Marconi M, Almini D, Pizzi M N, Riccardi D, Bergamaschi W, Giovanetti A M, Rebulla P, Sirchia G
Centro Trasfusionale e di Immunologia dei Trapianti, IRCCS Ospedale Maggiore, Milano, Italy.
Transfus Med. 1996 Mar;6(1):11-9. doi: 10.1046/j.1365-3148.1996.d01-48.x.
Guidelines, algorithms and recommendations have been issued in the attempt to ensure appropriateness of transfusion practice, but the results are less than satisfactory, mainly due to the difficulty to turn paper procedures into actual practice. In our hospital we have tried to overcome this difficulty through the implementation of a quality assurance programme which includes giving the privilege of nonurgent blood prescription to a limited number of physicians and a computerized prospective audit of blood requests. The latter is performed through verification of the compliance of blood requests, which are designed to include a patient's laboratory and clinical data, with hospital guidelines for the proper use of blood. In the 12 months since implementation of the computerized prospective audit the transfusion service has evaluated 7884 requests. Of these, 63.4% (n = 4998) were for red blood cells, 21.1% (n = 1664) for platelets and 15.5% (n = 1222) for fresh frozen plasma. The prospective audit showed that 96.8% and 98.1% of requests for red units and platelets were appropriate, respectively. Conversely, approximately 27% of plasma requests did not comply with guidelines, mainly because the evidence of coagulopathy was missing. However, inappropriateness of plasma requests for elective general surgery decreased from 39% at the onset of the programme to 14% in the last trimester considered. Moreover, the evaluation by retrospective audit of the proportion of patients transfused with both red blood cells and plasma in the perioperative period out of those transfused with red blood cells only, as an indicator of unwanted reconstitution of whole blood, showed that this proportion decreased from 47.6% (320/672) in the 12 months before implementation of computerized audit to 37.8% (244/646) in the following 12 months (difference = -9.8%, 95% confidence interval of the difference from -4.5% to -15.1%; P < 0.005 by chi 2 test). Our initial experience, together with the present system, shows that (1) the restriction of nonurgent blood prescription to a group of clinicians more educated in transfusion medicine than average clinicians practicing in a large multispecialty hospital is feasible; (2) prospective audit is a useful tool for assuring the quality of blood requesting.
为确保输血操作的合理性，已发布了指南、算法和建议，但结果却不尽人意，主要原因是难以将书面程序转化为实际操作。在我们医院，我们试图通过实施一项质量保证计划来克服这一困难，该计划包括赋予少数医生开具非紧急用血处方的特权以及对用血申请进行计算机化的前瞻性审核。后者通过核查用血申请的合规性来进行，这些申请旨在纳入患者的实验室和临床数据，并符合医院合理用血指南。在实施计算机化前瞻性审核后的12个月里，输血服务部门评估了7884份申请。其中，63.4%（n = 4998）是红细胞申请，21.1%（n = 1664）是血小板申请，15.5%（n = 1222）是新鲜冰冻血浆申请。前瞻性审核显示，红细胞单位和血小板申请分别有96.8%和98.1%是合适的。相反，约27%的血浆申请不符合指南，主要是因为缺乏凝血功能障碍的证据。然而，择期普通外科手术的血浆申请不适当率从该计划开始时的39%降至所考虑的最后一个季度的14%。此外，通过回顾性审核评估围手术期同时输注红细胞和血浆的患者占仅输注红细胞患者的比例，以此作为全血不必要重组的指标，结果显示该比例从计算机化审核实施前12个月的47.6%（320/672）降至随后12个月的37.8%（244/646）（差异=-9.8%，差异的95%置信区间为-4.5%至-15.1%；经卡方检验，P<0.005）。我们的初步经验以及当前系统表明：（1）将非紧急用血处方限制在一组比大型多专科医院的普通临床医生在输血医学方面更有学识的临床医生中是可行的；（2）前瞻性审核是确保用血申请质量的有用工具。
