How do hospitals respond to feedback about blood transfusion practice? A multiple case study investigation

National clinical audits play key roles in improving care and driving system-wide change. However, effects of audit and feedback depend upon both reach (e.g. relevant staff receiving the feedback) and response (e.g. staff regulating their behaviour accordingly). This study aimed to investigate which hospital staff initially receive feedback and formulate a response, how feedback is disseminated within hospitals, and how responses are enacted (including barriers and enablers to enactment). Using a multiple case study approach, we purposively sampled four UK hospitals for variation in infrastructure and resources. We conducted semi-structured interviews with staff from transfusion-related roles and observed Hospital Transfusion Committee meetings. Interviews and analysis were based on the Theoretical Domains Framework of behaviour change. We coded interview transcripts into theoretical domains, then inductively identified themes within each domain to identify barriers and enablers. We also analysed data to identify which staff currently receive feedback and how dissemination is managed within the hospital. Members of the hospital’s transfusion team initially received feedback in all cases, and were primarily responsible for disseminating and responding, facilitated through the Hospital Transfusion Committee. At each hospital, key individuals involved in prescribing transfusions reported never having received feedback from a national audit. Whether audits were discussed and actions explicitly agreed in Committee meetings varied between hospitals. Key enablers of action across all cases included clear lines of responsibility and strategies to remind staff about recommendations. Barriers included difficulties disseminating to relevant staff and needing to amend feedback to make it appropriate for local use. Appropriate responses by hospital staff to feedback about blood transfusion practice depend upon supportive infrastructures and role clarity. Hospitals could benefit from support to disseminate feedback systematically, particularly to frontline staff involved in the behaviours being audited, and practical tools to support strategic decision-making (e.g. action-planning around local response to feedback)

The change in haemoglobin concentration between the first and third trimesters of pregnancy: a population study

© 2019 The Authors. Published by BMC. This is an open access article available under a Creative Commons licence. The published version can be accessed at the following link on the publisher’s website: https://doi.org/10.1186/s12884-019-2495-0Background: The physiological fall in haemoglobin concentration from the 1st to the 3rd trimester of pregnancy is often quoted as 5 g/L. However, other studies have suggested varying levels of fall between 8 and 13 g/L. We evaluated the change in haemoglobin concentration between the 1st and 3rd trimesters of pregnancy in a multi-ethnic population of pregnant women. Methods: A retrospective cohort analysis of 7054 women with singleton pregnancies, giving birth during 2013-15 in a single urban maternity unit in England. We calculated the changes in haemoglobin concentration from 1st to 3rd trimester using the first trimester haemoglobin as the reference point. The population was stratified into sub-groups to explore any differences that existed within the population. Results: In general the fall in haemoglobin concentration was in the order of 14 g/L or 11% of the first trimester value. This fall was consistent for the majority of sub-groups of the population. The fall was lower (7.7%) in the most deprived section of the population, IMD1, but it increased to 11.7% when we restricted that sub-group to pregnant women without health problems during the index pregnancy. Conversely, there was an increase in haemoglobin of 10.2% in women whose first trimester haemoglobin concentration was in the lowest 5% of the total study population. The population fall in haemoglobin was 10.2 g/L (7.8%), after excluding cases above the 95th and below the 5th centiles, and women with a medical and/or obstetric disorder during the pregnancy. Conclusion: The fall in haemoglobin during pregnancy is in the order of 14 g/L or 11% of the first trimester level. This is 2 to 3 times higher than suggested by some guidelines and higher than previously published work. The results challenge the current accepted thresholds for practice, and have broader implications for diagnosis and managment of antenatal anaemia. Tweetable abstract: Fall in haemoglobin across pregnancy is around 14 g/L (11%) and significantly higher than previously stated in the pregnant population. This poses questions over currently accepted thresholds for anaemia in pregnancy.Marian Knight is funded by a National Institute for Health Research (NIHR) Research Professorship. The funding sources had no role in the study, and the researchers were independent from the funders. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.Published versio

Iron supplementation to treat anaemia in adult critical care patients: a systematic review and meta-analysis

Anaemia affects 60-80 % of patients admitted to intensive care units (ICUs). Allogeneic red blood cell (RBC) transfusions remain the mainstay of treatment for anaemia but are associated with risks and are costly. Our objective was to assess the efficacy and safety of iron supplementation by any route, in anaemic patients in adult ICUs.Electronic databases (CENTRAL, MEDLINE, EMBASE) were searched through March 2016 for randomized controlled trials (RCT)s comparing iron by any route with placebo/no iron. Primary outcomes were red blood cell transfusions and mean haemoglobin concentration. Secondary outcomes included mortality, infection, ICU and hospital length of stay, mean difference (MD) in iron biomarkers, health-related quality of life and adverse events.Five RCTs recruiting 665 patients met the inclusion criteria; intravenous iron was tested in four of the RCTs. There was no difference in allogeneic RBC transfusion requirements (relative risk 0.87, 95 % confidence interval (CI) 0.70 to 1.07, p = 0.18, five trials) or mean number of RBC units transfused (MD -0.45, 95 % CI -1.34 to 0.43, p = 0.32, two trials) in patients receiving or not receiving iron. Similarly, there was no difference between groups in haemoglobin at short-term (up to 10 days) (MD -0.25, 95 % CI -0.79 to 0.28, p = 0.35, three trials) or mid-term follow up (last measured time point in hospital or end of trial) (MD 0.21, 95 % CI -0.13 to 0.55, p = 0.23, three trials). There was no difference in secondary outcomes of mortality, in-hospital infection, or length of stay. Risk of bias was generally low although three trials had high risk of attrition bias; only one trial had low risk of bias across all domains.Iron supplementation does not reduce RBC transfusion requirements in critically ill adults, but there is considerable heterogeneity between trials in study design, nature of interventions, and outcomes. Well-designed trials are needed to investigate the optimal iron dosing regimens and strategies to identify which patients are most likely to benefit from iron, together with patient-focused outcomes.PROSPERO International prospective register of systematic reviews CRD42015016627 . Registered 2 March 2015

Pathways of association between maternal haemoglobin and stillbirth: Path-analysis of maternity data from two hospitals in England

© 2018 The Authors. Published by BMJ Publishing Group. This is an open access article available under a Creative Commons licence. The published version can be accessed at the following link on the publisher’s website: http://dx.doi.org/10.1136/bmjopen-2017-020149© 2018 Article author(s) (or their employer(s) unless otherwise stated in the text of the article). Objective To investigate the mechanisms that link maternal haemoglobin concentration with stillbirth. Design A retrospective cohort analysis using anonymised maternity data from two hospitals in England. Setting The Royal Wolverhampton NHS Trust and Guy's and St Thomas' NHS Foundation Trust. Study population 12 636 women with singleton pregnancies ≥24 weeks of gestation giving birth in the two hospitals during 2013-2015. Method A conceptual framework of hypothesised pathways through birth weight-for-gestational age and maternal infection including potential confounders and other risk factors was developed and examined using path-analysis. Path-analysis was performed by fitting a set of regression equations using weighted least squares adjusted for mean and variance. Goodness-of-fit indices were estimated. Main outcome measures Coefficient of association (β) for relationship between each parameter, and direct, indirect and total effects via the postulated pathways. Results The path-model showed a significant adjusted indirect negative effect of maternal haemoglobin on stillbirth mediated via birth weight-for-gestational age (standardised estimate (SE)=-0.01; 95% CI=-0.01 to-0.001; P=0.028). The effect through maternal infection was not significant at P<0.05 (SE=0.001; 95% CI=-0.004 to 0.01; P=0.610). There was a residual direct negative effect of maternal haemoglobin on stillbirth (SE=-0.12; 95% CI-0.23 to-0.02; P=0.020) after accounting for the two pathways. Total indirect SE=-0.004; 95% CI-0.01 to 0.003; P=0.267; total direct and indirect SE=-0.13; 95% CI-0.23 to-0.02; P=0.016. The goodness-of-fit indices showed a good fit between the model and the data. Conclusion While some of the influence on risk of stillbirth acts through low birth weight-for-gestational age, the majority does not. Several new mechanisms have been suggested for how haemoglobin may be exerting its influence on the risk of stillbirth possibly involving genetic, epigenetic and/or alternative obstetric and nutritional pathologies, but much more research is needed.MK is funded by a National Institute for Health Research (NIHR) Research Professorship (NIHR-RP-011-032).Published versio

Learning To Be Affected: Social suffering and total pain at life’s borders.

The practice of Live Sociology in situations of pain and suffering is the author’s focus. An outline of the challenges of understanding pain is followed by a discussion of Bourdieu’s ‘social suffering’ (1999) and the palliative care philosophy of ‘total pain’. Using examples from qualitative research on disadvantaged dying migrants in the UK, attention is given to the methods that are improvised by dying people and care practitioners in attempts to bridge intersubjective divides, where the causes and routes of pain can be ontologically and temporally indeterminate and/or withdrawn. The paper contends that these latter phenomena are the incitement for the inventive bridging and performative work of care and Live Sociological methods, both of which are concerned with opposing suffering. Drawing from the ontology of total pain, I highlight the importance of (i) an engagement with a range of materials out of which attempts at intersubjective bridging can be produced, and which exceed the social, the material, and the temporally linear; and (ii) an empirical sensibility that is hospitable to the inaccessible and non-relational

Coagulation status of critically ill patients with and without liver disease assessed using a novel thrombin generation analyzer

Funding Information: NHS Blood and TransplantPeer reviewedPublisher PD

Evidence-based selection of theories for designing behaviour change interventions : using methods based on theoretical construct domains to understand clinicians' blood transfusion behaviour

Peer reviewedPostprin