Blood Matters audits

The aim of the audit is to identify if health service blood administration policies and practices are consistent with the ANZSBT guidelines for the administration of blood products 3rd edition (2024).

The audit is conducted in 2 parts:

• Part A – a desk top audit of the blood administration policy, specifically the pretransfusion checking procedure.

• Part B – observation of the pretransfusion patient identification and blood component check prior to administration.

Data entry is to be completed from 1 March to 12 May 2025 via REDcap.

• Part A data entry
• Part B data entry.

A data collection tool can be printed to assist in the collection of data at the bedside prior to entry into REDcap.

Contact Blood Matters if you are experiencing problems entering data or if you have questions. Call 03 9694 0102 or email bloodmatters@redcrossblood.org.au.

• The Blood Matters audit for 2024 is the indications for the use of O RhD negative red cells.
• The demand for group O RhD negative red blood cells (RBC) remains higher than the proportion of the population who is O RhD negative.
• Australian Red Cross Lifeblood provide guidance on appropriate use of group O RhD negative red cells at Use of group O RhD negative red cells | Lifeblood.
• The audit tool aims to document the use of O RhD negative red blood cells and compare the patient characteristics against the Lifeblood guidelines.
• Data entry will be open from 1 May to 14 June 2024.
• Both tabs "Policy" and "Usage" of the Excel data collection spreadsheet are to be completed.
• Completed data is to be returned by 14 June 2024 via email to bloodmatters@redcrossblood.org.au

The 2023 Blood Matters audit is the appropriate use of fresh frozen plasma (FFP), in accordance with the National Blood Authority Patient Blood Management Guidelines and Australian Red Cross Lifeblood (Lifeblood) - Use of fresh frozen plasma (FFP) - Lifeblood.

The audit has been developed in conjunction with Lifeblood, the National Blood Transfusion Committee and Blood Matters, to gain an understanding of FFP use in adult patients across health services and assess if use is in accordance with current guidelines.

• The audit will be open from 1 April to 30 June 2023.
• Audit instructions and definitions:

• FFP data collection tool:

• Data entry is electronic using Lifeblood Audit tool
• Please complete the audit and email the data via Blood Matters as outlined in the instructions by 1 July 2023.

The audit determines if blood transfusion consent policy and practice has changed. The results will be compared to those of a similar audit conducted in 2012.

It consists of two parts:

• Part A is a blood transfusion consent policy review
• Part B is an audit of blood transfusion consent practice (a retrospective medical record audit of up to 30 patients who have received a blood component transfusion).

The audit was open from 27 June to 12 August 2022.

Part A: Data entry
Part B: Data entry

The documents below can assist with data collection and submission:

Audit instructions and definitions

Consent audit questions

Part B data collection tool

For best data entry experience, it is recommended to use Chrome. If you only have Microsoft Edge or Explorer, ensure you have the web browser screen maximised to full screen.

The survey will be open from 2 August - 24 September 2021

Limited information is available about the implementation and use of electronic medical records (EMR) with regard to blood management and transfusion practice. This survey will help develop an understanding of current design and implementation of EMRs specific to blood management and transfusion practice.

The survey is designed to identify, the number of health services with an electronic medical record (EMR) and the level of staff participation in the design, development and implementation of the EMR, as well as the clinical quality and safety achieved by using an EMR.

The survey is designed to be completed by different staff in varying roles within the health service. The staff member may or may not have been directly involved in the design and implementation.

This audit has been designed to assess the compliance of practice to the PBM guidelines: Module 2 related to the assessment and management of reversible anaemia prior to elective surgery, and blood conservation strategies used intraoperatively to reduce postoperative anaemia.

To assist with data collection and submission, please see attached documents:

• Audit instructions and definitions

• Data collection tool

For best data entry experience, it is recommended to use Chrome. If you only have Explorer, ensure you have the web browser in Maximise (full screen) rather than “restored down”.

This survey has been designed to determine what processes are in place within health services to assess anaemia in the perioperative patient undergoing elective procedures in which substantial blood loss is anticipated.

The survey requires an upload of your preoperative assessment template, if applicable. It is suggested you have the file ready in a PDF, doc or docx format before commencing data entry.

For every 100 mL of blood withdrawn for sampling, there is a decrease of 7 g/L in haemoglobin. A reduction in iatrogenic blood loss reduces the risk of anaemia and potentially the need for blood transfusion (NBA 2018). The use of micro-sampling has been shown to significantly reduce the volume of blood loss and has been associated with a significant reduction in blood transfusion (Tinmouth 2008). Implementing strategies to reduce iatrogenic blood loss in an organisation requires strategic planning, communication and implementation with relevant stakeholders such as medical staff, laboratory scientist and nursing staff.

In 2017, Blood Matters undertook a snapshot audit of health service policies and practises that could minimise iatrogenic anaemia associated with blood sampling. This audit builds on the 2017 audit to identify changes in policy and practice, and to assess total blood volume taken from patients for samples (testing & discard).

This audit comprises of two parts:

Part A: Desktop audit of policy and procedures - Audit questions

Part B: Bedside prospective audit of practice – of all patients in one selected clinical area for one week (7 days)

Bedside data collection tool

Excel data entry

Further instructions for this audit can be downloaded here.

This audit is accredited for a total of 40 QI points in the RACGP QI&CPD 2017-2019 triennium. In order to qualify for points, GPs will be required to complete Parts 1 and 2 of the audit and the Evaluation and QI activity.

This audit is complete.

The administration of prophylactic RhD Ig to pregnant RhD negative women results in a significant reduction in the incidence of Rh isoimmunisation, leading to a reduction in the risk of haemolytic disease of the newborn, a potentially fatal consequence.

Since January 2015, RhD Ig administration errors have been reportable to Blood Matters serious transfusion incident reporting system (STIR). Common error themes include:

• omission of prophylactic RhD Ig doses; increasing risk for future pregnancies
• administration of RhD Ig inappropriately; exposing women to an unnecessary blood product.

This audit aims to review the policies, procedures, and practices to assess compliance with the current "Guidelines for the use of RhD immunoglobulin in obstetrics in Australia".

The supply of group O RhD negative red blood cells (RBC) units to Australian health services is an ongoing challenge.

Approximately 9 per cent of the Australian population is group O RhD negative, while the demand for O RhD negative units by health services is 15 per cent of total RBC issues. This is expected to a certain degree, due to it being a 'universal' blood group given justifiably to some non-Group O RhD negative recipients, for example in emergencies before the patient's blood group is known. However, it must be acknowledged that group O RhD negative blood is a limited resource and must be used wisely.

The Australian Red Cross Lifeblood Guidelines for the Use of Group O RhD negative red blood cells provide recommendations for the use of Group O RhD negative red blood cells in order to conserve stocks and ensure availability for those patients for whom there is no alternative.

The aim of this audit is to determine how Blood Matters can support health services to meet these guidelines, by better understanding the current pattern of use for group O RhD negative blood, and determining potential recommendations to conserve for O RhD negative inventory.

Currently in Victoria there are no data on practices that are in place to reduce iatrogenic blood loss potentially resulting in anaemia (that is, the anaemia that results from blood loss due to repeated blood sampling to obtain specimens for laboratory testing, also known as hospital-acquired anaemia).

The aim of this audit was to determine how Blood Matters can support health services to reduce this type of blood loss by better understanding what practices are currently in place and what barriers are in place, if any.

• 2017 snapshot audit: Minimal volume blood sampling to prevent iatrogenic anaemia

Snapshot audit of minimal volume blood sampling to prevent iatrogenic anaemia 2017

The aim of this audit was to provide information to improve practice related to the assessment and management of reversible anaemia prior to surgery, and improve outcomes for patients undergoing elective surgical procedures.

Clinical audit of preoperative anaemia assessment and management in elective surgical procedures 2015

• Part A: Gap analysis survey (2015)
• Part B: Audit of current preoperative anaemia management practice (2015)

The aim of this audit was to improve the quality of care provided to adult patients (greater than or equal to16 years of age) by ensuring the appropriate use of elective red blood cell (RBC) transfusion and patient blood management practices.

• Clinical audit of elective red blood cell use in medical, surgical and obstetric adult patients (2014)

The aim of this audit was to improve the quality of care provided to patients by ensuring blood and blood product transfusion acute reaction management policies are available, appropriate, understood and practiced within hospitals.

• Introduction and definitions: ATR management and knowledge audit (2013)
• Policy and procedure for blood and blood product acute transfusion reactions
• Procedural management of acute transfusion reactions
• Survey of clinical staff awareness of acute transfusion reaction (2013)
• Audit of acute transfusion reaction management and knowledge 2013 report.