Osho et al: Analysis of Blood Inventory Levels and Availability in Clinical Practice

Original Article

Analysis of Blood Inventory Levels and Availability in Clinical Practice: A Prospective Study

Osho PO.1, Oluwole MT.1, Fasipe OJ.2, Osho SE.3, Koledoye VO.1, Oni OI.1, Akinbodewa A.4

1Department of Hematology and Virology, State Specialist Hospital, , , . 2Department of Clinical Pharmacology and Therapeutics, University of Medical Sciences, Ondo City, Ondo State, Nigeria. 3Department of Radiology, Trauma Surgical Centre, University of Medical Sciences, Ondo City, Ondo State, Nigeria. 4Department of Internal Medicine, Kidney Care Centre, University of Medical Sciences, Ondo City, Ondo State, Nigeria.. .

* Correspondence: Dr Olumuyiwa John Fasipe, Clinical Pharmacologist and Senior Physician, Department of Clinical Pharmacology and Therapeutics, University of Medical Sciences, Ondo City, Ondo State, Nigeria. E-mail address: [email protected] ABSTRACT For reprints contact: [email protected]

The aim of this study was to determine the extent of blood usage during blood transfusion procedures with evaluation of blood transfusion prescription practices in view of optimal and efficient utilization of blood transfusion services. We prospectively analyzed all the blood ordered between May 2015 to April 2017 from the blood bank of Hematology Laboratory in State Specialist Hospital, Akure, Ondo State Nigeria. The indices used were in compliance with the international blood transfusion clinical practice guidelines. Out of 1,536 blood units ordered and cross-matched in this study, 62.57% units were transfused to patients and 37.43% were not transfused. This indicates judicious blood usage during transfusion procedure to saving lives. The overall blood transfusion indices for Cross match to Transfusion ratio (C/T), Transfusion probability (%T) and Transfusion Index (TI) were 1.60, 62.57 and 1.00, respectively. This implied that blood at the point of utilization within the Hospital, enjoyed a favorable status of blood prescription practice compare to the standard reference values (that is; C/T Ratio≤2.5, %T≥30 and TI≥0.5) in most of the departments under study. Departments like Obstetrics and Gynaecology (CT=2.45, %T=25.45, TI=0.41) and General Theatre (C/T=3.8, %T=16.44, TI=0.26) exhibited inappropriate order of excessive cross- matched blood by junior medical officers which may be subsequently cancelled by senior colleagues on later review of the patients were common. This study showed a reliable and efficient clinical practice in the management of blood transfusion services from the point of order to the point of need which amount to a more appropriate, prudent and conserved utilization of blood products, resources and services.

Keywords: Cross match to Transfusion Ratio, Shortage, Wastage level, Transfusion probability, Transfusion Index.

INTRODUCTION

lood transfusion is the administration of donated blood system elements. It is indicated in the treatment of various 180 B products with the intention to replace lost blood, medical and surgical conditions to save lives during increase the flow rate of cardiac output, boost blood emergency or elective circumstances, which include elements, and to replace missing clotting factors and immune trauma/accidents, bleeding disorders, major surgeries,

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chemotherapy, inherited/acquired hematological diseases and The probability of blood transfusion for a given department malignancies.1-5 A well-organized Blood Transfusion Service is denoted by %T and was suggested by Mead et al.56. (BTS) is a vital component of any health care delivery Values more than 30% show significant probability of blood system. For quality, safety and efficacy of blood and blood usage.35-39,56 Excessive demand for blood is a common products, well-equipped blood centers with adequate problem in hospitals, which causes such problems as infrastructure and trained manpower are essential inappropriate distribution of blood products among requirements.6-10 The evolution of blood transfusion services different units/departments, rising cost of preparation, and was one of the most important medical advances derived also increasing workload of preservation. The rising from World War I. The use of stored or bank blood began demand is for the fear of running out during surgery during World War 1 (1914-1918), but the first large scale (irrespective of use or otherwise), or due to lack of a clear blood bank was not created until 1937, in Chicago.11-13 The blood ordering pattern that ultimately leads to blood Canadian surgeon (Major L.B Robertson) serving in shortages and worsening of overall storage. It can be Canadian Army Medical Corps in the first World War was argued that blood ordering is done at will in most responsible for introducing transfusion in the management of hospitals.40-44 Since the introduction of blood transfusion war casualties to the British Army. Blood transfusion was into clinical practice, its appropriate use has been the subject generally accepted as the treatment of choice for severe for debate among several medical experts.45-50 blood loss by the end of the war.14-17 Millions of lives are The aim of this study is to investigate blood demand via saved each year through blood transfusion, yet the quality prescription practice and evaluation of its usage in view of and safety of blood transfusion are still the concern optimal utilization of cross-matched blood service in especially in the developing countries.18-22 different sections of Hospital. To assess extent of To maximize usage for each unit of whole blood, it is wastage/shortage and ensure appropriate use in compliance separated into three different therapeutic applications as Red with the international blood transfusion clinical practice Blood Cells (RBC), Platelets (PLT) and Plasma. The guidelines.18,22,53,57,58 The study will also assess factors estimated national need for blood in Nigeria is about 1.4-1.7 responsible for the blood prescription and utilization practice, million; 20, 22,26,53,59 unfortunately less blood is collected by determine the blood group mostly being requested and to the Nigerian National Blood Transfusion Services (NBTS) evaluate the hospital department whose demand is on the and of these, only ten percent are from Voluntary Non- high side in the State Specialist Hospital Akure, Ondo State Remunerated Blood Donors (VNRBDs).23-28 According to Nigeria. several studies, approximately half of all RBC units are used for surgical indications in the surgery departments and the MATERIALS AND METHODS other half for other medical indications in other departments.29-34 Today, blood transfusion indices such as Study Area Cross match to Transfusion ratio (C/T),Blood Transfusion This prospective study was conducted for duration of 2-year Index (TI) and Blood Transfusion Probability (%T) can be period from May, 2015 to April, 2017 at the Hematology and used for proper assessment of blood demand and use in Blood Transfusion Medicine Unit of State Specialist various hospital wards. Cross match to Transfusion ratio Hospital, Akure, Ondo State, Nigeria. The hospital receives (C/T) is the ratio of cross-matched blood units to transfused medical, surgical and dental referrals from within and outside units. The Scottish Intercollegiate Guidelines Network the state. recommended cross match to transfusion ratio (C/T ratio) for Study Population evaluating blood demand and consumption for transfusion The study participants were 1,246 hospitalized patient who practices not be more than 2.5. Blood Transfusion Index (TI) for some medical or surgical reasons needed blood is the ratio of transfused blood units to patients with prepared transfusion and blood samples were collected from both cross-matched blood. A Blood Transfusion Index (TI) value patients (recipients) and donors. of 0.5 or more is indicative of efficient blood usage and it 181 signifies that appropriate numbers of blood units are Sampling Design transfused. The Blood Transfusion Probability (%T) is the This was a prospective study in which data were retrieved

ratio of the number of patients receiving blood to the number from the laboratory information system and hard copies of patients with prepared cross-matched blood in percentage. register technique of donated blood and transfused patients.

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In this study, recipient‟s names, age, gender, barcode Cross-match Routine number, blood group, the amount of blood type were Transfusion prescription order are subjected to emergency properly documented. Overall, a total of 1,536 records were and full cross-matched on recipient serum with donor‟s red included in the study. cell from the blood bag tagged for compatibility and safety of life. The tagged and labeled blood in reserve for indexed Laboratory Assays recipient did not stay for more than 72 hours (3 days) after Routine screening of potential donors‟ blood samples were which it would re-enter the blood bank inventory. conducted daily. All donors blood were grouped (typed), screened and theblood level estimated by PCV. Three Data Collection Methods milliliters (3mls) of venous blood were aseptically collected We collected data on all blood inventories into the blood from each study participant into EDTA anticoagulant bank anonymously from May, 2015 to April, 2017. All blood container. Packed cell volumes were done using hematocrit prescriptions and their sources were noted according to the machine and hematocrit reader to ascertain adequacy of the clinical departments (wards/units). These include male blood level in percentage. Next is the determination of blood medical wards, female medical wards, children ward, special type using manufactured anti-sera to identify the presence or intensive-care-unit, female surgical ward, male surgical absence of inherited antigenic substances on the surface of wards; Obstetrics and Gynaecology, Accident and the red blood cells, through agglutination reaction. These Emergency etc. The number of transfusion orders, the blood samples were later centrifuged at 1500 rpm and the number of units requested and the number of units that were extracted plasma used for the screening of transfusion collected within 72 hours were properly noted. transmissible infections (TTIs) like HIV I & II, HbsAg, HCV and Syphilis using serological method to determinethe Statistical Analysis presence or absence of transfusion transmissible pathogens. Data were statistically analyzed using Microsoft Excel These potential donors‟ whose blood samples were certified 2007(released 2006; Microsoft Inc., USA)and Statistical non-reactive or reactive according to the manufacturers‟ Package for the Social Sciences (SPSS) Version 17 (released procedure. These potential donors whose blood samples were 2008; SPSS Inc., USA). Frequencies were calculated for all certified non-reactive to these transfusion transmissible variables to assess the statistical significance of difference in infections (TTIs) were bled and tagged for storage. The blood utilization between different departments reactive donors were referred to clinic for management. The (wards/units). The standard compliance indices used to collected plasma specimens were also transported frozen assess the appropriateness of blood ordering and utilization within 12 hours with the aid of iceboxes from Akure to the services during this study include Cross match to Transfusion National Blood Transfusion Service (NBTS) Centre, Ado ratio (C/T), Blood Transfusion Index (TI), Blood Transfusion o Ekiti and kept frozen at -20 C until the point of serological Probability (%T), Shortage Calculation, and Total Blood assays for further testing by the fourth generation enzyme- Units Ordered perthous and population during a particular linked immunosorbent assay (ELISA) method. period of time. The data obtained were computed by simple proportion (frequency, Percentages and ratios) using the Blood Re-screening Techniques following formulas below: In partnership with Ondo State Blood Transfusion services Cross match to Transfusion ratio (C/T) equals to the ratio and NBTS South-West Zonal centre, , and of cross-matched blood units to transfused units. Scottish NBTS , , blood units were re-screened Intercollegiate Guidelines Network recommended cross using the second algorithm (combo-Antigen and antibody) match to transfusion ratio (C/T ratio) for evaluating blood 4th generation ELISA technique with STATFAX-2600 demand and consumption for transfusion practices not be washer and STATFAX-2100 reader (Awareness more than 2.5. Technology); Biorad Genscreen Ultra HIV Ag-Ab were used for HIV I & II screening, Bio-rad Monolisa HBsAg ULTRA Cross match to Transfusion ratio (C/T ratio) were used for HBsAg screening while HCV and Syphilis = No. of units of blood cross matched 182 were screened using Dia-Pro Diagnostic Bioprobes. After re- No. of units of blood transfused screening confirmation, the NBTS returns the non-reactive blood units with results of all units sent to them. Blood Transfusion Index (TI) equals to ratio of transfused blood units to patients with prepared cross-matched blood.

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Regarding TI, a value of 0.5 or more is indicative of efficient (HREC) of the Ondo State Ministry of Health, Akure, blood usage and it signifies that appropriate numbers of Nigeria. blood units are transfused. RESULTS

Blood Transfusion Index (TI) Table 1showed the frequency distribution for the patients' = No. of units of blood transfused blood group and rhesus types. It can be observed that the O No. of units of cross matched positive blood type conveyed the highest percentage of Blood Transfusion Probability (%T) equals to ratio of the 52.01%, followed by 20.63% for A positive blood type, B number of patients receiving blood to the number of patients positive blood type with 19.90%, AB positive patients with with prepared cross-matched blood in percentage. The 2.65%, O negative blood type with 2.81%, while B negative, probability of blood transfusion for a given department is A negative and AB negative blood type having 1.04, 0.88 denoted by %T and was suggested by Mead et al. (1980). and 0.08% respectively in the tabulation.

Values more than 30% show significant probability of blood Table 1: Frequency distribution for the patients' blood group and rhesus types usage. ABO and Rh blood type Frequency Percentage A+ 257 20.63 Transfusion Probability (%T) A- 11 0.88 = No. of patient transfused X 100 AB+ 33 2.65 No. of patients cross matched AB- 1 0.08 B+ 248 19.90 B- 13 1.04 Blood transfusion indices such as C/T Ratio (ratio of number O+ 648 52.01 O- 35 2.81 of cross-matched blood units to transfused units), TI index Total 1,246 100 (blood transfusion index) and %T (blood transfusion probability) can be used for proper assessment of blood Table 2 showed the frequency distribution for transfused and demand and consumption in various hospital wards. non-transfused bloods. Regarding these cross-matched Shortage referred to an order not filled by NBTS as the bloods, a total of 62.57% were transfused while the specific blood product was not available as of the time of remaining 37.43% were not transfused. request. Table 2: Frequency distribution for transfused and non-transfused bloods. Shortage Calculation Frequency Percentage = Calculated shortage X 100 Transfused 961 62.57% Calculated demand Non-transfused 575 37.43% Total 1,536 100.00% OR Shortage Calculation Table 3 showed the age group distribution for the patients' = Actual Shortage X 100 that were transfused during the time period under Transfused + Actual Shortage consideration. This revealed that most of the blood

Total blood units ordered = Unit undelivered + Unit delivered transfusions were done in the age range of thirty-one to forty Shortage = undelivered - (cancelled+filled+Rejected) year-old (26.08%) and the least transfusion were done in the Transfused = (unit delivered - returned) + re-issued age range of Ninety-one to one hundred years (1.36%). Actual shortage = Shortage – Re-issued The Blood Demand and Supply was calculated as: Table 3: Frequency and percentage distribution of patients Age Total blood collection Units per 1000 population Age Frequency Percentage = Total Collection (units) X 1000 0-20 183 14.69 Total Populationduring a particular period of time 21-30 273 21.91 31-40 325 26.08 41-50 170 13.64 183 Ethical Considerations 51-60 115 9.23 This study was conducted in compliance with the Declaration 61-70 88 7.06 43 71-80 49 3.93 on the Right of the Patient. Also; approval was sought and 81-90 26 2.09 received from the Health Research Ethical Committee 91-100 17 1.36 Total 1,246 100

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Table 4 showed that in State Specialist Hospitals, Akure, the overall C/T index was 1.60, overall %T was 62.57%, and 12×100 = ______overall TI was 1.00. The highest C/T Ratio was linked to General Theatre (C/T=3.80, %T=16.44, and TI=0.26). In (634+12) other words, the number of ordered blood units by this = 1.86% department was nearly 4 times the transfused units. The lowest C/T was related to hematology/virology unit The Blood Demand and Supply was Calculated as: (C/T=0.65, %T=96.00 and TI=1.53) Total blood collection Units per 1000 population Table 5 showed the Blood Demand, Supply and Usage. The = Total Collection (units) X 1000 actual shortage, shortage calculation and total blood Total Population during May 2015 to April 2016 collection units per 1000 population from May 2015 to April = 1034X1000 2016 were 12 units, 1.86% and 0.28 units per 1000 3700000 population, respectively. The Shortage calculation for blood Total blood collection Units per 1000 population from May 2015 to unit requested and total blood collection units per 1000 April 2016 = 0.28 units. population from May 2015 to April 2016 is as follows: This revealed that the Ondo State National Blood Actual Shortage = Shortage – Reissued Transfusion Service (NBTS) total blood collections amount = 71- 59 = 12 units from May 2015 to April 2016 was 0.28 units per 1000 population which is very low compared to the WHO (Calculated Shortage) X 100 Shortage Calculation = ______recommendation reference value of 10-20 units per 1000 (Calculated Demand) population per year.

Table 4: Blood transfusion indices in various wards of State Specialist Hospitals Akure

Wards/Units Cross-matched (C) Transfused (T) Standard Indices assessment for Blood ordering and transfusion practices No. of Patients No. of unit (%) No. of Patients No. of unit (%) C/T Ratio %T TI Children Ward 83 5.40 57 5.93 0.91 68.67 1.10 Female Medical Ward 158 10.29 146 15.19 0.68 92.41 1.48 Male Medical Ward 87 5.66 66 6.87 0.82 75.86 1.21 Surgical Operation Unit 40 2.60 31 3.23 0.80 77.50 1.24 General Theatre 73 4.75 12 1.25 3.80 16.44 0.26 Intensive Care Unit 22 1.43 9 0.94 1.52 40.91 0.66 Obstetrics &Gynaecology 448 29.17 114 11.86 2.46 25.45 0.41 Accident & Emergency 261 16.99 214 22.27 0.76 81.99 1.31 Hematology/Virology Unit 75 4.88 72 7.49 0.65 96.00 1.53 Septic Unit 30 1.95 25 2.60 0.75 83.33 1.33 Male Surgical Ward 92 5.99 84 8.74 0.69 91.30 1.46 Antenatal Care Unit 56 3.65 33 3.43 1.06 58.93 0.94 Female Surgical Ward 111 7.23 98 10.20 0.71 88.29 1.41 Total 1,536 100.00 961 100.00 1.60 62.57 1.00

Table 5: Blood Demand, Supply and Usage.

May, 2015- April, 2016 May, 2016- April, 2017 Total Unit Order: 1,034 Total Unit Order: 502 Order Indices N Indices N Indices N Indices N 1 Unit undelivered 245 Unit delivered 789 Unit undelivered 117 Unit delivered 385 2 cancelled 37 Returned (unused) 214 cancelled 23 Returned (unused) 38 3 Filled (uncollected) 112 Re-issued 59 Filled (uncollected) 51 Re-issued 10 4 Rejected 25 Expired 18 rejected 8 Expired 17 Total Shortage 71 Transfused 634 Shortage 42 Transfused 327

184 DISCUSSION Ondo State Nigeria for the purpose of appropriate health planning and management of transfusion services. Our study The purpose of this study was to obtain data on blood order did not evaluate blood ordering pattern in specific surgical (demand) and usage in State Specialist Hospital, Akure, and medical indications. It is however helpful to have a high

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index of suspicion of likely anemia transfusion therapy. This least frequency was AB and there was no significant will help in reducing the high C/T ratio and improve on the variation in the frequencies between blood group A and B.47 rather low clinical utilization of ordered blood. The optimal Whether this was a coincidence or has a pre-defined practice of transfusion therapy depends on three factors: genealogical objective remains an issue especially since availability of blood donors, efficient clinical practice, and the pattern has remained constant in virtually all the societal forces. Availability of suitable and willing epidemiological studies carried out over the years in the donors has an effect on the availability of blood South-western region of Nigeria.48,49 One of the major components; efficient clinical practice influences the findings of this study was that Rhesus D positive patients amount of needed blood, and societal forces (resources, have the highest percentage while Rhesus D negative patients legislation) affect both. The optimum efficiency of have the lowest percentage across the study. This is transfusion practices and services are also location related consistent with findings of previous studies conducted in and changes over time. Elele in Nigeria,48,50 which showed that the incidence of This study demonstrated that most of the blood transfusions Rhesus negativity in all the studies conducted in Nigeria was were done for the age range of thirty-one to forty years olds found to be low, between 1.69% and 5.5% as similar to (26.08%), while the least transfusions were done for the age 0.08% to 2.8% obtained in this study. range of ninety-one to one hundred years (1.36%). In low- Blood transfusion no doubt, has saved millions of live income countries, up to 65% of blood transfusions are given worldwide. However, it is reported that recipients stand to children under five years of age, whereas in high the risk of becoming infected with blood-borne diseases income countries, the most frequently transfused patient age through transfusion of infected blood and blood group is over 65 years, accounting for up to 76% of all products.51 Blood transfusion undoubtedly has a major role in transfusions;58 making our finding in this study to be at reviving patients undergoing surgery and those at the verge discordance with this trend. This discordance could be partly of death for medical conditions. However, growing demand linked to the difference in socio-economic status and bone for storing blood and blood products has led to reduced shelf marrow failure/inefficiency at the extreme ages of life life of blood bags stored, increased workload, and between the developing and developed nations which has a ultimately, increased financial burden for patients and blood direct impact on their populace standard of living conditions. banks. Blood donation rate in high income countries is 39.2 The use of cross-match to transfusion ratio (C/T ratio) was donations per 1000 population; 12.6 donations in middle- first suggested by Boral Henry.52 Subsequently, a number income and 4.0 donations in low income countries.58 Around of authors used C/T ratio for evaluating blood transfusion 107 million units of blood donations are collected practices. The results of the present study demonstrated globally every year.58 Nearly 50% of these blood donations that, C/T ratio varied widely across the departments are collected in high-income countries, home to 15% of the under study from 0.65 at hematology/virology department world„s population.58 As observed, “blood group O” has to 3.80 at the General Theatre department. This was continuously sustained its predominance and this was the somewhat similar to that reported in a Nigerian study reason forlabeling the carriers of this blood group O as but to a lesser extent where the C/T ratio values ranged “Universal Donor”. This group was followed in from 1.60 in Obstetrics and Gynecology department to preponderance by blood group A and B in that order with 3.30 in Orthopedics, Accident and Emergency departments.53 blood group AB constituting the least in terms of frequency The excessive ordering of blood by General Theatre distribution pattern. Thus, the old appellation of carriers of department is more often guided by their prevention habits this group as “Universal Recipients” was still confirmed in and hospital routines rather than actual clinical needs. This this study. Comparatively, although blood group O was also attitude is defended by the simple excuse that, it provides a predominant and prevalent in other regions.11,44,45 This trend safety measure in the event of excessive unexpected blood (i.e. blood group A coming next in distribution to that of loss during surgery in the general theatre department. blood group O) was also observed from results obtained Notwithstanding, there are varying C/T ratios from one unit 185 in other parts of the world including among black Afro- to another unit within our Institution. The C/T ratio in the Americans in the of America (USA).46In Accident and Emergency Unit of our hospital was 0.76 another study carried out in Mauritania, it was observed that compare to the other departmental points of care within the blood group O had the highest frequency followed by A and institution. This C/T ratio of 0.76 in this study for the

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Accident and Emergency Unit was very low when compared resulted into 1034units of total blood being collected in the to the values obtained in previous studies done in other State Specialist Hospital, Akure between May 2015 and centres which were relatively high. These relatively high April 2016. The 0.28 units collected per 1000 populations values of C/T ratios experienced may be explained by the resulted in 1.86% shortage. This is far lesser than the study panic response to a bleeding patient with an attempt at conducted in Guyana National Blood Transfusion Service transfusion of donor blood even when full and (NBTS). At George town, Guyana, a Population of 750000 comprehensive examination has not be concluded. This people in 2007 resulted into 5475 units total blood collected, panic response is further re-enforced by the rowdy which account for 7.3 units collected per 1000 population environment experienced in most Accident and Emergency resulted in an 8.7% shortage.57,58,59 The impact of cost Unit; often due to mass critical event, from road traffic containment should be of paramount importance in an accidents, gunshot injuries in victims of armed robbery under resourced blood bank in terms of human capital and attacks or even communal conflict. fund. This is acutely critical in blood shortage situation Concerning TI, a value of 0.5 or more is indicative of where there is no budget either at local hospital level or even efficient blood usage and signifies the appropriateness of at ministry of health level.58,59 This indicates appropriate numbers of units transfused.54 The TI reported in the clinical prudency and efficiency in the management of current study as an overall value (1.00) and the values cross-match blood orders on the basis of actual need which of the different departments under the study are result in a more efficient utilization of blood products to considered appropriate except for the department of conduct blood transfusion services. General Theatre (0.26) and Obstetrics and Gynecology (0.41) department that exhibit deviation from the blood CONCLUSION supply standards and the routine activities of wrong blood This study showed a reliable and efficient clinical practice in orders in these departments. This result was similar to the the management of blood transfusion services from the point study conducted in an Indian tertiary care hospital where TI of order to the point of need which amount to a more 55 ranged from 0.36 - 0.15. The results of these studies show appropriate and conserves utilization of blood products, that various factors can affect values of C/T ratio and TI resources and services. The continuous increase in blood indices such as type of disease, type of blood product need within the hospital facility calls for the amendment of required, type of surgery, and hospital ward/department/unit. practice guidelines to avoid blood supply shortage. One The Transfusion probability [%T] for a given simple way of improving the quality of routine blood use is department/unit was suggested by Mead and colleagues in to target blood orders to the patients that need them urgently. 56 1980. A value of more than or equal to 30% has been If blood ordering is carried out according to proper practice recommended to be appropriate and signifies accuracy in the guidelines; the inappropriate distribution of blood among numbers of blood units cross-matched. According to what various wards/units, rising costs of blood preparation, and is recommended in the reference literatures, the Transfusion also increased blood bank workload can be prevented. probability [%T] values reported in the current study for the different departments under this study were considered Recommendation appropriate except for the department of General Theatre Although patient‟s disease condition affects the level of (16.44%), and the department of Obstetrics and Gynecology blood order; ordering at will among physicians in different (25.45%). This finding from our own study was higher than departments/units of the our hospital is clear because many the study conducted in an Indian tertiary care hospital where doctors prescribing blood are unaware of recommended the %T was between the range of 11.1% - 25%.55 published guidelines for transfusion practices and still The level of blood shortage was suggested by Sridhar et al. adhere to historical practice and not evidence based (2007), 57 using blood Supply and demand approaches. The practice. Thus, the issue can be properly addressed through World Health Organisation (WHO) recommended standard the establishment of National blood regulation act, Hospital for blood collection is between 10 units to 20 units per 1,000 blood transfusion committee, Standard blood ordering form, populations per year; which is used to reduce wastage and properblood transfusion ordering guidelines, establishment of 186 account for appropriate stock management. A total blood maintenance and monitoring system, changes in population of 3.7 million people lives in Ondo State blood ordering and transfusion patterns. In addition, according to 2006 National Population Census, which practical and continuous medical education training

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programs in relation to blood ordering and transfusion 8. Lefrere J.J, Hewitt P. from mad cows to sensible blood services in every hospital system are paramount in transfusion: the risk of prion transmission by labile addressing the issue of blood shortage. We recommend that blood components in the United Kingdom and in decisions to order for blood transfusion be taken in France. Transfusion 2009;49:797-812. accordance to accurate clinical and laboratory indicators. 9. Alimba C.G, Adekoya K.O, Oboh B.O. Prevalence and gene frequencies of phenylthiocarbamide (PTC) taste Acknowledgement sensitivity, ABO and Rhesus factor (Rh) blood groups, We would like to thank the staff of blood bank services and haemoglobin variants among a Nigerian population. Akure specialist hospital, Ondo State Nigeria for their The Egyptian Journal of Medical immense assistance during the course of this study. Their Humangenetics2009;11, 153-158. support was of paramount importance to the completion of 10. Landsteiner K, Weiner A.S. An agglutinable factor in this study. human blood recognized by immune sera for rhesus blood. Proc. Soc. Exp. Biol. Med.1940;43:223-224. Conflict of Interest 11. Akinnuga A.M, Bamidele O, Amosu A.M, Ugwah G.U. None declared Distribution of ABO and Rh Blood Groups among Major Ethnic Groups of Medical Students of Madonna REFERENCES University Teaching Hospital Elele, Nigeria. Asian 1. The Franklin Institute Incorporation “Blood” The Journal of Medical Sciences2011;3(3): 106-109. Human Heart.2014. 12. Thompson J.S, Thompson M.W. Genetics in Medicine http://www.fi.edu/learrn/heart/blood.blood.html.Last 3rd edition, Philadelphia, , Toronto: W.B accessed on 03/04/2018. Saunders Company1980. 2. OmotoshoIshiaq. A Survey of ABO, Rhesus (D) Antigen 13. Reid ME and Lomas-Francis C. The blood group and Haemoglobin Genes Variants in Oyo State, Nigeria, antigens fact book 2nd edition San Diego, Elsevier Niger. J. Physiol. Sci. 2015;30:25-129. Academic Press 2004 Link:https://www.ajol.info/index.php/njps/article/viewFi 14. Hess JR and Thomas, MJ. Blood use in war and disaster: le/145528/135056 lessons from the past 3. Uma S, Arun R, Arumugam P. The Knowledge, century. Transfusion 2003;43(11):1622-1633. Attitude and practice towards blood donation among 15. Sarkar RS, Philip J, Kumar S.Yadav P. Evolution of the voluntary blood donors in Chennai India. J ClinDiagn role of armytransfusion services in the management of Res. 2013;7(6):1043-1046 trauma patients and battle casualtieswith massive 4. Samaa Z. Ibrahim, Heba M. Mamdouh, Amal M. hemorrhage. Med J Armed Forces India, 2012:68(4), Ramadan. Blood Utilization for Elective Surgeries at 366-370. Main University Hospital in Alexandria, Egypt, Journal 16. Mc-Carthy P.R. Blood Donation. Microsoft Corporation, of American Science. 2011; 7(6): 683-689. Redmond 2007. Link:http://www.jofamericanscience.org/journals/am- 17. Pinkerton, P.H. Canadian Surgeon and the Introduction sci/am0706/112_5853am0706_683_689.pdf of Blood Transfusion in War Surgery. Transfusion 5. Schreiber GB, Bisch MP, Klenman SH, Korelizt JJ. Medicine Reviews 2008;22:77-86. The risk of transfusion-transmitted viral infections. http://dx.doi.org/10.1016/j.tmrv.2007.09.004 NEJM 1996;26;1685-1690. 18. Miller R, Hewitt P.E, Warwick R, Moore M.C, Vincent 6. Sandler SG, Vassallo RR. Anaphylactic transfusion B. Review of Counseling in a Transfusion Service: The reactions. Transfusion 2011;51:2265-2266. London (UK) Experience. VoxSanguinis, 1998;74:133- 7. Kleinman S, Caulfield T, Chan P, Davenport R, 139. http://dx.doi.org/10.1046/j.1423- McFarland J, McPhedran S, Meade M, Morrison D, 0410.1998.7430133 Pinsent T, Robillard P, Slinger P. Toward an 19. Ejeliogu EU, Okolo SN, Pam SD, Okpe ES, John 187 understanding of transfusion-related acute lung injury: CC, Ochoga MO. Is Human Immunodeficiency Virus still transmissible through blood transfusion in statement of a consensus panel. Transfusion 2004;44:1774-1789. children with Sickle cell anaemia in , Nigeria? Br J Med Med R. 2014;4(21):3912–3923.

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