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Hospital Circulars Home < Circulars 2002 Home <
Date Issued:
15 April 2002
Publication: 07/2002
Distribution: Public and Private Hospitals
Subject:
Hospital/Health Service Transfusion Committees
Purpose:
This circular details requirements for Hospital/Health Service Transfusion
Committees (HTC) to promote transfusion best practice through the enhancement
of transfusion awareness and education, facilitation of policy development,
and monitoring and review of the use of blood and blood products and adverse
incidents involving these products.
Background:
Issues surrounding the supply and demand of blood and blood products are:
- the introduction
of the donor deferral policy to address the theoretical risk of transmission
of variant Creutzfeldt-Jakob Disease.
- an increasing
demand for blood and blood products, possibly related to increasing
volume and complexity of medical and surgical procedures.
- safety aspects
of blood transfusion practice with increased attention to surveillance
of transfusion reactions and infections, and auditing of transfusion
practices.
- significant variability
in the use of blood and blood products in comparable clinical situations,
and possible inappropriate administration of blood products which may
result in wastage and increased patient risk.
- increased community
awareness of risks associated with blood transfusion.
Monitoring Utilisation
Of Blood And Blood Products
The administration
of blood and blood products is a multi-stage process where each activity
must be strictly controlled to prevent adverse effects and ensure patient
safety. At each stage it is necessary to consider issues as they relate
to:
- patient factors:
clinical indications for transfusion, verification of identity, cross
matching procedures.
- blood product
factors: reservation, identification, storage and management of used
and unused products.
- the interaction
between the patient and blood product(s): treatment protocols and monitoring
of outcomes.
Pathways for clinical
use and hospital management of blood and blood products are attached
(PDF File 137KB).
To date, blood transfusion
quality improvement strategies have focussed on haemovigilance, or the
monitoring and prevention of adverse effects:
- In the United
Kingdom, since March 1999, all National Health Service Trusts undertaking
blood transfusion activities have been required to set up transfusion
committees and participate in the 'Serious Hazards of Transfusion' program1.
- In France, the
Blood Transfusion Act 1993 (amended 1999) prescribes mandatory reporting
and follow-up of all adverse transfusion effects2,3.
- In Germany, the
Act Regulating Transfusion Practice (Transfusion Act) 1998 prescribes
the establishment of blood transfusion quality assurance systems including
transfusion commissions by all acute health care services4.
- In April 2000,
the United States Department of Health and Human Services' Blood Safety
and Availability Committee recommended the establishment and implementation
of a national blood transfusion reporting and monitoring system5.
In Australia, there
are no regulatory requirements to guide blood transfusion practice. However,
recently there has been increased attention to blood transfusion quality
activities:
- 1998/9 the Australian
Red Cross Blood Service (ARCBS) established a Haemovigilance Working
Party and presented results of a pilot study undertaken at Concord Hospital
in NSW 6.
- The National Health
and Medical Research Council (NHMRC) published Clinical Practice Guidelines
on the Use of Blood Components in October 2001. www.nhmrc.gov.au/publications/cphome.htm
- The Commonwealth
Review of the Australian Blood Banking and Plasma Product Sector was
finalised in March 2001 and recommended the establishment of a National
Blood Authority. A Blood Safety and Quality Working Group has been established
with consideration of implementing a National Haemovigilance system
a key issue.
In 1998, Dean and
Vincent7 surveyed 224 NSW hospitals to ascertain whether they have HTCs.
Of the 144 respondents, only 25 (17%) had a HTC. A recent article from
The Alfred (Melbourne) has reinforced the importance of establishing HTCs
8. As well, a study undertaken by The Australian Centre for
Effective Healthcare and Red Cross Blood Service in New South Wales demonstrated
that >25% of transfusions were inappropriate9.
Hospital/Health
Service Blood Transfusion Committees
To promote best practice
in the use of blood and blood products, Hospitals/Health Services need
robust transfusion quality improvement and risk management programs including
HTCs. This requires commitment of hospital/health service management and
clinical/laboratory staff to a transfusion infrastructure including HTCs,
blood issue and transfusion policies, a maximum blood-ordering schedule,
and a monitoring process.
Not all Hospitals/Health
Services using blood and/or blood products need to have a stand alone
Transfusion Committee. However, all Hospitals/Health Services should have
structures and processes in place that fulfil the role and function of
a Transfusion Committee, either by having a HTC or by formal participation
in a HTC. It may be appropriate for Metropolitan Health Services, Rural
Health Alliances, and groups of private hospitals, to establish one HTC
to oversee blood transfusion practice at affiliated campuses. There would
need to be at least one representative from each Hospital on the HTC.
A key responsibility
of HTCs is risk management. The primary role of an HTC is to provide an
active forum for communication between staff directly involved in clinical
and laboratory-based blood transfusion activities, to provide solutions,
feedback and education in relation to identified problems, and to ensure
that transfusion practice accords with best practice.
Terms of Reference:
1. To monitor,
review and improve hospital transfusion practices relating to appropriateness
of usage of blood and blood products, wastage, expiry and adverse events
by:
- reviewing ordering
schedules.
- conducting surveys
of usage, wastage and expiry of blood and blood products at regular
intervals, and providing forums in which to address these issues.
- implementing quality
improvement reporting systems.
- maintaining databases
that record clinical indications, blood products requested and administered,
and adverse events.
- formulating and
evaluating performance indicators that reflect current best practice.
2. To assist
in the development and refinement of blood transfusion policy by ensuring
that the current state of knowledge informs the appropriate use of blood
products.
3. To promote
transfusion best practice by:
- considering requirements
of clinical staff for the management of specific conditions
- adopting international
and locally recognised best-practice guidelines
- developing and
implementing appropriate clinical and laboratory protocols
- providing advisory
support regarding alternatives to autologous blood for elective surgical
procedures where transfusion may be indicated.
4. To promote
transfusion awareness in relation to:
- transfusion products
being a scarce resource
- the potential
for adverse effects
- laboratory practices,
techniques and problems that are encountered
- the current status
of transfusion guidelines
- the current status
of blood and blood product safety, quality, supply and demand.
5. To promote
communication and collaboration between all staff involved in blood transfusion
activities, executive management, blood and blood product suppliers such
as the ARCBS - Victoria, and local and national blood user groups.
6. To promote
the training of all staff involved in blood transfusion activities, and
the education of both staff and patients.
Meeting Frequency:
It is expected that the HTC would meet at regular (monthly/quarterly/biannually)
intervals, depending upon hospital size, demand for transfusion services,
and pre-existing systems and arrangements relating to auditing and monitoring
of blood and blood product utilisation.
Administration
and Reporting Lines: The HTC would be administered by and report through
the Pathology Department and the hospital/health service quality improvement
structure.
Membership:
Membership of the HTC would include representation from the following:
- executive management
- quality assurance/
clinical risk management
- clinical haematology/
oncology/ pathology
- surgery/ orthopaedics/
obstetrics and gynaecology
- anaesthetics/
emergency/ ICU
- nursing
- blood and blood
product suppliers (ARCBS - Victoria).
Others that may
be relevant either ongoing or from time to time are pharmacists, bioethicists
and perfusionists.
|
SHANE SOLOMON
Executive Director
Metro Health & Aged Care Services
|
DR C W BROOK
Executive Director
Rural & Regional
Health & Aged Care Services |
References:
1. Provan
D, Better blood transfusion (editorial), British Medical Journal, 1999;
318: 1435-1436.
2. Debeir J et al, The French Haemovigilance System, Vox Sanguinis,
1999; 77: 77-81
3. David B, Analysis of national incident reporting scheme organised
under the haemovigilance system (slide presentation), Agence Francaise
de Securite Sanitaire des Produits de Sante, 2000.
4. Bundesministerium fur Gesundheit, Act Regulating Transfusion
Practice (Transfusion Act) of 1 July 1998.
5. Busch M et al, Oversight and Monitoring of Blood Safety in the
United States, Vox Sanguinis, 1999; 77: 67-76.
6. Australian Red Cross Blood Service Haemovigilance Working Party,
Formulation, piloting and implementation of a proposed haemovigilance
program for Australia (slide presentation), presented to the Australasian
Society of Blood Transfusion, 2000.
7. Dean MG & Vincent NC, Infrastructure for monitoring blood
transfusion practice in New South Wales hospitals, Medical Journal of
Australia, 2000; 173; 241-243.
8. Street AM & Cole-Sinclair MF, Blood transfusion practice:
mayhem or monitoring? Medical Journal of Australia, 2000; 173; 230-231.
9. Rubin GL et al, Appropriateness of red blood cell transfusions
in major urban hospitals and effectiveness of intervention. Medical Journal
of Australia, 2001; 175
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