Common aspects and differences between policy and practice

Below is a summary of the similarities and differences between the common generic vein-to-vein policies and how they are practiced at KATH.

Blood Donation

1. Donors should be selected using rigorous criteria

a. Donors are clearly selected using a specific set of criteria. These criteria do, however, vary by country. It is unclear why this variation exists, but it is likely due to meet the local population’s needs.

For example, the minimum age for donation varied between policies from 16 to 18 years (in Ghana it is 16 years). Recommended frequency of blood donation varied from 2 to 4 times a year, whereas in Ghana men are recommended to donate no more than 4 times a year and women 3 times a year. The minimum weight for donors varied considerably between policies.

In Ghana, donors must weigh at least 50kg. However, one national policy suggested donors weighing less than 50kg should be permitted to donate between 60-80ml per kg of body weight. Another policy document recommended that donors weigh at least 42kg and that only 250ml be collected from donors weighing 42-44kg and 450ml from donors 45+kg. The minimum blood pressure set by various African national blood policies ranged between 90/50 mmHg-100/60mmHg. High blood pressure deferral was ranged from 140-180mmHg systolic. At KATH the minimum blood pressure requirement was 100/60mmHg and hypertension was considered to be a systolic pressure of 140mmHg OR a diastolic pressure of 100mmHg.

2. Donor confidentiality must be maintained

a. Confidentiality is maintained throughout at KATH

3. Pre-Donation counselling for all donors

a. Pre-Donation counselling is practiced at KATH, but much of it revolves around obtaining the relevant health and risk assessment information from the donor.

Post donation, donors are educated about post-donation care. In the Ghana policy, counselling is recommended for those donors testing positive for a transfusion transmitted infection (TTI).

There is, however, no standardised outline of what information should be provided to donors pre and post donation. Counselling may also include information about the donation process, more information on how blood is grouped and cross-matched or discussing any concerns or fears a donor may have. There is no information in the literature outlining any minimum criteria for donor counselling. It is important to remember that a donor may have very little face time with staff members and that this may be the only opportunity staff have to ensure a positive experience which might encourage the donor to return. It is therefore important to develop and test various counselling tools (pre and post) to determine which donors find the most favourable, how it impacts their donation experience and whether it affects their likelihood to return.

Counselling may also be a useful opportunity to outline the donation process and illustrate that the blood transfused to patients is safe. One donor interviewed at a mobile site stated:

“Particularly the pre-screening to rule out hepatitis B, hepatitis C and HIV, and they make sure that if you are reactive to any of those tests that you are taken out and not allowed to give blood in the first place. There is some assurance that the blood donated is good for transfusion.” (VNRD, Nursing student, female, unknown age).

This donor was a nursing student and therefore understood the pre-screening process and the implication of safe blood. However, this may not be true for everyone. At the same time, we must be careful not to prevent those who are scared of finding out their HIV status from donating. Thus, counselling needs to be tailored to the individual needs of the donor

Screening Blood

1. All blood should be traceable

a. All blood is traceable at KATH. Each blood bag is assigned a unique ID number, which is recorded on the donor’s health and risk assessment forms. As everything is handwritten, human error is possible, but based on direct observations, rarely occurs. Later, the blood group is also written on the blood bag. Once a patient’s blood transfusion begins, the unique ID number of the blood bag is written in that patient’s notes. This ensures that the blood is traceable from donor to patient transfused.

2. All blood should be screened for transfusion-transmitted infections

a. Different policy documents recommend different infections for which blood should be screened. All recommend HIV and Hepatitis B while some others recommend screening for malaria, syphilis and Hepatitis C. At the time of the pilot study, KATH screened for HIV, Hepatitis B and Hepatitis C. However, towards the end of 2013, the hospital began screening for syphilis as well.

Blood Grouping

1. All blood should be grouped for ABO and Rh and labelled

a. All blood is grouped for ABO and Rh and organised in the fridge by blood group.

Blood Components

1. Preparation and Availability of blood components

a. Blood components are prepared and available at KATH. However, there is no clear policy or practice regarding what proportion of blood collected should be prepared into components. Additionally, doctors may not be aware of all the components available. Greater communication between blood prescribing clinicians and blood services is needed.

Clinical Use of Blood

1. Doctors are accountable for appropriate clinical use of blood and alternatives to transfusions

Blood Requests

1. Blood request forms must be completed prior to transfusion. The minimum criteria across all policies is patient identity and quantity requested

a. This policy is well practiced at KATH. Additional information that is sometimes not included is the volume of blood required, whether whole blood or a component is specifically required and how urgently the blood is needed. If

the volume and type of blood required is not listed, the blood bank assumes the doctor requires one unit of whole blood.

3.6 Conclusion

The identified discrepancies between the common vein-to-vein policies and practice at KATH formed the basis of the following objectives of this study. Many of the discrepancies are due to limited local evidence to inform how some of the general policies should be implemented. This guided me as to what aspects of the blood services require more evidence in order to develop and implement policies that meet the hospital’s needs.

The common vein-to-vein policies lacking sufficient evidence or presented in a manner that was too vague to be implemented properly were prioritised and formed the basis of sub-objectives 1-3. My aim was to try and collect more data for these policies, with the hope that the information would aid in implementing them in a more systematic way. I looked at all 12 policies and based on my review of the national blood policies and the literature reviews I conducted for each of the 12 policies, I found that donor criteria, donor counselling and blood component production were heavily emphasised in the literature, but that there were no details or gold standard on how to implement these policies effectively. In addition, I felt that my data collecting tools (semi-structured interviews, donor and hospital records and direct observation) would permit me to obtain rich data that would address the paucity of evidence in the above noted areas. These three themes, therefore, informed sub-objectives 1-3.

Sub-objective 4 was created based on my observation of a complete lack of information regarding the patient’s experience in obtaining a blood transfusion and their experiences in finding replacement donors. To my mind, securing a replacement donor while ill and in hospital sounded like it could pose a significant burden and I was interested in learning more about this to see if this in fact was the case or not.