Accelerated red cell transfusion for selected patients receiving blood transfusion at home

Grey, Sharran Louise (2018) Accelerated red cell transfusion for selected patients receiving blood transfusion at home. Doctoral thesis (DClinSci), Manchester Metropolitan University.

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Abstract

Background: The Community Intravenous Therapy (CIVT) service gives patients the benefit of receiving IV therapies (including blood transfusion) in their own home, avoiding hospital admission. It is important to ensure this service can be offered to as many patients as possible. If red cell transfusion could be safely performed over a shorter duration (accelerated transfusion), this could theoretically increase the capacity of the service without additional resource. Red cell transfusions are usually administered over a minimum of 90 minutes to a maximum of four hours per unit. It was proposed that one unit could be given in 60 minutes (up to a maximum of 2 units per transfusion episode) to medically selected patients who do not have heart failure or other risk factors for circulatory overload. Methods: Physiological tolerability and safety of accelerated transfusion was evaluated by clinically assessing patients for symptoms and signs of transfusion-associated circulatory overload (TACO) after standard and accelerated rate transfusions. The impact on service capacity and staff resource was evaluated by auditing home transfusion workload data to determine the number of patients who were eligible for accelerated rate transfusion and the potential impact this had on treatment delivery time. Patient and practitioner experiences of accelerated transfusion were evaluated by conducting thematic analysis on semi-structured interviews to assess the acceptability and desirability of service change. Results: When accelerated red cell transfusion was performed on medically selected patients who had been screened for risk factors for circulatory overload, accelerated transfusion appeared to be safe. None of the patients in the study (n=25) developed transfusion associated circulatory overload across 269 accelerated transfusions performed. The mean arterial pressure appeared to statistically significantly increase up to 24 hours after blood transfusion regardless of whether it was infused at a standard or accelerated rate, with the group mean remaining within the normal range (standard rate transfusion: p = 0.0441; accelerated rate average across three transfusions: p = 0.009). There was no statistically significant difference between pre and post-transfusion mean arterial pressure measurements when standard and accelerated rate transfusions were compared (average across three accelerated rate transfusions: p = 0.473), showing that accelerated transfusion itself did not cause an increase in mean arterial pressure above that of standard rate transfusion. A significant proportion of haematology patients (57%, 26/46) were medically eligible for accelerated transfusion, and 49% of total transfusion episodes (224/459) were performed as such. Performing accelerated transfusion on eligible patients could potentially save 105 nursing hours, allowing an additional 35 three hour visits or 26 four hour visits per year. Accelerated transfusion was well received by patients. Positive themes from the data included less time receiving healthcare allowing freedom and time to do other things, improvements in comfort and altruism from knowledge that other patients and the service was benefitting. CIVT practitioners were highly motivated and positive about accelerated transfusion. Themes included satisfaction in seeing positive benefits in quality of life and social aspects of patient’s lives; improved continuity of care, better work scheduling; increased service capacity, job satisfaction; better working conditions and professional autonomy in clinical decision-making. Conclusion: Accelerated red cell transfusion appears to be safe in medically selected patients. It can potentially increase service capacity through efficient use of staff resource whilst maintaining a safe and high quality service. Understanding of patient and practitioner experience suggested that changing the service to offer accelerated transfusion would be both acceptable and desirable.