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 located in the Clinical Care Fresh Blood Component Transfusion (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 published Clinical Practice Guidelines on the Use of Blood Components in October 2001.
- 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
- blood and blood product suppliers (ARCBS - Victoria).
Others that may be relevant either ongoing or from time to time are pharmacists, bioethicists and perfusionists.
Metro Health & Aged Care Services
DR C W BROOK
Rural & Regional Health & Aged Care Services
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