Maternal iron deficiency anaemia in pregnancy: Lessons from a national audit.

We describe the management and the prevalence of iron deficiency anaemia (IDA) during pregnancy by comparison to standards. A cross-sectional national cohort study of women who had given birth six weeks prior to data collection was conducted at maternity units in the UK and Ireland. Participating centres collected data from 10 consecutive pregnant women. Analysis was descriptive to define the prevalence of IDA in pregnancy and the puerperium, and to compare the outcomes in women who had IDA with women who did not have anaemia anytime during pregnancy. Eighty-six maternity units contributed data on 860 pregnancies and births. The overall prevalence of IDA during pregnancy was 30.4% and in the puerperium 20%. Anaemic women were more likely to be from ethnic minorities, odds ratio 2.23 (1.50, 3.32). Adherence to national guidance was suboptimal, and the prevalence of anaemia in pregnancy remains very high. There is pressing need to explore barriers to early identification and effective management of iron deficiency. IDA should be considered a major public health problem in the UK.

Effectiveness of Enhanced Performance Feedback on Appropriate Use of Blood Transfusions: A Comparison of 2 Cluster Randomized Trials.

Importance: Auditing and feedback are frequently used to improve patient care. However, it remains unclear how to optimize feedback effectiveness for the appropriate use of treatments such as blood transfusion, a common but costly procedure that is more often overused than underused. Objective: To evaluate 2 theoretically informed feedback interventions to improve the appropriate use of blood transfusions. Design, Setting, and Participants: Two sequential, linked 2 × 2 cluster randomized trials were performed in hospitals in the UK participating in national audits of transfusion for perioperative anemia and management of hematological disorders. Data were collected for a surgical trial from October 1, 2014, to October 31, 2016, with follow-up completed on October 31, 2016. Data were collected for a hematological trial through follow-up from July 1, 2015, to June 30, 2017. Trial data were analyzed from November 1, 2016, to June 1, 2019. Interventions: Hospitals were randomized to standard content or enhanced content to improve feedback clarity and usability and to standard support or enhanced support for staff to act on feedback. Main Outcomes and Measures: The primary end point was appropriateness of transfusions audited at 12 months. Secondary end points included volume of transfusions (aiming for reductions at patient and cluster levels) and transfusion-related adverse events and reactions. Results: One hundred thirty-five of 152 eligible clusters participated in the surgical audit (2714 patients; mean [SD] age, 74.9 [14.0] years; 1809 women [66.7%]), and 134 of 141 participated in the hematological audit (4439 patients; median age, 72.0 [IQR, 64.0-80.0] years; 2641 men [59.5%]). Fifty-seven of 69 clusters (82.6%) in the surgical audit randomized to enhanced content downloaded reports compared with 52 of 66 clusters (78.8%) randomized to standard reports. Fifty-nine of 68 clusters (86.8%) randomized to enhanced support logged onto the toolkit. The proportion of patients with appropriate transfusions was 0.184 for standard content and 0.176 for enhanced content (adjusted odds ratio [OR], 0.91 [97.5% CI, 0.61-1.36]) and 0.181 for standard support and 0.180 for enhanced support (adjusted OR, 1.05 [97.5% CI, 0.68-1.61]). For the hematological audit, 53 of 66 clusters (80.3%) randomized to enhanced content downloaded the reports compared with 53 of 68 clusters (77.9%) randomized to standard content. Forty-nine of 67 clusters sites (73.1%) assigned to enhanced support logged into the toolkit at least once. The proportion of patients with appropriate transfusions was 0.744 for standard content and 0.714 for enhanced content (adjusted OR, 0.81 [97.5% CI, 0.56-1.12]), and 0.739 for standard support and 0.721 for enhanced support (adjusted OR, 0.96 [97.5% CI, 0.67-1.38]). Conclusions and Relevance: This comparison of cluster randomized trials found that interventions to improve feedback usability and guide local action were no more effective than standard feedback in increasing the appropriate use of blood transfusions. Auditing and feedback delivered at scale is a complex and costly program; therefore, effective responses may depend on developing robust local quality improvement arrangements, which can be evaluated using rigorous experimental designs embedded within national programs. Trial Registration: isrctn.org Identifier: ISRCTN15490813.

Repeated analyses of national clinical audit reports demonstrate improvements in feedback methods.

BACKGROUND: There is growing interest in the impact of national clinical audit programmes on the quality of healthcare. There is also an evolving evidence-base for enhancing the design and delivery of audit and feedback. We assessed the extent to which a sample of UK national clinical audit feedback reports met a set of good practice criteria over three time points. METHODS: We undertook three cross-sectional content analyses. We developed good practice criteria for the content and delivery of feedback based upon evidence, behavioural theory and expert opinion. We applied these to a feedback reports from 23 national audits listed on the Healthcare Quality Improvement Partnership (HQIP) website in November 2015. We repeated our assessments in January 2017 for 20 repeat feedback reports, after HQIP had published reporting guidance for national audits, and in August 2019 for a further 14 repeat feedback reports. We verified our assessments, where possible, with audit leads. RESULTS: Feedback reports consistently included strengths at baseline, including past or planned repeated audit cycles (21; 91%), stating the importance of the topic in relation to patient care (22; 93%), using multi-modal data presentation (23; 100%), and summarising key findings (23; 100%). We observed improvements over subsequent assessments, so that by 2019, at least 13 out of 14 (93%) feedback reports presented easily identifiable key findings and recommendations, linked recommendations to audit standards, and proposed easily identifiable action plans. Whilst the use of regional comparators did not improve, audit leads highlighted that programmes now provide local data via additional means. The main shortcoming was the time lag between data collection and feedback; none of the 14 reports assessed in 2019 presented performance data less than 6 months old. Audit leads highlighted that some of these data might be available via programme websites. CONCLUSION: We identified increased adherence to good practice in feedback by national clinical audit programmes that may enhance their impact on service delivery and outcomes. There is scope for improvement, especially in the recency of performance data. With further refinements, a criterion-based assessment offers an efficient means of monitoring the quality of national clinical audit feedback reports.

International Survey of Trials of Convalescent Plasma to Treat COVID-19 Infection.

The collection and clinical use of COVID-19 convalescent plasma (CCP) as a therapy for COVID-19 infection is under development and early use in many centers worldwide. We conducted an international survey of centers undertaking studies of CCP to provide understanding of the common themes and differences between them. Sixty-four studies in 22 countries were identified from clinical trial registries and personal contacts of the authors. Twenty of the 64 centers (31%) from 12 of 22 countries (55%) responded to the survey. Of the 20 studies, 11 were randomized controlled trials (RCTs), and 9 were case series. Only 4 of the RCTs plan to recruit 400 patients or more, and only 3 RCTs were blinded. The majority of studies will study the effect of CCP on sick patients requiring hospitalization and those requiring critical care, and none is examining the role of CCP in non-infected at-risk individuals. A wide variety of primary and secondary outcomes are being used. The donor eligibility criteria among the studies are very similar, and the use of plasmapheresis for the collection of CCP is almost universal. The planned dose of CCP ranges from as little as 200 mL to well over 1 L, but is 400 to 800 mL or 4 mL/kg or greater in all the RCTs. There is considerable variability in donor antibody testing with no consistency regarding the cut-off for antibody titer for acceptance as CCP or the use of pathogen-inactivation. Our survey provides an understanding of the similarities and differences among the studies of CCP, and that by virtue of their design some studies may be more informative than others.

The evaluation of enhanced feedback interventions to reduce unnecessary blood transfusions (AFFINITIE): protocol for two linked cluster randomised factorial controlled trials.

BACKGROUND: Blood for transfusion is a frequently used clinical intervention, and is also a costly and limited resource with risks. Many transfusions are given to stable and non-bleeding patients despite no clear evidence of benefit from clinical studies. Audit and feedback (A&F) is widely used to improve the quality of healthcare, including appropriate use of blood. However, its effects are often inconsistent, indicating the need for coordinated research including more head-to-head trials comparing different ways of delivering feedback. A programmatic series of research projects, termed the 'Audit and Feedback INterventions to Increase evidence-based Transfusion practIcE' (AFFINITIE) programme, aims to test different ways of developing and delivering feedback within an existing national audit structure. METHODS: The evaluation will comprise two linked 2×2 factorial, cross-sectional cluster-randomised controlled trials. Each trial will estimate the effects of two feedback interventions, 'enhanced content' and 'enhanced follow-on support', designed in earlier stages of the AFFINITIE programme, compared to current practice. The interventions will be embedded within two rounds of the UK National Comparative Audit of Blood Transfusion (NCABT) focusing on patient blood management in surgery and use of blood transfusions in patients with haematological malignancies. The unit of randomisation will be National Health Service (NHS) trust or health board. Clusters providing care relevant to the audit topics will be randomised following each baseline audit (separately for each trial), with stratification for size (volume of blood transfusions) and region (Regional Transfusion Committee). The primary outcome for each topic will be the proportion of patients receiving a transfusion coded as unnecessary. For each audit topic a linked, mixed-method fidelity assessment and cost-effectiveness analysis will be conducted in parallel to the trial. DISCUSSION: AFFINITIE involves a series of studies to explore how A&F may be refined to change practice including two cluster randomised trials linked to national audits of transfusion practice. The methodology represents a step-wise increment in study design to more fully evaluate the effects of two enhanced feedback interventions on patient- and trust-level clinical, cost, safety and process outcomes. TRIAL REGISTRATION: http://www.isrctn.com/ISRCTN15490813.

Study protocol: first nationwide comparative audit of acute lower gastrointestinal bleeding in the UK.

INTRODUCTION: Acute lower gastrointestinal bleeding (LGIB) is a common indication for emergency hospitalisation worldwide. In contrast to upper GIB, patient characteristics, modes of investigation, transfusion, treatment and outcomes are poorly described. There are minimal clinical guidelines to inform care pathways and the use of endoscopy, including (diagnostic and therapeutic yields), interventional radiology and surgery are poorly defined. As a result, there is potential for wide variation in practice and clinical outcomes. METHODS AND ANALYSIS: The UK Lower Gastrointestinal Bleeding Audit is a large nationwide audit of adult patients acutely admitted with LGIB or those who develop LGIB while hospitalised for another reason. Consecutive, unselected presentations with LGIB will be enrolled prospectively over a 2-month period at the end of 2015 and detailed data will be collected on patient characteristics, comorbidities, use of anticoagulants, transfusion, timing and modalities of diagnostic and therapeutic procedures, clinical outcome, length of stay and mortality. These will be audited against predefined minimum standards of care for LGIB. It is anticipated that over 80% of all acute hospitals in England and some hospitals in Scotland, Wales and Northern Ireland will participate. Data will be collected on the availability and organisation of care, provision of diagnostic and therapeutic GI endoscopy, interventional radiology, surgery and transfusion protocols. ETHICS AND DISSEMINATION: This audit will be conducted as part of the national comparative audit programme of blood transfusion through collaboration with specialists in gastroenterology, surgery and interventional radiology. Individual reports will be provided to each participant site as well as an overall report and disseminated through specialist societies. Results will also be published in peer-reviewed journals. The study has been funded by National Health Services (NHS) Blood and Transplant and the Bowel Disease Research Foundation and endorsed by the Association of Coloproctology of Great Britain and Ireland.

Where do all the red blood cells (RBCs) go? Results of a survey of RBC use in England and North Wales in 2014.

BACKGROUND: Knowledge of blood utilization can assist clinicians in directing patient blood management (PBM) initiatives and can facilitate demand planning by blood services. We describe a national study of red blood cell (RBC) utilization in England and North Wales in 2014. STUDY DESIGN AND METHODS: All hospitals that are supplied with blood components by NHS Blood and Transplant (NHSBT) were asked to provide data on the age and sex of all recipients of transfusions of RBCs, and the clinical indication for every unit transfused, for two separate weeks in 2014. Clinical indication categories were derived from those used in previous studies in an English region. Completeness of data collection was checked against NHSBT issue and wastage data. RESULTS: Data on 46,111 RBC units were collected, representing 73% of all RBCs issued by NHSBT during the weeks surveyed. A total of 67% of RBC units were transfused for a medical indication, with 27 and 6% being transfused for surgical and obstetric/gynecologic indications, respectively. For comparison, figures from a study in the North of England in 2009, on which this national study was based, showed that 64% of RBCs were transfused to medical patients. All but 20 units could be ascribed to a broad clinical heading, for example, "gastrointestinal bleeding." CONCLUSION: Our findings confirm the previous regional finding that the percentage of RBC units that are transfused to surgical patients in England and North Wales is now much lower than for medical patients and suggest that PBM initiatives should now focus on medical patients.

Assessing transfusion competency in junior doctors: a retrospective cohort study.

BACKGROUND: There is scope to further improve the safety of transfusion practice within the United Kingdom. This study aims to identify the current role of junior doctors in the transfusion process and to assess their competency to appropriately prescribe blood and blood products to patients. STUDY DESIGN AND METHODS: Transfusion competency in junior doctors training in a single region was addressed through anonymized questionnaires assessing factual knowledge, personal reflection, and documented evidence of competency. Factual knowledge comprised 33 true-false questions (competency score) covering indications for transfusion, special requirements, risks of transfusion, and guidelines for testing in transfusion. Background data on current practice and education in transfusion medicine were addressed using multiple-choice and single-response questions. RESULTS: A total of 787 newly qualified doctors, comprising 79% of first-year (F1) and 62% of second-year (F2) Foundation doctors, completed the assessment over a 3-week period. There was no improvement in competency score between F1 and F2 doctors (p = 0.1). Competency scores correlated most strongly with undergraduate education in transfusion medicine and attendance at hospital induction (p < 0.01). Junior doctors had a high confidence level with regard to prescribing blood, although only 78% were aware they had been competency assessed against national standards. CONCLUSION: Junior doctors are involved in sampling, prescribing, consenting, and documenting transfusion practice frequently enough to maintain competency. They are rarely involved in the collection, bedside checking, or administration of blood despite current curriculum requirements. There is scope to significantly improve both the training and the assessment of transfusion competency in doctors.

Red blood cell transfusion practice in children: current status and areas for improvement? A study of the use of red blood cell transfusions in children and infants.

BACKGROUND: Patterns of red blood cell (RBC) transfusion are less well understood for children than adults. This study was undertaken to document current pediatric practice, to identify specific areas for improving patient care and safety. STUDY DESIGN AND METHODS: All UK hospitals were invited to participate. All children less than 18 years old admitted and receiving a RBC transfusion during a 3-month period in 2009 were eligible for inclusion. RESULTS: A total of 160 of 247 (65%) sites treating children or neonates responded; 119 provided data on 1302 pediatric patients transfused in nonneonatal wards. A total of 74% of patients received a single RBC transfusion during their admission. More than half (53%) of recipients had a hematologic or oncologic underlying diagnosis, and 33% were on general pediatric wards. The median pretransfusion hemoglobin (Hb) level was 7.9 g/dL (interquartile range [IQR], 6.9-9.4 g/dL), varying by location and diagnosis. The median volume prescribed was 15 mL/kg (IQR, 11.8-19.2 mL/kg). Prescribing by units instead of milliliters was recorded for 493 of 1264 (39%) of transfusions. For 734 of 1302 (56%) where Hb levels were available within 2 days between pre- and posttransfusion Hb, the median transfusion increment was 2.8 g/dL (IQR, 1.4-3.9 g/dL). CONCLUSION: This study of UK pediatric RBC transfusion practice has demonstrated significant variation in pretransfusion Hb, frequent prescribing in units rather than milliliters, and a high proportion of single transfusions during admissions. Future education and research should target transfusion triggers and prescription volumes for children in all clinical areas.

The use of fresh-frozen plasma in England: high levels of inappropriate use in adults and children.

BACKGROUND: Fresh-frozen plasma (FFP) is given to patients across a range of clinical settings, frequently in association with abnormalities of standard coagulation tests. STUDY DESIGN AND METHODS: A UK-wide study of FFP transfusion practice was undertaken to characterize the current patterns of administration and to evaluate the contribution of pretransfusion coagulation tests. RESULTS: A total of 4969 FFP transfusions given to patients in 190 hospitals were analyzed, of which 93.3% were in adults and 6.7% in children or infants. FFP transfusions to adults were given most frequently in intensive-treatment or high-dependency units (32%), in operating rooms or recovery (23%), or on medical wards (22%). In adult patients 43% of all FFP transfusions were given in the absence of documented bleeding, as prophylaxis for abnormal coagulation tests or before procedures or surgery. There was wide variation in international normalized ratio (INR) or prothrombin times before FFP administration; in 30.9% of patients where the main reason for transfusion was prophylactic in the absence of bleeding the INR was 1.5 or less. Changes in standard coagulation results after FFP administration were generally very small for adults and children. CONCLUSIONS: This study raises important questions about the clinical benefit of much of current FFP usage. It highlights the pressing need for better studies to inform and evaluate quantitative data for the effect of plasma on standard coagulation tests.

Assessment of anaemia in elective pre-operative orthopaedic patients.

The transfusion of components made from human blood carries a small risk to the recipient. Pre-operative preparation, ensuring that the patient is not anaemic before surgery, is important to ensure that blood is not transfused unnecessarily. This article highlights that pre-operative anaemia is often not effectively managed in patients presenting for elective total hip replacement surgery, putting them at risk of unnecessary transfusion. A national comparative audit conducted by the authors suggests that there is a role for nurses who manage pre-operative assessment clinics to ensure that patients with anaemia are managed effectively before surgery. Nurses managing these clinics have an opportunity to decrease the need for peri-operative transfusion. The management of patients attending pre-operative assessment clinics should be reviewed to ensure that mechanisms are in place to allow the identification, investigation and treatment of anaemia.

Management of allergic rhinitis in UK primary care: baseline audit.

BACKGROUND: : Evidence suggests that the UK primary care management of people with allergic rhinitis is sub-optimal. Common deficiencies are thought to include under-diagnosis, mis-diagnosis and sub-optimal treatment. OBJECTIVES: : We sought to assess GPs' understanding and perspectives on key issues in the management of allergic rhinitis, comparing these with recommendations contained in the Consensus statement on the treatment of allergic rhinitis. METHODS: : Sampling frame of 210GPs with a self-declared interest in the management of allergic and respiratory disorders from 70GP practices in the UK. Semi-structured interviews were used to assess GPs' knowledge and views on clinical practice. Trained personnel conducted all interviews. Interviews were taped and transcribed; each transcript was scrutinised to see if GP knowledge and practice was consistent with the standards set. STANDARDS AND CRITERIA:: We used the most recent Consensus statement on the treatment of allergic rhinitis as our standard, aiming to assess quality of care in four main domains: identification of symptoms; collection of information to support a clinical diagnosis; examination and investigations performed to support the clinical diagnosis; treating and managing the condition. RESULTS: : We successfully interviewed 90% (n=188) of GPs. Only 14% (n=26) of GPs satisfied all the criteria set for Standard 1 (identification of symptoms); 23% (n=43) satisfied criteria for Standard 2 (collection of information to support a clinical diagnosis); 0% (n=0) satisfied criteria for Standard 3 (examination and investigations performed to support the clinical diagnosis); and 0.6% (n=1) satisfied criteria set for Standard 4 (adequate treatment issued). CONCLUSIONS: : This national baseline audit of GPs with a self-declared interest in allergic and respiratory disorders reveals considerable scope for improvement in GP awareness and management of allergic rhinitis.

Infection control in British nursing homes.

Infection control in British nursing homes is different from that in U.S. nursing homes in seveal ways. Most British nursing homes, for example, do not have a designated on-site infection control nurse, and several agencies are responsible for regulatory oversight. This article discusses the state of infection control in British nursing homes.