University of Pittsburgh, Pennsylvania, United States
Background/Case Studies: Blood is an essential medicine, but in many rural settings across the world, the closest stocked blood bank is hours or days away effectively rendering them without reliable access to screened blood for transfusion. In the military, providers have mobilized donors for just-in-time transfusion strategies but few guidelines exist to standardize this process in civilian, low-resource settings. This study aimed to develop a context-specific protocol for emergency blood transfusion at a low-resource district hospital in rural Kenya, when screened blood is unavailable.
Study
Design/Methods: We conducted ten semi-structured interviews with medical and clinical officers, nurses, blood bank staff and hospital administrators inquiring about blood availability and measures undertaken when stored blood was not available for blood transfusion. Interview transcripts were analyzed by four coding teams, using a hybrid inductive-deductive approach as informed by literature review. Emerging themes were validated through a member-checking session with study participants and key stakeholders. We additionally conducted two focus group sessions, where groups were presented with two patient scenarios where blood was urgently needed but stored blood was unavailable. Groups were asked to outline the steps they would take to procure safe blood for transfusion in this context.
Results/Findings: Screened blood was not always available when needed and emergency transfusion measures were required to treat patients at impending risk of death without transfusion. Participants noted that implementation of emergency transfusion processes were uneven and that protocols were needed to optimize safety, efficiency, and risk-sharing of an emergency transfusion process. Such a protocol would need to address activation criteria, the process of recruitment of volunteer donors for fresh whole blood collection, the use of quality rapid diagnostic testing or other methods for transfusion transmitted infection (TTI) screening, the informed consent process for patients and family, and subsequent haemovigilance plans. When considering the preferred transfusion donor in this setting, a risk stratification discussion is warranted to weigh risk of TTI against emergent blood need. Participants recommended a hospital-based, multidisciplinary quality review process after each emergency transfusion activation to continually improve the process. Conclusions: Screened blood is frequently unavailable in much of the world to treat emergent conditions such as hemorrhagic shock and severe anemia. Emergency transfusion measures are essential to save life and prevent poor patient outcomes; in such situations the risks must be weighed against benefits. Context-appropriate protocols are necessary to optimize the safety, efficiency, and risk-sharing of emergency transfusion processes in civilian, low-resource settings experiencing chronic unavailability of blood.
Importance of research: Millions die of hemorrhage from trauma each year in settings without access to sufficient blood for transfusion. The "Walking Blood Bank (WBB)" is a military process for emergent blood transfusion in austere settings without a blood bank. However, little is known about WBBs in the civilian context, and there are questions about the best practices for employment. This work highlights the use of a CWBB in a rural Kenyan district hospital and emphasizes the need for formalization of this process.
