Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
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An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

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Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : December | Volume : 16 | Issue : 12 | Page : EC15 - EC18 Full Version

Quality Audit Towards Improvement of Transfusion Services: An Institutional Assessment


Published: December 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/59084.17260
Nikhil, Subhashish Das, R Kalyani

1. Senior Resident, Department of Pathology, Sri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka, India. 2. Professor, Department of Pathology, Sri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka, India. 3. Professor, Department of Pathology, Sri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka, India.

Correspondence Address :
Dr. Subhashish Das,
Professor, Department of Pathology, Sri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka, India.
E-mail: daspathology@gmail.com

Abstract

Introduction: Maintaining quality in transfusion services is a vital cogwheel of Quality Management System (QMS) in a hospital to impart safe blood to the patients. Quality Indicators (QI) play a pivotal role in quality management as they dispense imminent information regarding the execution of transfusion services and could help in utilising QI as a benchmark for safe quality of blood. Less is known about the authentic utilisation of QI in hospitals.

Aim: To assess the comprehensive quality performance of the blood centre and evaluating the five obligatory QIs as per National Accreditation Board for Hospitals and Healthcare Providers (NABH) and make necessary suggestions for refinement of the same.

Materials and Methods: The cross-sectional study was conducted at the blood bank attached to RL Jalappa Hospital, Tamaka, Kolar, Karnataka, India. The five compulsory QIs, as defined by NABH, were noted and monitored on monthly basis, from December 2019 to December 2020. The particulars were collected in a methodical outline and root causes for any deviation were assessed. Accordingly, particular corrective and preventive measures were taken. Data was entered in Microsoft excel spreadsheets and analysed using Statistical Package for Social Sciences (SPSS) v22 software.

Results: The mean transfusion reaction rate was 0.18 in patients, with a highest value of 0.9 noted in the month of March-2020; there was no transfusion reaction at all in the month of February, April, June, July, October, November and December-2020. The mean wastage rate was 12.9. The maximum wastage was noted in August-2020 (21.7%) and was least in October 2020 (7.2%). Turnaround Time (TAT) was <30 minute for emergency cases with a mean of 27.11 minutes. For routine cases mean TAT was 140.9 minutes.

Conclusion: Stringent enforcement of quality indicators, as mandated by NABH, can help in preventing errors in transfusion services. This, in turn, helps in maintaining a better quality and performance of the blood bank.

Keywords

Quality indicators, Quality management system, Transfusion transmitted infections

Over the last decade the pursuit for safe blood supply has led to enormous growth in the context of Transfusion Medicine (TM) practices. Quality indicators are a part of QMS tool. These are implemented in an institution with the intention of collecting proof for the level of quality performances, and the data can also be used to improve performance in an establishment (1). To ascertain zero-risk blood transfusion, huge efforts were made to increase the quality of the transfusion services, so there was a need to establish substantial parameters for measuring the quality of transfusion services. These colossal efforts have been made by government and non government based blood banks, to collect, create and assess quality QIs for quality healthcare services. Noteworthy considerations were proposed by reputed bodies such as the Agency for Healthcare Research and Quality (AHRQ) and the College of American Pathologists (CAP) (2). However, these considerations have been addressed to a limited extent for blood banking services. International Society of Blood Transfusion (ISBT) constituted its Working Party on Quality Management (WPQM). Measures for improving blood banking services utilising QIs: Three benchmarks are categorised for selection of QIs: a) importance, b) scientifically sound parameters along with possibility. Various strategies are instituted by organisations for constant improvement of quality services. Most common strategies utilised are 1. FOCUS-PDCA (Find, Organise, Clarify, Understand and Select-Plan, Do, Act and Check), and 2. Six-sigma. The FOCUS-PDCA had proven considerable benefit in QI projects of blood banking services (3),(4). Here, FOCUS means to find or search what is required for improvement, organisation of team with sound knowledge, clarification of the knowledge in relation to the process implied, understanding factors leading to variations in the process, selection of interventions that may help in improvement of the process. Here, PDCA means planning for improvement, doing the required changes at a very small level on trial basis, checking to note if the changes of data are efficacious or not and acting accordingly to collate the benefits obtained. Six-sigma means that 99.99966% of the process results are anticipated to be free of defects (meaning <3.4 defects per million cycles of the procedure).

Data analysis and collection are also considered as a crucial benchmark for QIs and QIs projects. For obtaining data of QIs usually routine sources are utilised. Computers are considered for storing of data, retrieval of data along with evaluation QIs data. Manual collection of data by manual method is also possible but is slower and has less accuracy. A noteworthy implementation that can augment data collection for QIs manually is the “check sheet”. So, these measures can be implied to enhance quality of QIs for blood banking services. Subsequently this led to the development of QIs in blood banking system. Implementing QMS in all the phases of transfusion services such as blood collection, processing and storage can help in achieving Blood Transfusion Services (BTS) with greater degree of efficacy (5). Eleven QIs are defined by NABH, of which the first five indicators are compulsorily accredited for blood bank to report and monitor quarterly to NABH (6). The main goal of BTS is to maintain and provide superlative quality standards in every facet of patient care.

The present study was conducted to evaluate the quality performance as well as to inspect the preparedness of the blood bank of a rural tertiary care hospital and make necessary recommendations required for betterment of the same.

Material and Methods

The cross-sectional study was conducted at the blood bank centre attached to RL Jalappa Hospital Kolar, Karnataka, India. The first five mandated QIs by NABH (6) were documented on a monthly basis, from December 2019 to December 2020. Ethical clearance was obtained for the study from Institutional Ethical Committee with IEC.No DMC/KLR/IEC/480/2022-23).

Study Procedure

The particulars were collected in a methodical manner and root causes for any deviation were assessed, and accordingly particular measures were taken. Essential information with regards to QI parameters were gathered monthly from all the wards, Intensive Care Units (ICUs), Operation Theatre (OT), and also from the blood storage unit itself by blood bank technicians. The whole procedure was carried out under supervision of “incharge” of blood storage unit.

The QIs noted were as follows:

1. Percentage of Transfusion Transmitted Infection (TTI%) Calculated as: TTI%=Total combined TTI cases inclusive of Human Immunodeficiency Virus (HIV)+Hepatitis B Virus (HBV)+Hepatitis C Virus (HCV)+Syphilis+Malarial Parasite (MP)×100 divided by total numbers of donors in that month.
2. Percentage of adverse transfusion reactions Calculated as : Percentage of adverse transfusion reactions=number of adverse transfusion reactions multiplied by 100 divided by entire number of blood or component units issued in that particular month.
3. Percentage of outdated whole blood or concentrated Red Blood Cells (RBCs) (wastage rate): Number of whole blood or concentrated RBC discarded (outdated)/by the entire (total) number of whole blood and concentrated RBC collected or prepared in that month×100.
4. Turnaround time was derived as follows: TAT=Sum of the time acquired divided by the grand total number of times whole blood or RBC issued. Time taken was derived from the time of issue of request or receiving of sample in the blood bank to the time until the blood was cross-matched and made available for transfusion.
5. Percentage of component Quality Control (QC) failures (for each component) was derived as follows: Number of a particular component QC failures×100 by total number of that component tested in that month.

Statistical Analysis

Data was entered in Microsoft excel sheet and analysed utilising SPSS Software 22. The unpaired Student’s t-test was applied.

Results

Total donors who enrolled for blood donation during the study period was 26,200, of which 575 donors (2.19%) were deferred, 488 donors (84.86%) were temporarily deferred, and 86 donors (14.95%) were permanently deferred as per the DGHS criteria (7). The total blood collection for the one year study period was 25,625 blood units with 100% component separation. Among the donor population the voluntary blood donors constituted 25,112 (98%), and the relative blood donors were 513 (2%).

(Table/Fig 1) The most common reason for discarding Packed Red Blood Cells (PRBCs) was underweight 600 units (46.54%). The most common cause for discarding Fresh Frozen Plasma (FFP) was lipemic 800 units (43.36%). The most common cause for discarding Platelet Concentrates (PCs) was leakage in 90 units (36%).

The final decision for discarding blood unit was done as per the Standard Operating Procedure (SOP) with prior knowledge and permission from Blood Bank Officer (BBO) along with proper documentation mentioning the date, units involved, and the cause of discard.

The (Table/Fig 2) represents TTI% with maximum TTI% noted in the month of May 2020, (4.2%) followed by October 2020 (3.2%) and December 2019 with TTI% of 2.7%, lowest value was noted in the month of July 2020 (0.2%) with mean TTI of 1.87. The (Table/Fig 3) demonstrates adverse transfusion reaction rate%, maximum adverse transfusion reaction rate was noted in the month of March 2020 (0.9%) and no transfusion reaction was noted in the months of February, April, June, July, October, November and December-2020.

The (Table/Fig 4) depicts wastage rate %, maximum wastage rate was observed in the month of August 2020 (21.7%) and minimum wastage rate was noted in the month of October 2020 (7.2%) with mean wastage rate of 12.9%.

The (Table/Fig 5) represents TAT, TAT was found to be <30 minute for emergency cases except in month of February and May 2020 with TAT value being 40.2 minutes and mean TAT value was 27.11. For routine cases mean TAT was noted 140.9 minutes. The (Table/Fig 6) represents number of TTI’s, maximum TTI’s were observed in the month of May 2020 (29 units) and least TTI’s were noted in the month of December 2020 (11 units). For routine cases mean TAT was noted 140.9 minutes. For Percentage of component quality control (QC) failures: PRBC (Packed RBC) QC failure and FFP (fresh frozen plasma) QC failure were entirely zero during the whole study duration.

Discussion

It is vital to have a strict quality program which must be safe and effective for transfusion services. The present research assessed the five compulsory QI to evaluate the quality control of transfusion services in the study institution. The QC of blood banking was based on these parameters. Published QIs globally are mainly based on Cross match Transfusion ratio (CT ratio), expiration rate and wastage rate of RBC. These services gives only estimation about the utilisation of blood (8). So, the current study evaluated the obligatory QIs comprehensively for assessing the quality performance of blood bank in the institution.

In current study, the overall TTI% observed 1.87%. The most common TTI observed in the present study was HIV, followed by most seropositive cases in Hepatitis B. Contrary to the present study, the TTI prevalence was 0.6% and 0.6% as reported by Fernandes H et al. and Hariharan A et al., (9),(10). Zulfikar A et al., and Varshney L et al., reported TTI to be 0.93% and 0.82%, respectively (11),(12). Reason for increased TTI% in the current study can be attributed to usage of chemiluminescence in the current blood centre which has increased sensitivity for detection of viral markers. Average TAT for routine cases in current study was 140.9 minutes whereas Average TAT was 153 minutes in the study done by Gupta A and Gupta C (13) which was higher in comparison to the current study and Average TAT reported in the study done by Varshney L et al., (12) was 135.8 minutes which was lower in value being contrary to the present study. Average for TAT emergency cases was 27.11 minutes in the current study, which is comparable to study done by Varshney L and Gupta S (29.87 minutes) (12). In the current study there was no delay in TAT and the recommended AT time was less than 30 minutes (7). There are no available comparable studies published in English scientific literature with respect to TAT.

Delay (>30 min) in the TAT for emergency cases was observed in the month of February and May 2020. When Root Cause Analysis (RCA) was done for the same it showed that the current blood bank was running short of staff due to some unavoidable leaves of the BTS staff. To resolve the same the technical manager of blood bank was advocated to conduct and manage BTS employees in an appropriate manner so it does not affect the working pattern in the centre. Another quality parameter noted in the current study was adverse transfusion reaction rate, which was 0.18, with a maximum of 0.90 observed in March 2020. Contrary to the present study, Bhattacharya P et al., and Hariharan A et al., reported adverse transfusion reaction rate 0.16 and 0.14, respectively (14),(10). There was no transfusion reactions at all in the month of February, April, June, July, October, November and December-2020. Bulk of the cases which showed transfusion reaction were allergic reactions followed by Febrile Non Haemolytic Transfusion Reactions (FNHTR).

In the present study, the mean wastage rate was 12.9%. Maximum wastage rate was observed in the month of August 2020 around 21.7% and minimum in the month of October 2020 (around 7.2%) which was higher in value as compared to the study done by Mukherjee G et al., (5) and Hariharan A et al., (10) which reported wastage rate value of 13.5% and 15.93%, respectively. The most common cause of wastage was TTI reactivity in the index study; other causes were excess collection or decreased volume collection. Other reasons for wastage were breakage of blood bags during processing and storage. Regular auditing was organised and adopting of “first in first out policy” for issuing of blood. A schedule was chalked out for” maximum blood order schedule” after discussing with the operating surgeons and hospital transfusion committee to prevent further wastage. The study noted that stringent enforcement of quality indicators as mandated by NABH can help in preventing errors in transfusion services and thus in turn helps in maintaining a better quality and performance of the blood bank.

Limitation(s)

This was a unicentric study and only five mandated QIs were evaluated.

Conclusion

In the index study TTI% was 1.87% which was higher in comparison to other studies because usage of chemiluminescence in the current blood centre increasing the sensitivity for detection of viral markers. In current centre mean wastage rate was noted to be higher in month of August 2020 which was higher in comparison to the other studies. So, well constructed transfusion strategies can help in decreasing the discard rate of blood bags due to expiry as whole blood is not indicated frequently. So collection of whole blood should be reduced to prevent expiry due to non-utilisation along with connecting and networking to other blood banks for outsourcing of the components when needed can help in efficient usage of blood components and hence preventing wastage. In the current study emergency TAT was found to be more than 40.2 minutes in the month February 2020 and May 2020. It should be ensured that properly trained BTS staff must be available for issuing of blood and its components by strictly following the TAT policy as per institute norms. This study concludes that every hospital should have stringent quality control assurance program for transfusion services and to develop a core committee of transfusion members.

References

1.
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DOI and Others

DOI: 10.7860/JCDR/2022/59084.17260

Date of Submission: Jul 15, 2022
Date of Peer Review: Sep 03, 2022
Date of Acceptance: Nov 14, 2022
Date of Publishing: Dec 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 30, 2022
• Manual Googling: Nov 11, 2022
• iThenticate Software: Nov 13, 2022 (7%)

ETYMOLOGY: Author Origin

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