regular training and continuous monitoring is a must in all processes regarding blood transfusion in blood banks.

Keywords: quality, quality assessment blood bank performance


How to cite this article:
Elgendy MF, Alanwar RM, Shaker RH, Abdelwahab SM, Taher AM. Quality assessment of blood bank performance in Benha University Hospitals. Benha Med J 2017;34:123-9

How to cite this URL:
Elgendy MF, Alanwar RM, Shaker RH, Abdelwahab SM, Taher AM. Quality assessment of blood bank performance in Benha University Hospitals. Benha Med J [serial online] 2017 [cited 2018 May 22];34:123-9. Available from: http://www.bmfj.eg.net/text.asp?2017/34/2/123/218831




  Introduction Top


Quality assurance (QA) deals with the maintenance of a system to ensure that the performance in that system is of the required quality. In a blood transfusion center, it means that a management system should exist to look into provision of a safe unit of blood, and if any errors are identified they should be corrected [1].

Quality has been central to blood banking from its inception, with the evolution of a quality program since the opening of the first blood bank in the USA at the Cook County Hospital. Over the ensuing decades, continuous scientific progress in blood preservation, filters, viral and blood group testing, cross matching, automation, and computerization including bar coding, etc. has contributed to the quality and safety of the blood products and transfusion service [2].

Blood transfusion is an essential therapeutic intervention, and we all may need blood in emergency situations and some of us need regular transfusions [3].

People are exposed to avoidable life-threatening risks through transfusion of unsafe blood [4].

Therefore, we believe that quality improvement will help in saving resources and gain satisfaction and coping with rapid world changes and competition.

Objectives

The objective of this study was to detect defects in different procedures followed at the Benha University Hospitals’ blood bank in relation to standard procedures.


  Materials and methods Top


The present study was an observational study carried out to identify defects in blood bank processes and to assess knowledge of staff members about performance standards.

Place of study

This study was performed at the blood bank of Benha University Hospitals in Benha city, Kalyobia governorate, Egypt.

Time of study

The present study was carried for 6 months from November 2012 up to April 2013

The study included three phases:

A situation analysis phase was carried out to define defects in the different processes of the blood bank through the following:
  1. Studying all processes carried out in the blood bank and drawing a high-level flow chart.
  2. Assessing the process of donor selection using a donor history checklist and a donor examination checklist structured by the researchers guided by Standard Operating Procedures (SOP 1) for blood transfusion service published by the WHO [5]. Three items from the SOPs (SOP 1) were excluded, which concerned sexual history as it was against our culture, and one item was added that asked about menstruation, guided by Bruce [6], who stated that whole-blood donation harms menstruating females by iron depletion.
  3. Assessing the performance of nurses during donation using venipuncture site checklist and bag procedure checklist. This was structured by the researchers guided by SOPs for blood transfusion service published by the WHO [7].
  4. Assessing the performance of nurses after blood collection, using an after-collection checklist structured by the researchers guided by SOPs for blood transfusion service published by the WHO [5]. Serological testing was excluded as it was not the point of our study.
  5. Assessing refrigeration status using a refrigerator status checklist structured by the researchers guided by the manual on the management, maintenance, and use of blood cold chain equipment published by the WHO [3].
  6. Assessing the process of transportation of blood bags from one bank to another and from the bank to hospital wards using a transport checklist structured by the researchers guided by the manual on the management, maintenance, and use of blood cold chain equipment published by the WHO [3].
  7. Assessing knowledge of staff about standards of different processes using doctor knowledge sheet and nurses’ knowledge sheet, which were structured by the researchers in relation to the above standards.


All standards that had been written in English were translated, revised, and validated.

Ethical aspects and administrative approach

To carry out the present study, the necessary official permission was obtained from the blood bank manager at Benha University Hospitals. In addition, an informed verbal consent was obtained from doctors and nurses. They were reassured about the confidentiality of any obtained information, and that the results would be used only for research purposes.

Statistical analysis

Data were analyzed using SPSS, version 21, Chicago, USA. The normality of data was first tested with one-sample Kolmogorov–Smirrnov test.

Qualitative data are described using n (%). The association between categorical variables was tested using the χ2-test. Continuous variables were presented as mean±SD for parametric data and as medians for nonparametric data. The two paired groups were compared using a paired t-test.

For all the above-mentioned statistical tests, the threshold of significance was fixed at the 5% level (P-value).

The following results were considered:
  1. Nonsignificant when the probability of error was more than 5% (P>0.05).
  2. Significant when the probability of error was less than 5% (P<0.05).
  3. Highly significant when the probability of error was less than 0.1% (P<0.001).


The smaller the P-value, the more significant the results are.

Budget

The study was completely financed by the researchers.


  Discussion Top


This study was conducted to assess the quality of blood transfusion and donation at Benha University Hospitals by assessing the following:
  1. Process for donor selection.
  2. Performance of nurses during blood donation.
  3. Refrigeration status of blood bags.
  4. Process of transportation of blood bags from one bank to another.
  5. Process of transportation of blood packs from the bank to hospital wards.


In our sample, we had six physicians (two males and four females), three of whom had a Master’s degree, one with a doctorate, and two residents, aged 24–33 years with a mean age of 28.83±3.48 years, working since 3–5 years, and 22 nurses (two males and 20 females) aged 22–52 years with a mean age of 39.95±SD and working since 2–34 years ([Figure 1] and [Figure 2]).
Figure 1 Qualification degree

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Figure 2 Sex of the studied group of physicians and nurses

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Data were collected using checklists for nurses and physicians. The results show that there was no system for assessing the training needs of staff, either nurses or physicians, in the blood bank, but all the parameters in the checklists for reviewing quality were routinely met as required. Moreover, all the basic facilities as required by the Food and Drug Administration were provided; however, there was no provision for duty doctors’ room, expert room, medical technologist room, and duty care service.

The present study was able to measure through direct observation the performance of healthcare workers in specific techniques.

First, as inclusion criteria of services in the sample were highly selective, it is impossible to generalize the results. However, it is possible to assume that this sample can represent university blood banks that follow WHO guidelines.

The small sample size did not allow for more complex statistical analyses that could identify factors associated with better or worse performance, making the necessary changes in case of misunderstandings.

A study by Torres et al. [8] on peripheral venipuncture, in which a total of 55 nursing professionals were observed while performing the respective procedures three times every other day, identified that nursing professionals performed the techniques with similar percentiles of success and failure, with an overall median of 78%. Another study by Almeida et al. [9] on intramuscular injection evaluated the technical performance of vaccinators by 123 observations through the ‘checklist’ at two state public health services. The study analyzed the individual performance of each vaccinator, the group, and also compared the two units studied, as well as the use of the instrument ‘checklist’ as a means of evaluating a nursing technician. The study also demonstrated that the performance of this technique varied from 83.5% success in the ambulatory setting of a teaching hospital to 76.7% in a primary-care unit; however, our results showed that regarding venipuncture site, the total score was 20 for 10 checked items. The studied sample had a mean score of 17.14 out of 20 with a SD of 1.88. The highest percentages of the items showed good disinfection patterns and infection control, as 89.3% of the staff washed their hands properly before preparation, 92.9% wore new gloves, all staff disinfected the venipuncture site with an alcohol swab, with 17.9% doing it in a circular manner and 75.0% from the center outwards, 89.3% did not touch the venipuncture site after disinfection, and 78.6% of the staff changed gloves between donors.

Regarding communication in different studies, some studies [8],[9] showed compromised performance. Regarding the step ‘explain procedure to the client’, the results obtained by one study [8] showed partially satisfactory performance by nursing assistants (median: 100%, 25 percentile=33) and unsatisfactory performance by nurses and technicians. In the step ‘Guide the clients regarding necessary care for puncture’, the three categories presented unsatisfactory results. Our study showed satisfactory results regarding care of nurses with respect to donor characteristics, which showed that all donors were healthy. Among the 28 individuals, only one person had donated blood recently, two were menstruating, one was unmarried, none were pregnant but one was lactating, and another had a previous abortion. In addition to these results, the examination of donors showed that 27 (96.4%) of 28 individuals were of normal general appearance, only five had their blood pressure measured, four had pulse monitoring, and 24 out of 28 underwent hemoglobin estimation. None of them had their weights measured, and only two of them had their temperatures measured.

Moreover, in the technical core, steps regarding antisepsis were compromised in both phases of the study, with negative variation. Only the performance of the nursing team did not change in terms of quality in the technical core, and only the peripheral venipuncture performance level varied in the technical core from 70 to 67%. Antisepsis steps such as washing hands before and after the procedure and disinfecting the site and others are part of the technical core. To be successful, they require, in addition to knowledge, skills and attitude of the worker, material resources, and infrastructure. We observed the absence of sinks in the wards studied, which made it difficult to wash hands.

In the study performed by Almeida et al. [9], who studied the technical performance of the nursing staff in Sao Paolo, Brazil, concluded that the ‘hand washing’ step was not performed or incorrectly performed by all people in the two units studied. According to Torris et al. [8] ‘washing hands before the procedure’ presented partially satisfactory performance by nurses and unsatisfactory performance by nurse assistants and technicians, and ‘washing hands after the procedure’ presented unsatisfactory performance in all categories.

The nursing team presented improved performance, and although there was no continued professional development in the premises, the team was the best, and there was an effective monitoring program. The changes in nurses’ knowledge were highly significant regarding history taking, examination, venipuncture site, and blood bags suitable for donation; this is may be because of the continuous education as well monitoring by the supervising team.

There is a need to link educational processes of health workers with the work processes that they actually perform and the management of work as recommended by the idea of permanent health education [10]. Current theoretical studies on teaching–learning show that professionals cannot mechanically transport what they have learnt in class to a real work situation.

Regarding the accuracy of the checklists concerned, all the checklists in the blood bank were used routinely and were complete in all aspects and were quite good; however, there was no checklist for routine observation of hemolysis and deterioration of blood and plasma ([Table 1],[Table 2],[Table 3],[Table 4],[Table 5],[Table 6]).
Table 1 Demographic characteristics of the studied groups

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Table 2 Results of checked items regarding donor history

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Table 3 Results of checked items regarding examination

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Table 4 Results of checked items regarding venipuncture site

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Table 5 Bag procedure performance

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Table 6 Postcollection procedures for blood bags

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Procedural techniques, shown in [Table 7],[Table 8],[Table 9],[Table 10], were found to be adequate and performed properly and regularly, fulfilling the SOPs requirements. Blood transfusion management activities were performed properly in every aspect from donor selection to temperature monitoring and cold chain maintenance. This was in agreement with other studies, such as the study by Bayliss and Jensen [11], which was performed for validating the selection of quality indicators for venipuncture procedures at a Radiation Therapy Department in Canada.
Table 7 Description of refrigeration status

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Table 8 Results of practice regarding transportation in an insulated box and presence of thermometers in containers

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Table 9 Results of practice regarding transport of blood bags to clinical areas

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Table 10 Performance of disinfection for blood donation before intervention

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All instruments were in working condition, and they were regularly calibrated and serviced. The instruments were placed properly and had alarm systems to indicate change in temperature. All the parameters in the checklists were performed properly according to SOPs.


  Conclusion and recommendations Top


  1. Blood and blood components are frequently ordered and utilized in many hospitals without proper analysis of the real needs, deviating from evidence-based practice.
  2. Continuous monitoring through standard quality indicators of a quality management system will improve blood transfusion services.


From the course of our study we recommend the following:
  1. Regular training programs for professionals, independently of category or level.
  2. All laboratories and hospitals must participate in a quality assurance system for blood transfusion programs, which will definitely help them to improve from what they learn.
  3. Improvement of transfusion services in terms of performance evaluation, patient care and safety issues, and the overall quality of laboratory practices.
  4. Continuous evaluation of all activities of the Blood Transfusion Services.
  5. Optimizing blood collection and processing would reduce waste and improve the efficiency of the Blood Transfusion Services.
  6. Regular audit of blood bank services needs to be initiated in all blood banks.
  7. Testing of blood units for transfusion-transmitted infections is a major concern.
  8. Automate sample labeling.


Acknowledgements

The authors express their deepest gratitude to Prof. Dr. Neveen A. Abdelhafeez, head of the blood bank of Benha University Hospital, who was of great help and support during their research. It was most fruitful to work guided with her scientific advice. They sincerely thank her for her advice and help. They also deeply thank their staff (doctors, lab. technicians, and nurses) at the blood bank of Benha University Hospital who were of great help to them throughout their research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
WHO. World Health Day 2000. Strategies of safe blood transfusion. Geneva, Switzerland: World Health Organization; 2006.  Back to cited text no. 1
    
2.
Kim DU. The guest for quality blood banking program in the new millennium the American way. Int J Hematol 2002; 76:258–262.  Back to cited text no. 2
[PUBMED]    
3.
WHO. Manual on the management, maintenance and use of blood cold chain equipment. Geneva, Switzerland: World Health Organization; 2005.  Back to cited text no. 3
    
4.
WHO. World blood saves life – WHO report on blood transfusion safety. Geneva, Switzerland: World Health Organization; 2000.  Back to cited text no. 4
    
5.
WHO. Model standard operating procedures for blood transfusion service model. Geneva, Switzerland: World Health Organization; 2002  Back to cited text no. 5
    
6.
Bruce N. Iron depletion by whole-blood donation harms menstruating females by iron depletion. Transfusion 2006; 46:1667–1681.  Back to cited text no. 6
    
7.
WHO. Quality systems for blood safety, department of blood safety and clinical technology. Geneva, Switzerland: World Health Organization; 2002  Back to cited text no. 7
    
8.
Torres MM, Andrade D, Santos CB. Peripheral venous puncture: Performance evaluation of nursing professionals. Rev Latinoam Nurs 2005; 13:299–304.  Back to cited text no. 8
    
9.
Almeida MCP, Gomes DLS, Silva E. Evaluation of intramuscular injection technique through the check list. Rev Bras Nurs 1980; 33:428–442.  Back to cited text no. 9
    
10.
Ceccim RB, Feuerwerker LCM. The quadrilateral training for health care. Teaching management attention and social control. Physis (Rio J) 2004; 14:41–65.  Back to cited text no. 10
    
11.
Bayliss Y, Jensen K Validating the selection of quality indicators for venipuncture procedures performed in a radiation therapy department. J Med Imag Radiat Sci 2011; 42:74–80.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]



 

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