Transfusion of blood and blood components is an emergency tool in the management of acute life-saving conditions. The transfusion chain comprises complex activities, from the donor's vein to the patient's vein, involving various medical and paramedical staff.1 Hence, there is always an impending threat of transfusion error. The post-graduate course in transfusion medicine has been commenced and recognized by the Medical Council of India to improve transfusion services. Clinicians' knowledge about blood products and their preparation, storage, demands, doses and administration may profoundly impact patient care and transfusion outcomes. Wide variation in transfusion practices and inappropriate transfusion may jeopardize their safety.2 The intent of establishing transfusion medicine (TM) will go in vain if the same is not executed at the bedside by our clinician colleagues.3 Inappropriate utilization of blood components adds unnecessary costs and transfusion reactions. Optimal utilization of blood is vital to minimize alloimmunization and the spread of transfusion-transmitted infections.4 Physicians and surgeons make the majority of transfusion decisions without formal training in TM. The clinician transfusion practices are based on their individual experiences and they are mostly unaware of the error in the transfusion chain.5,6 Resident doctors from clinical specialties have an active role in blood transfusion. The best transfusion is the transfusion of the right component to the right patient at the right dose at the right time. Therefore, the same is expected from the residents and interns. But they are provided with minimal education and practical exposure, as TM is not a part of the undergraduate curriculum.7,8 Only one previous study in India and some foreign literature described inadequate TM knowledge and awareness amongst resident doctors.9-11 Hence, we planned to conduct a knowledge, attitude and practice (KAP) survey among the residents and interns about safe blood transfusion to ascertain the knowledge gap and design the educational materials.

A total of 247 residents and interns participated in this study. Thirteen participants were excluded because of incomplete responses. Out of 234 participants, SR, JR and interns were 70, 96 and 68 participants, respectively. The participant characteristics, median KS and PS, along with the interquartile range, are depicted in Figure 1.

Figure 1.

Participants characteristics.

(0.09MB).

The median KS was highest among the SR and lowest among interns. The categorization of the KS showed only 16 participants (6.8%) had good knowledge (KC1). The Kruskal-Wallis test detected a significant difference in knowledge and practice scores among designation groups. The KS of JR and SR were significantly increased, as compared to interns. (Figure 2a) However, the difference in PS was significant only between JR and interns, with better scores among JRs than interns, as shown in Figure 2b. Furthermore, the post hoc analysis using the Dunn test showed a significant difference in the KS of SR and JR with Interns. However, the difference in the PS was significant only between the JR and interns and not between the SR vs. JR or the SR vs. interns. The multiple pairwise comparisons of the KS among experience categories using the Dunn test and BH correction found a significant difference only between the experience category 1 versus the rest with better KS among the JR and SR, compared to the interns in the experience category 1. [Table 1 and Figure 3a] However, no difference was noted in pairwise comparisons of PS among experience categories. (Table 1) Among knowledge categories, the PS were significantly different in KC1-KC3 and KC2-KC3 pairs. (Table 1) Moreover, the comparison of PS among three KC groups separately in all designation groups was significant with better PS in the good knowledge category in all three designations, as shown in Figure 3b. The proportionate distribution of knowledge, attitude and practice-based responses is described below under separate headings (Table 2).

Figure 2.

(a) Analysis of knowledge score among Residents and Interns. 2(b) Analysis of practice score among Residents and Interns.

(0.3MB).

Figure 3.

(a) Showing comparison of knowledge score with various designation among experience categories. (b) Showing comparison of practice score with various designation among knowledge categories.

(0.66MB).

This KAP study found a statistically significant difference in patient safety knowledge related to blood transfusion among the designated groups between residents and interns. Both senior, as well as junior residents, had better knowledge scores than interns. This knowledge level was also reflected in their practice score and the comparison of the practice score with three knowledge categories was significant among SR, JR and interns, as shown in Figure 3b. However, the PS was not significantly different between JR, SR and interns, when compared with their experience categories. In general, interns and JR were following the instruction given by their SR; thus, despite the significant variation in their KS, the PS was not different. One more reason could be the low sample size of the JR and SR in the 2, 3 and 4 experience categories and the statistical analysis may not be true in such a situation. The attenuation of knowledge, which reflects their practice score in subsequent years among the SR, compared to the JR, may be another possibility of not getting a significant difference and this reason was highlighted by previous studies.3,6,9

Residents and interns are the backbones of hospital services. They are actively involved in ordering blood components, transfusing them at the bedside and managing any untoward events due to transfusion. The lack of knowledge among them endangers patient safety. As per the SHOT report, 2020, approximately 30.7% of incorrect blood component transfusion errors occur at blood ordering.12 Most of the survey focused on the attitudes and bedside transfusion practices limited to post-analytical activities of the nurses and clinicians. We conducted this study analyzing knowledge levels among different categories of residents and interns involved in blood transfusion services and their actual bedside practices. Our single-center study highlighted an existing knowledge gap among the residents.

As detailed in the results, interns have alarmingly poor knowledge about various aspects of blood transfusion services. A total of 41.5% of the residents had poor knowledge, which is similar to some other studies.9,13 This could be explained by the fact that there are significantly fewer, only three-hour educational sessions on transfusion medicine during the entire undergraduate Bachelor of Medicine, Bachelor of Surgery (MBBS) course.8,9 As per the national blood policy, transfusion medicine must be integrated into undergraduate courses to encourage appropriate clinical use of blood and blood components.14 With increased years of experience, the JR and SR have more knowledge, but there is no statistically significant difference. Haspel RL et al. found that the third and fourth year postgraduates had statistically higher scores than those in their first year, but the difference was less than 7% [9].

The purpose of pretransfusion compatibility testing is to prevent an incompatible red blood cell transfusion, leading to a hemolytic transfusion reaction. Immediate spin (IS) cross-matching is performed to avoid an ABO-mismatch. Antihuman globulin (AHG) cross-matching detects antibodies against minor blood group antigens, thus, preventing a delayed hemolytic transfusion reaction.15 The AHG (Coomb's phase) cross-matching requires a longer time. The clinician and transfusion medicine consultant's decision to omit the AHG cross-matching depends on the urgency of the situations. The compatibility form provided along with the blood unit details the type of cross-matching performed. Thus, the resident doctors should know about adequately filling out the blood requisition, mentioning the name, registration number, bed number, ward and the urgency or elective transfusion schedule. They also should check the compatibility form before administration of the PRBC to avoid the most common transfusion error and chaotic situation. The blood component modification, such as leukoreduction, irradiation, washing to prevent transfusion reactions, i.e., FNHTR, GVHD, allergy, respectively, should be mentioned in the requisition as per the patient need.16 Here in our study, more than half of the participants were not aware of the above facts. Most residents knew about the type of component prepared in the blood bank from the whole blood unit and its storage temperature and shelf-life. Nevertheless, there was little knowledge on single-donor apheresis platelets, which are ordered frequently.

The TTI testing before the release of blood components and informed written consent before transfusion are obligatory in India. Most of the participants (69.6%) had the perception of taking consent before transfusion and approximately 63.6% had the good practice of taking vitals before, during and after transfusion. In contrast, many studies in the literature found poor documentation of informed consent and vitals and improper patient identification as the major drawbacks in bedside transfusion practice.17,18 The use of a blood warmer is indicated for exchange transfusion in neonates, massive transfusion and rapid transfusion procedures. Improper warming methods may contribute to hemolysis and bacterial infections.17,19 The bedside transfusion checks prior to blood component administration are the final crucial step in the prevention of untoward events. Transfusion practices at the bedside help to generate information to establish evidence-based transfusion guidelines.20-23 Adequate knowledge and timely recognition of possible transfusion-related complications at the bedside help to ensure the best patient outcomes. However, our study reflected poor practice among the interns, as compared to the JR and SR. These findings could be due to poor knowledge of transfusion medicine and lesser educational or training session exposure. There was a significant difference in transfusion practice between different knowledge categories. Most of them acquire the knowledge from their seniors and have not been familiarized with the actual procedure and guidelines. Our residents and interns also favored continuous induction training to enhance their knowledge and good bedside transfusion practice.

The previous literature has focused on the transfusion practice of nurses and many of the studies included very few doctors. The strength of the study is that this study reflects the knowledge level and practice pattern of blood transfusion focusing on patient safety, mainly among resident doctors and interns. Most of the residents involved in bedside transfusion practices have participated in this study. However, it is a single-center study and a questionnaire-based KAP study. Hence, the real-time auditing of bedside practices was not performed.

In conclusion, the transfusion practices depend on the knowledge of the residents. Adequate knowledge of various aspects of transfusion medicine is a necessity for a successful patient blood management system. The introduction of the transfusion medicine course in the undergraduate curriculum can aid the young budding doctors in implementing the patient blood management system early and in an effective way in their practices. Undergraduate students and interns should understand the importance of blood transfusion in patient safety and transfusion medicine needs to be integrated into their study curriculum. Induction and continuous training sessions at regular intervals of all residents and staff, emphasizing the evidence-based transfusion approach, pre-transfusion checks, bedside blood administration practices, recognition and management of transfusion reactions, will help optimize patient safety.