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A nursing contribution to research issues in blood transfusion

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Sally Ballard, Research Nurse, MA, BA, RN, PGCE.

National Blood Service, Oxford Centre, John Radcliffe Hospital, Oxford

Blood transfusions save lives, and every day hospitals in England and North Wales alone need 10 000 donations of blood to treat patients (NBS, 2003). Last year patients needed a total of 2.5 million units of blood.

Blood transfusions save lives, and every day hospitals in England and North Wales alone need 10 000 donations of blood to treat patients (NBS, 2003). Last year patients needed a total of 2.5 million units of blood.

The National Blood Service (NBS), an integral part of the NHS, delivers blood components, blood products and tissues from its blood centres to anywhere in England and North Wales. It ensures that the blood is properly screened and safe for patients. It collects, tests, processes, stores and issues blood donations.

Another vital role of the NBS is to carry out research into improving the safety of blood and new ways in which it can save more lives.

Nurses take a clinical lead at blood donor sessions and apheresis clinics, and now their profile within the NBS is expanding, with six research nurses contributing to innovative ongoing research projects.

Barcoded blood
Blood transfusions save lives, but are not without risk. There are risks associated with transfusion-transmitted infection, and with 'wrong-blood' incidents, for example, where a patient is given blood intended for another patient.

The Serious Hazards of Transfusion (SHOT) scheme collects information on wrong-blood incidents. During 2000-2001, 213 such incidents were reported, including six cases of major morbidity.

The single most important cause of incidents is misidentification of the patient at some stage during the transfusion process, according to SHOT. Using electronic transfusion aids and barcode technology has the potential to minimise such episodes.

SHOT has called for a thorough evaluation of this type of technology. In response, the NBS has funded a two-year project, entitled 'Electronic transfusion aids and barcode patient identification as a transfusion safety measure', involving the use of hand-held computers that scan information from barcodes.

On admission, patients are allocated with a unique barcoded identification wristband. Once patients are wearing it, the information held in the barcode can be scanned, and duplicate identification barcodes generated for use on the patient's cross-match samples. When cross-matched blood is allocated to a specific patient for transfusion in the blood bank, another unique identification barcode can be generated, which is then stuck to the allocated blood pack.

Before administering blood to a patient, the nursing staff use the hand-held computer to scan the patient's barcoded identification wristband as well as the patient's unique barcode on the blood pack. If the barcodes are compatible the system advises that it is safe to continue. The computer also prompts staff to carry out vital pre-transfusion checks, such as asking the patient to confirm their details, checking the compatibility of the patient and donor blood groups, and checking the blood's expiry date.

When the nurse has indicated the checks have been done, the hand-held device shows it is safe to start the transfusion.

Research nurse Claire Turner led the first phase of the project with the haematology department at the John Radcliffe Hospital, Oxford. Amanda Davies has been employed to lead and manage the second phase in the cardiac unit. Both researchers have been involved in planning the timescales, educating and training staff, liaising with the suppliers of the hand-held computers and monitoring the impact on practice.

Their evaluations will not only look at the impact on transfusion safety but also on staff reaction to the technology. Correct patient identification is essential and the project has ramifications wider than blood transfusion. Links with the electronic patient record (EPR) initiative within the Oxford Radcliffe Hospitals NHS Trust are being investigated.

Another arm of the research is being undertaken at Addenbrooke's Hospital, Cambridge, led by biomedical scientist Claire Mellors, with the support of the Addenbrooke's transfusion nurse Claire Staras.

Transfusion recipients
The NBS produces blood components for use in hospitals throughout the country. However, it has little information on the profile of patients receiving these components, which makes it difficult to predict future demand.

A two-year national study on the profile of transfusion recipients, 'Epidemiology and the long-term outcome of transfusion recipients', is being conducted, with Jackie Buck and Moira Malfroy, based in Cambridge, and Sally Ballard in Oxford, as the research nurses appointed to the epidemiology team.

The three are part of a larger project team which includes a data manager, medical statisticians, and transfusion consultants.

The pilot phase was completed in September 2002. The three nurse researchers are now working on the main study.

They co-ordinate data transfer from participating hospitals, and prepare data for inclusion in a national database. They also prepare ethics committee applications, audit patient notes and write protocols for inclusion in the methodology.

The epidemiology project is timely in the light of variant Creutzfeldt-Jakob Disease (vCJD). There is concern that the number of people willing to donate blood will fall if a test for vCJD becomes available (Meikle, 2001).

By knowing the types of patient most dependent on transfusion, the NBS will be able to prioritise its component production.

Sickle cell disease
People with sickle cell disease often undergo several operations, such as cholecystectomy, due to the vaso-occlusive nature of the disease.

Before elective surgery, blood transfusion is often used, in the belief that it helps to prevent peri-operative complications (Vichinsky et al, 1995). This may be a top-up transfusion, to raise the level of haemoglobin, or an exchange transfusion, to decrease the level of sickle haemoglobin.

However, some clinicians believe it may not be necessary to transfuse patients for most operations, and that good supportive care may be enough (Griffin and Buchanan, 1993). Overall, there is a lack of evidence, as highlighted by Riddington and Williamson's systematic review (2002), to guide decisions, and a lack of knowledge of current practice. The NBS is conducting a one-year case note survey into pre-operative transfusion practice in patients with sickle cell disease in England and Wales.

The survey is being carried out jointly by Dr Lorna Williamson from the University of Cambridge/NBS and Professor Sally Davies of Imperial College and Central Middlesex Hospital. Jackie Buck, based at the NBS/Medical Research Council Clinical Studies Unit, Cambridge, is the research nurse planning and co-ordinating the survey.

She has attended conferences to promote the survey, and has successfully recruited consultant haematologists. She has gained ethics committee approval and designed data collection forms and a guidance leaflet. She also designed the study database and web-page.

It is hoped that the information gathered will be used to plan and design a randomised controlled trial, the results of which will allow clinicians to practise evidence-based medicine.

Thalassaemia
Nurses are also involved in a project on 'donor recruitment for transfusion-dependent thalassaemia patients'. Patients with thalassaemia require transfusions about once a month. They are exposed to blood from a large number of donors. Although the risk of transfusion-transmitted infection is small, exposure to a large number of donors increases the risk. If such patients received only red cells collected in double doses from individual donors, the risks would be halved. Furthermore, if patients could receive double-dose red cells from a small number of donors on a regular basis, donor exposure would be greatly reduced.

The Whittington Hospital in London has asked the NBS to recruit suitable donors. Rebecca Hargreaves is the research nurse working on this project, to recruit about 400 existing male whole-blood donors to carry out double-dose red-cell donation once every six months. Donors must weigh more than 70kg and have an Hb of more than 135g/l and haematocrit of 42 or more.

The nurse takes donors through the apheresis process. This involves attaching donors to an apheresis machine, which separates the blood through centrifugation, takes away the red cells, adds an optimal additive solution and returns plasma to the donor.

The 'double dose' of red cells is stored at 4oC overnight, then filtered to remove contaminating leucocytes. Mandatory blood group and microbiology tests are performed before the 'double units' are validated for issue to the Whittington Hospital.

The target is for each patient to have a panel of about 20 donors. Also, due to the relatively large numbers of red cells per unit of blood collected by apheresis, the need for transfusions for these patients may be reduced.

Better blood transfusion
In October 2001 the NBS and Department of Health chief medical officer held the Better Blood Transfusion second national conference. The purpose of the consequent Better Blood Transfusion circular (DoH, 2002) is to promote the safe and appropriate use of blood components. Each research project described in this article will inform this debate.

Blood is a limited resource and its safe and appropriate use is essential in an ever-changing medical and scientific environment. Continued research is crucial to achieving this. The inclusion of nurses on project teams brings in a perspective that takes a holistic view of patient care.

The research under way shows the diverse nature of the research nurse role in the NBS. It is hoped there will be further research opportunities for nurses, and that they will become an integral part of the NBS research and development strategy.

Further information
The National Blood Service

- To contact the NBS, nurses can get in touch with Catherine Howell, Lead Nurse, Clinical Development, National Blood Service, Oxford Centre, John Radcliffe Hospital, Oxford OX3 9DU. Tel. 01865-447917; email: catherine.howell@nbs.nhs.uk

- National Blood Service website: www.blood.co.uk

Department of Health. (2002)Better Blood Transfusion (Health Service Circular 2002/009). London: Department of Health.

Griffin, T.C., Buchanan, G.R. (1993)Elective surgery in children with sickle cell disease without preoperative blood transfusion. Journal of Paediatric Surgery 28: 5, 681-685.

Meikle, J. (2001)Blood supplies 'could be halved' as donors fear results of vCJD tests. The Guardian 2 October: 9.

National Blood Service. (2003)Website accessed January 2003 www.blood.co.uk

Riddington, C., Williamson, L. (2002)Preoperative transfusions for sickle cell disease (Cochrane Review). In: The Cochrane Library 3. Oxford: Update Software.

Vichinsky, E.P., Haberken, C.M., Neumayr, L. et al. and the Preoperative Transfusion in Sickle Cell Disease Study Group. (1995)A comparison of conservative and aggressive transfusion regimens in the perioperative management of sickle cell disease. New England Journal of Medicine 333: 206-213.

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