Improving the Transfusion Service at Nyangao Hospital

 

Improving the Transfusion Service at Nyangao Hospital

Another work related post, to tell you about what I have been doing for the last few months! 

When I first arrived here at Nyangao I could not quite believe the transfusion service provided by the laboratory.  It is such a contrast from the clean, efficient, safe and extremely tightly regulated systems in place in the UK.  Therefore I have made it my mission to improve the service and to make it safe and reliable.  It will never be as “good” as the service in more developed countries, and in practical terms it does not need to be as tightly controlled as CPA and MHRA would have you believe!  As long as there is a supply of safe blood and it can be transfused safely, that is all that matters.

However to get to this standard, there is a lot of work to be done, and so for the last few months I have been very busy!

I started with the office and paperwork, which was in quite a state and took a few weeks of organising and filing.  Next was the quality system.. SOPs, documents, recording controls results, fridge temperatures etc.  Although the previous volunteer did a fantastic job of introducing many of these things, over time they have lapsed and so I have tried to motivate staff into filling in the temperature charts, maintenance logs etc.  As for SOPs, there are good SOPs for most of the laboratory sections, but Blood Bank had just three SOPs which were outdated and did not reflect the work done, and so I have been writing many new SOPs and updating the existing ones.  I’ve also created a document control system to ensure that SOPs are regularly reviewed and updated.   Eventually I aim to translate them all into Kiswahili so that the staff can understand them easier

In addition to the back office tasks I have been doing direct training with the laboratory staff.  Only three of 13 staff are qualified laboratory technologists, the rest are assistants and so their knowledge of the theory of blood banking is quite poor even though they are working in the blood bank lab.  I have given tutorials on blood bank theory, starting from the basics of antigens and antibodies blood group systems, blood grouping techniques, blood safety and transfusion reactions.  These have been received well by the staff who are keen to learn and improve the service, and although I am not quite fluent enough in Kiswahili to do a whole presentation by the use of pictures and a few key words I have got the message across (I hope)!

Most importantly, (and the most rewarding for me), I have been doing practical training in Blood group techniques.  Currently, blood groups are performed using a fingerprick blood sample and using antisera on a ceramic tile, a method that the WHO recommend not to be used as it often gives false positive reactions thus determining an incorrect blood group.   Infact in the short time I have been here I have heard of three cases of incorrect blood groups, including one of incorrect blood type transfused to a patient (luckily the reaction was spotted and the patient suffered no further ill effects), so there is a definite need for change and the lab staff agree.

Blood groups using the tile method..... can you guess what it is yet??

Training in the new method

So I have been teaching the staff to perform tube grouping techniques.  I managed to salvage a centrifuge that was gathering dust in a store cupboard, and we are using some expired vacutainers as test tubes (which are washed and re-used ).   For the training, I explained the theory of forward and reverse grouping (The reverse group was a new concept to many people), and held practical demonstrations and practice sessions with the staff.  All the lab staff picked up the technique quickly and all agreed it was easier to determine reactions than the tile method (hooray!) .  I followed up with a competency test of five samples and a theory test of ten reaction patterns (including some tricky reverse groups… and was pleased when almost all the staff spotted these!)

Training in the new method

Compentency test... or "Blood Bank Testy"

Last week we “went live” with the new method, which also included a re-organisation of the working bench, a better recording systems for blood groups and the introduction of a “group and save” system for samples and again I have been very pleased with the results so far. 

Re-organised working bench... with wall charts for easy reference, and fridge temperature charts!

New method in action

New Method in action

My next aim is to introduce crossmatching!  Currently, for patients who need transfusions, blood units are only issued as group specific, and not crossmatched in any way.   (Gasp, I hear from the UK BMSs).   I have managed to find a waterbath in the storeroom, and have ordered some albumin and some AHG reagent!  Antibody screening as performed in more developed countries is impossible here as there is no way of getting screening cells or a panel of cells, however with an IAT crossmatch we should be able to detect incompatibility due to antibodies.

Also there is the ongoing battle with supply of blood from the BTS which shows no sign of improvement, but I do aim to increase the reliability and safety of the blood donations collected at our hospital through introducing a donor questionnaire and improving the donation collection method.   Another ongoing battle is the supply of reagents and consumables, which is a problem for every department in the hospital (I’m still waiting for delivery of products I ordered three months ago, and it’s hard to run a laboratory without tests and reagents), but again this shows no sign of improvement.

I’m also aiming to do clinical transfusion training for the doctors, medical officers and nurses introducing theory of blood safety and transfusion reactions.

However, like many things in Tanzania this will happen slowly, as although people are generally receptive to changes they need time to adapt and accept them as routine practice so that they continue after I leave.  Pole Pole as they say in Tanzania.

Overall, the work is challenging but very rewarding, seeing staff adopt the new methods.  I have been thanked by a few staff of the staff for the training, and one even asked for handouts of my presentations to read at home! I'm certainly fulfiling the VSO motto of "sharing skills".  

Well, I hope this work related post has not bored you all too much!  I will keep you updated on how it progresses.

In other news, it’s hot here.  Really hot.  And getting hotter.  HOT.  It was 37C in the lab today (not nice when you are in a labcoat), and stepping outside is like putting your face in an oven!  Everyone says it is going to rain soon, but we’ve only had one day of rain since I’ve been here.  I’m off to Mtwara at the weekend for a traditional dance festival where many Tanzanian tribes come and perform (I’ll take my camera). And next month is the Annual Volunteer’s Conference in Dodoma so I may have some pretty pictures and epic tales of adventure for you.  (although I’ve heard what goes on at AVC stays at AVC!)

I must also thank my former colleagues at PHT for being very helpful sending me information (I’ll be asking for more though as you are so good!).

 Stay in touch,

James

Blood Transfusion in Tanzania

Well what a busy few months I’ve had- hence no blog updates, sorry!  I expect you have had enough of stories of my fun times so I will explain a bit about what has been going on at work.. after all I am here to work, not just to sit on the beach.

In October I visited the Mtwara regional Blood Transfusion Centre (Damu Salama).  It is housed in an impressive purpose built building in the grounds of Mtwara’s Ligula district hospital and I was shown around by the very helpful Mr Msanja.   The centre has excellent facilities for collecting donations, the laboratory is modern, clean and well equipped with new equipment that some UK labs would be jealous of, and their policies, SOPs and systems are complete and thorough.  Only one slight problem, there is no blood!  When I visited there were only 3 units of blood in the bank fridge to serve the entire Mtwara and Lindi regions.

Recruitment and retention of donors is the major problem for the Tanzania BTS and this is due to many reasons.  Generally there is a lack of awareness and education about the necessity for blood donations, and the process involved and there is also some stigma and false information such as donating blood can give you diseases.  There is also the issue of HIV status as many people do not want to know their status and so will not donate blood as the BTS will tell them.  They do have an advertising and education campaign, but like most things in TZ, it is pole-pole (Slowly).

 The main source of donations is from college or university students and the BTS runs a mobile donation clinic during term time visiting locals institutions (I visited during school holidays hence there was no blood).  Collecting from students also helps to reduce the risk of Transfusion transmitted infections (TTI) as the HIV rate is lower amongst the younger generation.  Whilst the BTS does screen donations for TTI and has a comprehensive pre-donation exclusion questionnaire, the risk of TTI is still higher than in more developed countries due to the high prevalence in the community.

Given the erratic supply of blood, most hospitals in the region including Nyangao still rely on donations from patient’s relatives collected at the hospital.

Whole blood is still the main product used in Tanzania, although the BTS has the facilities to separate packed red cells and produce FFP and even platelets.  However, there seems to be a lack of education about blood components and their uses amongst medical and laboratory staff, as well as transportation and storage constraints which prevent the use of platelets and FFP in many hospitals.  (What use is an FFP freezer when there are regular power cuts?  And platelets stored at room temperature?  Well, RT is about 35C here!). 

Before I left I donated a unit of blood, bringing the grand total number of units in the region to 4!