|Year : 2017 | Volume
| Issue : 3 | Page : 108-116
Knowledge, attitude and practice of haemovigilance among healthcare professionals in a Nigerian Tertiary Hospital
John C Aneke1, Nkiru Ezeama2, Chide E Okocha1, Adaora N Onyeyili3, Christian E Onah4, Nancy C Ibeh5, Ugochinyere J Chilaka1, Geoffrey C Egbunike1
1 Department of Haematology, Nnamdi Azikiwe University Teaching Hospital, Nigeria
2 Department of Community Health, Nnamdi Azikiwe University Teaching Hospital, Nigeria
3 Department of Nursing Services, Nnamdi Azikiwe University Teaching Hospital, Nigeria
4 Department of Chemical Pathology, Nnamdi Azikiwe University Teaching Hospital, Nigeria
5 Department of Medical Laboratory Science, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, Nnewi, Nigeria
|Date of Submission||23-May-2017|
|Date of Acceptance||08-Aug-2017|
|Date of Web Publication||9-Nov-2017|
John C Aneke
Department of Haematology, Nnamdi Azikiwe University Teaching Hospital, PMB 5025, Nnewi, Anambra State
Source of Support: None, Conflict of Interest: None
Background The institution of effective haemovigilance protocols in health facility is essential to the attainment of universal blood transfusion safety.
Objective The objective of the article was to determine the knowledge, attitude and practice of haemovigilance by healthcare professionals in a Nigerian Hospital.
Patients and methods This was a cross-sectional study; an anonymous structured questionnaire was used. In all, 270 consenting hospital staff were randomly selected from among medical doctors, nurses and medical laboratory scientists. Statistical analysis of the data was done using SPSS, version 20.0.
Results Only 28.4 and 4.1% of all respondents were aware that graft versus host disease and cryoprecipitate were types of blood transfusion reaction and blood component, respectively. Fever was the most identified blood transfusion reaction among all respondents (84.6%) while a good number were not aware of the existence of local blood transfusion service (71.0%) and hospital blood transfusion committee (53.1%); 37.1 and 56.1% study participants were not aware that blood transfusion reactions should be investigated and results communicated to all stakeholders, respectively, while 20.8 and 28.8% did not know that there is a checklist for blood transfusion safety and reactions, respectively.
Conclusion The knowledge and practice of some key elements of haemovigilance is suboptimal among our health professionals. This will need to be improved through intensive in-service training and continuous medical education.
Keywords: blood transfusion reactions, haemovigilance, blood transfusion safety, blood transfusion service, Nigeria
|How to cite this article:|
Aneke JC, Ezeama N, Okocha CE, Onyeyili AN, Onah CE, Ibeh NC, Chilaka UJ, Egbunike GC. Knowledge, attitude and practice of haemovigilance among healthcare professionals in a Nigerian Tertiary Hospital. Egypt J Haematol 2017;42:108-16
|How to cite this URL:|
Aneke JC, Ezeama N, Okocha CE, Onyeyili AN, Onah CE, Ibeh NC, Chilaka UJ, Egbunike GC. Knowledge, attitude and practice of haemovigilance among healthcare professionals in a Nigerian Tertiary Hospital. Egypt J Haematol [serial online] 2017 [cited 2018 Jul 23];42:108-16. Available from: http://www.ehj.eg.net/text.asp?2017/42/3/108/217878
| Introduction|| |
Nigeria has poor health indices, which have been attributed to massive infrastructural deficits, dearth of qualified manpower and less than optimal blood transfusion services ,. In the country, blood procurement is predominantly from family replacement and commercial (paid) blood donors, leading to a significant demand–supply gap ,,.
Blood transfusion services are coordinated by the national blood transfusion service (NBTS), which is organized into national, zonal, state/local government, armed forces, private and other nongovernmental health establishment-based services . Despite this expansive network of the NBTS, the country continues to be faced with significant deficits in the availability of blood donor units; in its previous survey, the NBTS reported that only half a million units of blood were collected from both private and public sources in 1 year . This figure which will serve only a fraction of the health needs of the teeming population of the country underscores the need for more concerted efforts towards self-sufficiency in blood transfusion services.
Haemovigilance has been defined as the surveillance of adverse reactions that occur in both donors and recipients of blood and blood components as well as the epidemiological monitoring of donors . The spectrum of adverse reactions arising from the receipt or donation of blood is quite protean. Recent data from the Food and Drug Administration in seven different reports have shown that mortality from blood transfusion ranged from 20 to 75%, majority of these were reported to be due to patient misidentification . In another report, the predominant cause of death among transfusion recipients was transfusion-related acute lung injury (30%), followed by haemolytic transfusion reactions (16%) and bacterial contamination of blood donor units (16%) . Donor-adverse reactions to blood donation are increasingly encountered; prevalence rates of 1.6 and 0.7% have previously been reported among Nigerian and Indian blood donors ,. The predominant donor-adverse reactions in these series were vasovagal reactions and anxiety ,. Addressing donor-adverse events is vital to blood transfusion safety since its occurrence has been shown to constitute a significant deterrent to repeat blood donations and subsequent attainment of self-sufficiency in blood procurement . Therefore, overall the aim of instituting haemovigilance is to improve blood transfusion safety by forestalling the occurrence of these adverse events and reactions through the provision of adequate and proactive preventive measures.
There is a dearth of information on the practice of haemovigilance in hospitals in South-East Nigeria; this study was thus designed to fill this knowledge gap by evaluating its knowledge, attitude and practice among health professionals in a tertiary hospital in Nnewi (South-East Nigeria).
| Patients and methods|| |
This is across-sectional study which was carried out at the Nnamdi Azikiwe University Teaching Hospital, a tertiary healthcare facility located in Nnewi metropolis, Anambra State, South-East Nigeria. Oral informed consent was obtained from each participant at the point of recruitment.
A total of 270 respondents, comprising 96 medical doctors, 121 nurses and 53 laboratory scientists (with bias for haematology and blood transfusion) were selected using simple random sampling technique. The instrument for data collection was a self-structured questionnaire developed by the researchers which consisted of closed-ended and open-ended questions. The questionnaire consisted of two sections: one addressed the sociodemographic characteristics of respondents, while section 2 addressed the knowledge, attitude and practice of haemovigilance as well as awareness of protocols for addressing and reporting blood transfusion reactions. The data instrument was earlier reviewed by experts for face and content validity on 10 doctors and five nurses and laboratory scientists, respectively, and final adjustments in structure and language made thereafter as appropriate. Ethical approval for the study was secured from the Nnamdi Azikiwe University Teaching Hospital Ethical Committee and oral permission was obtained from the unit heads of each professional group. Using consecutive sampling method, the respondents were selected from the various professional groups in the hospital; they were given the questionnaire, and the same was collected back on the same day or the day after, the duration for data collection was 8 weeks. The data obtained were managed using SPSS (version 20; SPSS Inc., Chicago, Illinois, USA). Descriptive analysis was used to compute data on knowledge, attitude, practice, demographic distribution and also for professional affiliation, while χ2 statistic was used to determine the relationship among the respondent’s knowledge, attitude, practice and demographic characteristics; the level of statistical significance was 0.05.
| Results|| |
[Table 1] shows the distribution of surveyed professionals stratified by subspecialty. Doctors constituted 35.4% of the study sample, nurses 44.6% and laboratory scientists 19.6%. Majority of the doctors were of the internal medicine subspecialty. Nurses assigned to the paediatric ward had the highest proportion of respondents among the nurses (27.5%), while the highest proportion of laboratory scientists were of the routine haematology bench subspecialty (49.1%).
[Table 2] summarizes the demographic characteristics of the respondents. In general, the respondents were found most commonly in the 31–40 (39.5%) years age group. Specifically, doctors were mostly in the 31–40 (55.1%) years age group. Those aged 41–50 (83.3%) years were mainly nurses. In contrast, laboratory scientists were younger with the highest proportion (39.2%) found in the 20–30 years age group (P<0.0001). Majority of the respondents were women (67.2%). The male respondents were either doctors (66.7%) or laboratory scientists (33.3%). Nurses constituted the largest proportion of female respondents (66.5%). The differences in demographic characteristics among the three professions were all statistically significant (P<0.0001).
The respondents’ perceptions about blood transfusion are shown in [Table 3]. Ninety-nine per cent agreed that blood transfusion may be useful in some conditions. Similar proportions also agreed that blood transfusion may pose some risk to recipients and donors, 99.3 and 95.2% respectively. These differences were not statistically significant. The most frequently identified risks to recipients were fever/chills (93.5%; Fisher’s exact test=1.32; P=0.43), urticarial rash (83.3%; Fisher’s exact test=6.68; P=0.012) and respiratory distress (70.2%; Fisher’s exact test=13.13; P≤0.0001) while respondents least commonly identified bleeding diathesis/Disseminated Intravascular Coagulopathy (DIC) (47.9%; Fisher’s exact test=22.77; P≤0.0001) and graft versus host disease (28.4%; Fisher’s exact test=29.99; P≤0.0001) as risks to recipients. In the same vein, when asked about the risks posed by transfusion to donors, the respondents selected hypotension (78.7%; Fisher’s exact test=45.26; P≤0.0001) and loss of consciousness (67.7%; Fisher’s exact test=2.92; P=0.23) as the most frequently identified risks to blood donors, while the least selected one was convulsion (26.8%; Fisher’s exact test=21.81; P≤0.0001).
Whole blood was the blood product most commonly identified by all the respondents and within each professional group (90.3%; Fisher’s exact test=3.84; P=0.15), followed by sedimented cells (67.5%; Fisher’s exact test=23.64; P≤0.0001). Only 12 (4.5%) respondents and 11 (4.1%) respondents selected factor precipitate and cryoprecipitate, respectively. Anaemia (91.9%) and acute blood loss (79.5%) were the most frequently selected indicators for blood products among all respondents and within each professional group while infection was the least [42 (20.0%) respondents].
Majority of all respondents were not aware of the availability of a NBTS (38.0%), a regional blood transfusion service (57.2%), a local government blood transfusion service (66.8%) or a hospital blood transfusion committee in their institution (50.6%). Compared with doctors and nurses, laboratory scientists had higher proportions of respondents who affirmed the availability of these services except for the local government service. These differences were statistically significant ([Table 4]).
[Table 5] summarizes the respondents’ experiences and practice of haemovigilance. More than half (68.3%) the respondents had either transfused or cross-matched a blood product in the 1 year prior to the study. Across the professions, 98.1% of the laboratory scientists compared with 83.9% of doctors and 46.2% of the nurses had performed this service (P<0.0001).
[Table 6] details the occurrence of blood transfusion reactions witnessed by the respondents categorized according to profession. Up to 70% of all respondents had witnessed a transfusion reaction or received report of any transfusion reaction in the last 1 year prior to the study. There was a slightly higher proportion of doctors (77.4%) compared with nurses (76.3%) who had witnessed/received a report of a transfusion while laboratory scientists had the least proportion of 53.7%. This difference was statistically significant (Fisher’s exact=10.64; P=0.005). The transfusion reactions most commonly witnessed by the respondents were chills/fever (84.6%) and urticarial rashes (51.4%) and the differences across professional groups were statistically significant. Eighty-four per cent of doctors, 94.6% of nurses and 59.1% of laboratory scientists selected chills/fever as the most commonly witnessed/reported transfusion reaction (Fisher’s exact test=30.27; P≤0.0001).
[Table 7] summarized participants’ responses to questions on documentation and notification of transfusion reactions. Two hundred and nineteen (83.0%) respondents said that transfusion reactions were documented in their health facilities; 71.6% were doctors, 94.0% were nurses, 79.2% were laboratory scientists and this difference was statistically significant (Fisher’s exact test=20.45; P≤0.0001). Transfusion reactions were most frequently documented in the patient’s case notes (74.0%). However, this was most common for doctors (85.5%) and nurses (85.8%), while laboratory scientists most frequently identified the laboratory register for documenting transfusion reactions (88.6%). The distributions of responses for most of documentation sites (namely patient’s case notes, nurses’s register, laboratory register and ward book) across professional groups were statistically significant.
One hundred and sixty-one (62.4%) respondents agreed that blood transfusion reactions are notifiable to higher authorities. The proportions were higher among laboratory scientists (69.25) and nurses (68.1%) than doctors (51.1%) and this was statistically significant (Fisher’s exact test=10.75; P=0.03). Seventy-six per cent of respondents indicated that they notified their senior colleague on duty or the physician in-charge (37.9%). Nurses were more likely to notify the physician in-charge (57.4%) than doctors (23.6%) or laboratory scientists (12.5%) (Fisher’s exact test=47.99; P≤0.0001).
Majority of the respondents (52.5%) said that the causes of the transfusion reactions were further investigated, but 37.1% were not aware of any further investigation. The differences between professional groups were statistically significant (Fisher’s exact test=14.20; P=0.006). More than half of the respondents were unaware of any stakeholder feedback on the findings of further investigations into transfusion reactions.
The availability of checklists for blood transfusion safety and handling blood transfusion reactions were affirmed by 73.5 and 62.3% of the respondents, respectively, while 20.8 and 28.8% were not aware of the availability of such checklists in their facility. The proportions of health workers who were not aware of such checklists were higher for doctors (31.6 and 34.4%) than nurses (13.0 and 23.9%) and laboratory scientists (18.5 and 29.6%), respectively ([Table 7]).
| Discussion|| |
The occupational distribution of respondents in this study showed a preponderance of nurses (N=121; 44%) ([Table 1]). This finding was emphasized in an earlier study which showed that nurses predominated in the supply and demand dynamics of healthcare workers’ recruitment ,.
The presence an ageing workforce has consistently been recognized as the bane of healthcare delivery, globally ,. In fact, healthcare planners had envisaged a remarkable demographic shift in health workforce due to the ageing of the so-called ‘baby boomer’ generation which could place drastic demands on the global healthcare industry in future . The age distribution of all participants in this study showed that they were mainly in the 31–40 year age stratum (39.5%; [Table 2]). In addition, nurses were consistently older than other professional groups (83.3 and 84.6% were aged 41–50 and >50 years, respectively; [Table 2]). This implies a significantly aged nursing staff in our facility and deserves to be recognized by policymakers and healthcare job recruiters. Our finding is in keeping with the report of Wakaba et al.  among public sector nurses in Nairobi, Kenya, which showed that the average age of the nursing workforce was 44 years. A similar study in Australia highlighted an aged nursing workforce with attrition rates significantly higher in years 2006 and above, compared with year 2001 and below (P<0.001) . The reason for these observations include recurrent healthcare employment freezes by various governments (especially in sub-Saharan Africa) and attractive postretirement income policies ,.
Evidence has shown that timely administration of safe and affordable blood transfusion could make significant differences in many clinical scenarios in healthcare delivery. Indeed from patients presenting with anaemic heart failure to those with surgical haemorrhages, blood transfusion has significantly influenced clinical outcome . Our study participants showed good knowledge of the usefulness (99.0%) and potential risks to the recipient and the donor (99.3 and 95.2%, respectively); this knowledge was adequately spread across doctors, nurses and medical laboratory scientists. The P values were greater than 0.05 ([Table 3]).
The potential for adverse reactions to occur in transfusion recipients and blood donors have been abundantly alluded to earlier and these significantly impact transfusion safety ,. Fever/chills (93.5%) and urticarial rashes (83.3%) were the predominant reactions in recipients, while hypotension (78.7%) and loss of consciousness (967.7%) were the most recognized donor reactions in this study ([Table 3]). Very low proportion of all study participants knew that graft versus host disease (28.4%) and convulsions (26.8%) were part of the spectrum of possible recipient and donor-adverse blood reactions ([Table 3]). These need to be emphasized in future continuing medical education courses in other to adequately equip healthcare providers to handle all potential transfusion-related emergencies. The poor knowledge of blood component therapy among the study participants ([Table 3]) may be related to the fact that this practice is not well established in our hospital yet. An earlier multicentre study in Nigeria showed that only 14 (45%) of hospitals had adequate transfusion services as well as facility for component preparation .
Nigeria established its national blood transfusion policy in December of 2006 and this has formed a blueprint that regulates all transfusion services in the country . The policy divided blood transfusion services in the country into the following strata: (i) the NBTS, (ii) the Zonal Blood Service Centres, (iii) State and Local Government Areas Blood Service Centres, (iv) Armed Forces Blood Service, (v) private and other nongovernmental health establishments . In this study, a larger proportion of study participants were not aware of the existence of regional (60.8%; P=0.001) and local government level (71.0%; P<0.001) blood transfusion services ([Table 4]). Similarly, 53.1% of respondents were equally unaware of the existence of a blood transfusion committee in the hospital (P<0.001; [Table 4]). The above observation is quite worrisome and calls for more extensive information dissemination on the Nigerian blood transfusion service structure and function to the healthcare workforce in the country, so as to improve knowledge and engender full utilization of the benefits of the service.The high blood cross-match frequency in this study (98.1%) was not matched by a commensurate transfusion frequency by the hospital nursing staff (46.2%) ([Table 5]). This is probably because the transfusion policy in use in the hospital mandates that blood transfusions should be given by doctors. It will be important to subsequently study blood request, cross-match and use dynamics in our hospital, with a view to finding out how these relate and further explore possible mismatch in any of the ratios.
The frequency of reportage of adverse blood transfusion reactions to the laboratory staff appears to be low in this study; 46.3% of medical laboratory scientists did not receive report of any transfusion-related adverse reactions in the last 1 year ([Table 6]). This is in spite of high occurrence rates of adverse transfusion reaction reported by doctors and nurses ([Table 6]). This is contrary to the guidelines which stipulate that blood banks must be involved in the investigation of all transfusion-related adverse reactions .
The frequency of febrile transfusion reaction was uniformly higher in all study groups, compared with other reactions ([Table 6]). This is in agreement with earlier documentation on the spectrum of adverse reactions in Nigerian transfusion recipients .
The current guidelines on blood transfusion safety mandate that all transfusion reactions be notified to relevant regulatory authorities, be appropriately investigated and findings communicated to all stakeholders . Additionally, the blood banks and wards are required to have appropriate checklist that will ensure safety of blood and blood products use . The above guidelines are enshrined in the universal protocol and blood transfusion best practices of haemovigilance. It appears that there is poor penetration of information on the above guidelines among the healthcare workforce in this study. We observed that 23.6, 37.1 and 56.1% of respondents were not aware that blood transfusion reactions are notifiable to regulatory bodies, should be further investigated and feedback given to all stakeholders, respectively ([Table 7]). This information gap was equally emphasized by the observation that up to 20.8 and 28.8% of all study participants were not aware of the availability of checklists for transfusion safety and handling transfusion reactions, respectively ([Table 7]). This calls for more effective information dissemination among the healthcare workforce to ensure that the guidelines governing haemovigilance and blood transfusion safety are universally applied by all categories of healthcare staff.
| Conclusion|| |
The presence of a robust machinery for haemovigilance in hospitals and blood banks is an important prerequisite for the attainment of blood transfusion safety. The poor knowledge base of the components of haemovigilance and the hierarchical structure of the NBTS shown by the healthcare workforce in this study deserves urgent corrective intervention through intensive in-service and continuing medical education. Additionally, efforts must be intensified to ensure that blood transfusion reactions are promptly notified to appropriate authorities and equally investigated and the outcome of such investigations communicated to all stakeholders in the healthcare workforce.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]