Thalassemia management offers a unique opportunity for measuring the quality of blood transfusion services. Children suffering from thalassemia who are on chronic transfusion therapy generally come back to the same centre for treatment and management. This enable insights into blood transfusion medicine which otherwise may be very difficult to get.
An intent to periodically measure the quality of blood transfusion service and also to act upon the findings is obviously the first step. However, the largely resource crunched medical setups that we have do not allow for manpower to track each patient who receives transfusion. Thalassemia brings about immense opportunity in such situation to be able to measure and benchmark the quality of blood transfusion services and products. Let's explore some challenges and the opportunity points.
1. Adequacy of Blood Components
The first and foremost test is that of adequacy of blood 'components'. We highlight components because for thalassemia whole blood is not good enough - and processing blood into components necessary. Individuals who are on chronic transfusion therapy need blood every 2-4 weeks. By simply counting the number of units which were available off the shelf within the same blood bank for the patient versus the overall requirement one can get a simple metric to track the adequacy of blood supply. If the patient had to be returned because of unavailability of blood, the count of such events would serve as another powerful metric to measure the adequacy of blood supply.
Maintaining adequate supply of blood is a challenge for thalassemia also because the request for replacement blood units from individuals suffering from thalassemia is almost inhumane. The need to have sufficient voluntary blood donors is must. Therefore the second metric could be the number of times the patients were requested to replace blood units versus the overall issue to the thalassemia patients.
There is another challenge so far as the supply of blood components to thalassemia patients is concerned. Only fresh red blood cells collected within 7 days of the date of issue are suitable transfusion product for this indication. This implies that the blood bank needs to make sure that the stock of voluntarily donated blood is replenished in no longer than 7 days. This gives us another metric - the number of units which were issued to thalassemia patients within 7 days of collection versus total issues.
2. Appropriateness of Transfusion Product
The good thing as we all know is that we have very few naturally occurring antibodies. This implies that if a person has received blood for the first time in their life, even in case of a mismatch, they may not have a reaction. With every transfusion the risk of reactions increases and the challenge to find the suitable component for transfusion grows. It takes more than ABO and Rh forward and reverse grouping to manage proper blood transfusion product for patients on chronic transfusion therapy. If the blood bank is supplying blood to a thalassemia unit which gives feedback on the complications, it opens up massive opportunity to venture into finer aspects of identification of antigens and antibodies. It also opens up the challenge to provision for the adequate screening and supply of irregular blood types.
Repeated transfusions also lead to other kind of transfusion associated complications. Generally the first steps into hemovigilance program are most difficult because of the complexity of retrieving information about complications. Thalassemia unit is an opportunity to setup a strong hemovigilance program enabling close relationship between the clinical team and the blood bank.
Processing of blood products to be safer for transfusion is another opportunity opened up by thalassemia. Leuko reduction at the minimum; if not leuko depletion is essential for transfusion products for thalassemia. The quality metrics associated with this aspect could be the number of blood units leuko reduced and leuko depleted versus the total number of units issued.
3. Transfusion Transmitted Infection(TTI) related Safety
The occurrence of TTI in the children receiving transfusions for thalassemia is a powerful and simple to measure metric. In past, high rate of TTI has been tracked down to ineffectiveness of the mandatory testing of blood components. The TTI occurrences in thalassemia patients gives insights into the effectiveness of the screening process for TTIs as a whole.
4. Delivery of Service
The time taken to process blood components once the request is received from the wards is another metric which is easily measurable. For the same lot of patients the same blood bank processes almost the same number of units of blood periodically. Comparing the average time of processing across months could give valuable inputs into the delivery of service and also the association of the same with the performance if individual staff members at the blood bank.
As discussed above, thalassemia unit provides immense opportunities for blood transfusion medicine. The first step is to start measuring the above mentioned metrics within the institution. Once the obvious corrections are implemented, the above stated parameters could be used to compare quality of blood banking services across institutions and facilities. This in turn could be the seed for novel ideas and provide healthy feedback to blood transfusion medicine.
Sankalp India Foundation is keen to assist any blood bank which provides blood to children suffering from thalassemia and which is interested in capturing these metrics and compare them with peer blood banks. Please do write to us at sankalp.admin@gmail.com if your blood bank in interested to take this forward.