Transfusion Committee Research Articles

Antibodies to low-incidence antigens

Low-incidence antigens can be defined as those which are known to occur in less than 1% of individuals in most populations. The red cells of almost all blood recipients or prenatal patients therefore lack these rare antigens meaning a chance exposure to blood which does carry a lowincidence antigen almost always results in potential alloimmunization. However, since the antigens are so rare, the chance of exposure is very low. Incompatibility because of an antibody to a low-incidence antigen therefore does not happen very often, but when it does, can cause the same clinical problems, transfusion reactions, hemolytic disease of the fetus and newborn (HDFN), as antibodies to more common specificities. Table 1 lists the low-incidence antigens currently recognized by the International Society of Blood Transfusion Committee on Terminology for Red Cell Surface Antigens. Most have been shown by biochemical and/or molecular methods to be rare variations in established blood group systems as shown. The antigens listed in the 700 series are recognized as distinct low-incidence antigens but there is no biochemical or genetic data that proves they belong to any of the blood group systems. Molecular studies have shown that most of the antigens are the result of a single nucleotide mutation in the gene which codes for a blood group protein, which in turn leads to a change of only one amino acid in the protein. In some cases the antigenic basis is more difficult to determine, particularly in the Rh, MNS and Gerbich blood group systems, where hybrid genes may be involved. For further information on the molecular basis of antigens the interested reader should consult a comprehensive textbook [1–3] Low-incidence antigens are categorized by their low frequency in most populations. Usually this means they are found to be rare or absent in all populations studied but in some cases the frequency can be much higher in some races or ethnic groups. One of the most striking examples of this is the Di antigen. It is rare on red blood cells from Caucasians and Africans but occurs in approxi-

Naming blood groups and the genes that control them

The International Society of Blood Transfusion Committee on Terminology for Red Cell Surface Antigens devised and now maintains a genetically based terminology and classification for blood groups. The committee currently recognises 308 antigens, 270 of which belong to one of 30 blood group systems. The widespread application of molecular genetical methods for predicting blood group phenotypes from genotypes has made the creation of a logical terminology for blood group genes (alleles) crucial. A small team currently working on a gene terminology suitable for routine application in transfusion medicine is planning to produce a draft early in 2009.

Enhanced detection of blood bank sample collection errors with a centralized patient database

Pittsburgh's Centralized Transfusion Service (CTS) provides transfusion support to 16 hospitals and features an electronic database that contains patient transfusion and serologic histories. This database can be accessed from any hospital in the system. A major cause of ABO-incompatible transfusions is the "wrong blood in tube" (WBIT) phenomenon, that is, the sample is not from the recipient identified on the label. We hypothesized that having access to patient historical ABO types from anywhere in the CTS system can identify WBIT errors and prevent mistransfusions. The transfusion committee records of the 16 CTS hospitals from March 2005 to September 2007 were reviewed for major collection errors, that is, the current ABO type differed from the historical type in the database. The patient's historical ABO type, the discrepant type, and the hospital(s) where these samples were collected were recorded. In 6 of 16 major collection errors for which complete information was available, the current and historical ABO types were obtained from different hospitals within the CTS system. In 3 cases, selection of ABO type-specific blood based on the current sample would have led to an ABO-compatible transfusion (e.g., correct type A, current type O). In the other 3 cases, an ABO-incompatible transfusion would have resulted (e.g., correct type O, current type A). Access to a centralized patient database detected 38 percent more ABO typing errors and prevented six mistransfusions, which would not have been prevented at a single institution. Centralization of patient transfusion data should be encouraged.

A tabletop exercise to assess a hospital emergency blood management contingency plan in a simulated acute blood shortage

The objective was to assess both our local plan and the assumptions made in the national guidelines on how laboratories should prepare for an acute shortage of red cells. The Chief Medical Officer's National Blood Transfusion Committee for England and North Wales has issued guidance on how hospitals should prepare contingency plans to deal with a shortage of red cells for transfusion. This study has therefore assessed the practicalities of these proposals together with assessing how well local policies would deal with this situation. A tabletop exercise was carried out in which all requests over a 21-day period were assessed. The restrictions as suggested by the national blood transfusion committee were applied and the impact on the blood stocks during an acute blood shortage was assessed. The results show that application of the national guidelines on the restriction of the use of red cells during an acute blood shortage resulted in all transfusion requests for red cells being met. We also appear to have shown that the assumptions made by the national transfusion team are realistic. Carrying out a tabletop exercise is a useful method to assess local procedures for dealing with an acute reduction in the supply of red cells.

Changes in practice and organisation surrounding blood transfusion in NHS trusts in England 1995–2005

Background:Between 1996 and 2005 in the UK, the Serious Hazards of Transfusion (SHOT) scheme has reported 105 deaths and 296 patients developing major morbidity due to transfusion. Accurate patient identification...

Clinical Governance and Transfusion

Governance is the exercise of power consequent on the assumptions of responsibility. Clinical Governance is the process and framework through which Health Services achieve accountability for continuously improving the quality of their services and safeguard high standards of care by creating an environment in which excellence in clinical care can flourish in a patient centred environment. In terms of clinical governance as it pertains to safe and appropriate use of blood and blood products it is being rolled out in Victoria at two levels. At a hospital level, as part of clinical governance there is a requirement for organisations to have an active transfusion committee to provide oversight on the usage, appropriateness and adverse events related to blood and blood products. This committee should report through to the hospitals clinical risk/quality committee. Transfusion nurses have been funded to amongst other things resource this committee. At a state level Victoria has established a Better Safer Transfusion (BeST) practice program supported by a BeST advisory committee. The work will support hospital transfusion committees and advise on future work in the area.

Recidivism in Transfusion Quality Improvement: Support for the Role of Transfusion Nurses

Aim To evaluate longer term outcomes of a quality improvement strategy in transfusion. Method A Clinical Health Improvement Program (CHIP) quality improvement project was conducted in a 290 bed acute general hospital, to decrease the rate of transfusions with high pre-transfusion haemoglobins. Strategies for improvement included: formation of a Transfusion Committee; development of transfusion pathway; implementation of a Maximum Blood Order Schedule; educational strategies targeting clinical staff at all levels; promulgation of the NHRMC Clinical Practice Guidelines on the Use of Blood Components; and feedback to clinicians. The CHIP project was superseded by the ACT Haemovigilance Project, and an ACT wide concurrent transfusion audit was undertaken. There was no formal feedback on clinician performance during, or for 6 months prior to, the Haemovigilance audit. Red cell transfusion was assessed for compliance with the NHMRC Guidelines and compared with CHIP results. Result The CHIP project demonstrated successful implementation of the selected strategies, leading to a reduction in transfusions with pre-transfusion haemoglobins greater than 90 g/L. Follow up auditing commencing six months later demonstrated a progressive, and statistically significant, increase in inappropriate transfusions over the following six months. Conclusion Although improvement in transfusion practice was demonstrated with a multi-factorial approach to quality improvement, the improvement was not sustained in the medium term. Our results indicate the need for organisational commitment to long term quality improvement strategies in transfusion, and support the development of Transfusion Officers or Nurses to improve bedside clinical practice.

A Prospective Audit Program to Determine Blood Component Transfusion Appropriateness at a Large University Hospital: A 5-Year Experience

Predetermined transfusion guidelines, pretransfusion approval, and transfusion audits are useful tools in the education of those ordering blood components, potentially resulting in the reduction of inappropriate use of blood components. Our institution requires mandatory prospective audits for a proportion (10%) of packed red blood cell unit orders and all orders for fresh frozen plasma, platelets, and cryoprecipitate. Cases where the blood bank physician recommends against a transfusion and the ordering physician concurs, or when blood components are released against blood bank's recommendation, are referred to the transfusion committee. Transfusion committee members review the medical records to determine the circumstances surrounding the transfusion request as well as patient outcomes relating to their receiving or not receiving the transfusion. We analyzed 220 transfusion episodes brought before the transfusion committee from 2001 to 2005. The most requested blood component denied or changed was fresh frozen plasma. With only a few exceptions, the denial or change of blood components had no adverse effect on the patient. Nonetheless, these interventions were deemed appropriate by the transfusion committee. In most cases, blood components released based on the demand of the ordering physician, despite the advice of the blood bank physician, were deemed as inappropriate transfusions. This study therefore suggests that prospective audits of blood component orders can help reduce inappropriate transfusions and can be a valuable educational tool for the ordering physicians as well as for residents in training.

Teaching transfusion in UK medical schools: a survey by the National Blood Transfusion Committee

Teaching transfusion in UK medical schools: a survey by the National Blood Transfusion Committee

Hospital transfusion committee

Transfusion is a complex science with evidence‐based guidelines that need improvement and constant research. A lot of physicians can prescribe transfusion products and some physicians will not be frequent users.Because of these uncertainties and because of transfusion past history, a central forum is needed in the hospital to set forward discussions, consensus and to create links between the transfusion centre, the blood bank and the clinical staff.Description of the membership, mandate, and responsibilities are described and commented.

Guidelines for policies on alternatives to allogeneic blood transfusion. 1. Predeposit autologous blood donation and transfusion

SUMMARY This is the first of a series of newly prepared guidelines on alternatives to allogeneic blood transfusion. Further guidelines including the use of cell salvage and of pharmacological approaches to blood conservation will be published in due course. Decades of clinical application demonstrate that it is quite feasible to auto-transfuse blood that has been collected and stored for an interval of up to 6 weeks in standard storage media, and that up to three standard collection volumes (approximately 500 mL) can be collected from normal-sized adults (over 50 kg) during that interval. Furthermore, systems have been developed to reduce risk to participants and to boost haemoglobin (Hb) production during and after the procedure. However, such pre-operative autologous donations (PAD) are not without risk, are of low clinical efficacy and are poorly cost-effective for the vast majority of patients in the UK. These guidelines update those previously issued by the BCSH and do not recommend the practice and use of PAD unless the clinical circumstances are exceptional. They also give an update on the legal regulatory circumstances pertaining to the UK following recent European Directives.

Recombinant factor VIIa: safety and efficacy

Recombinant factor VIIa has been increasingly used to provide hemostasis in nonapproved indications. This trend has resulted in concerns about safety, efficacy and costs. Recombinant factor VIIa seems to have hemostatic effects in posttrauma and perisurgery excessive bleeding, although further studies are required. Recombinant factor VIIa may be used to reverse the effect of warfarin or other vitamin K-antagonist therapy following vitamin K administration. Some beneficial effects have also been suggested in a limited number of patients with liver disease and hemorrhagic stroke. Recombinant factor VIIa should be used with caution in cases with known hypercoagulability, excessive bleeding in the setting of disseminated intravascular coagulation or other states of generalized activation of the hemostatic system. In most of the nonapproved cases, a 4.8-mg vial administered to an adult patient weighing 50-100 kg to achieve a 50-100 microg/kg dose is recommended. While consensus recommendations on the use of recombinant factor VIIa in nonapproved settings have been developed, more studies are needed to define dose and timing in these diverse patient populations. For now, decisions about off-label use of recombinant factor VIIa remain at the physician's discretion, assisted by hospital pharmacotherapeutic or transfusion committees.

Legal and Ethical Considerations in the Transfusion of Infected or Untested Autologous Blood

Autologous blood transfusion grew in popularity in response to the recognition of transfusion-transmitted HIV and a lack of effective screening. Laboratory screening and donor deferrals have decreased the need for autologous transfusion. The issue of banking blood that has not been tested or has been tested and found positive for serious infectious diseases raises ethical and legal issues that must be addressed by transfusion services, transfusion committees, physicians, and administrators. This article provides a summary of pertinent federal and state laws regarding autologous blood transfusion and a framework to assess the ethical implications of various strategies.

The different tools in quality management

Background Since the mid 1980s hospital‐based blood banks, all parts of the public healthcare system in Denmark, have been inspected regularly by the Danish Medical Agency, a division of the National Health Authority. Blood components for transfusion were regarded as medicaments and should therefore fulfill some pharmaceutical requirements.Evolution From the time of ‘the surgical approach’ to blood transfusion, i.e. drawing whole blood and using it as such for treatment, a process of refinements have taken place within all aspects of transfusion medicine in the blood bank setting in Europe. In Denmark, blood banks are separate hospital departments covering all aspects of the transfusion activity with specially trained medical doctors (separate medical specialty), donor selection, production of blood components, testing for selected infectious markers, blood grouping and compatibility testing, investigation of adverse reactions/complications to transfusions and constructive dialogues with representative users of the services from the blood bank and blood bank personnel in the Hospital Transfusion Committees to secure appropriate use (clinical doctors and nurses) and relevant accessibility of blood components and laboratory testing (the blood bank output). At present, the level of implementation of quality management in transfusion centres in Denmark is at the accreditation level with reference to the EU Blood Directives the Danish Blood Law and orders in many aspects equivalent to the ISO 15189 standard.The tools of quality management The overall demand is to go ‘one‐way’. This can be achieved by having a quality manual (overall objectives), master description of procedures (master plans), standard operating procedures (SOPs) and a well‐prepared feedback system using quality control measurements of blood components and laboratory tests, through reports of variations (deviation from intended result or SOP), complaints, systematic internal audits, updated educational records of all personnel involved in the activities of the blood bank (nurses, secretaries, laboratory technologists, medical doctors, others), assurance that all equipment and utensils are only taken in use after proper validation/qualification and that a maintenance plan or acceptance test are in action. Furthermore, a relevant number of external proficiency testings are carried out to secure the analytical quality of all key parameters in the laboratory. Every second year the blood bank will be inspected by the Danish Medical Agency and identified issues must be addressed in a written response within a time limit. The issues pointed out can deal with the building, personnel, apparatuses, equipment, utensils, processing, data management, corrective actions and other issues relevant for the fulfillment of the requirements of a European blood bank setting in 2007. In addition, the area of transfusion is surveyed at a national level (blood components/blood donor accidents/clinical practice of transfusion treatments).Conclusions The benefits of quality management surpass the costs by creating high‐quality products and services for the benefit of patients, blood donors, hospitals and personnel in the blood bank.

Tuscan study on the appropriateness of fresh-frozen plasma transfusion (TuSAPlaT).

The considerable increase in the consumption of fresh-frozen plasma (FFP) recorded in 2002 in the Region of Tuscany made it necessary to check the appropriateness of the use of this blood component in all transfusion facilities in the Tuscan network. From July 1, 2003 to December 31, 2005, the Regional Blood Transfusion Coordinating Centre carried out an audit on the clinical use of FFP in the 40 structures included in the Tuscan transfusion network. The study had two complementary parts: a review of guidelines on the use of FFP and the involvement of Hospital Transfusion Committees in evaluating the outcome of the audit and in the consequent local policy decisions and in educating clinicians. The data from all 40 of the regional transfusion structures were analysed. The audit, which was initially retrospective, gradually became prospective. The percentage clinical use of FFP decreased, compared to 2002, in each of the 3 years of the study: a) 2003: - 8.92%; b) 2004: - 2.11%; c) 2005: -1.97%. The inappropriate requests for plasma decreased from 27% to 22.7% of the total. It was possible to classify the inappropriate requests for plasma on the basis of homogeneous, regionally defined criteria. The most frequent inappropriate indication (60.7% of the total) was the use of plasma in the case of haemorrhage in patients with a normal PT and/or PTT or unavailable results. Each hospital revised its own guidelines between 2004 and 2005 and the Hospital Transfusion Committees set up appropriate educational and behavioural interventions. The capacity of transfusion facilities to make data on the use of blood components available systematically and continuously is an essential feature of clinical governance; systematic clinical auditing increases the level of appropriate behaviours in the transfusion sector, contemporaneously contributing to self-sufficiency in transfusion products, and may direct research towards those clinical settings at greatest risk of inappropriate use of transfusion therapy with FFP.

International Society of Blood Transfusion Committee on Terminology for Red Cell Surface Antigens: Cape Town report

International Society of Blood Transfusion Committee on Terminology for Red Cell Surface Antigens: Cape Town report

Evaluation of a teaching pack designed for nursing students to acquire the essential knowledge for competent practice in blood transfusion administration

This article describes the evaluation of a teaching pack designed for nursing students to acquire the knowledge required for safe administration of blood transfusions. The Serious Hazards of Transfusion (SHOT) Committee is a confidential reporting body, which gathers data from the United Kingdom and reports the serious sequelae of blood transfusion. The SHOT reports have repeatedly identified that errors in blood transfusions are wholly avoidable. Nurses, as the health care professionals ultimately responsible for the bedside check, have the final opportunity to prevent a mis-transfusion [Nursing and Midwifery Council, 2004a. The NMC code of professional conduct: standards for conduct, performance and ethics. NMC, London; Serious Hazards of Transfusion, 2002. SHOT Annual Report 2001-2002. SHOT Scheme, Manchester]. The educational strategies implemented will be explained and evidence that applying structured learning programmes in the undergraduate nursing curriculum can improve students' knowledge presented. A structured questionnaire was employed to assess students' knowledge of the process for transfusing blood components pre- and post-teaching and evaluate the effectiveness of the teaching pack. The results will be presented and discussed.

Serious hazards of transfusion: a decade of hemovigilance in the UK.

The Serious Hazards of Transfusion (SHOT) scheme is a UK-wide, independent, professionally led hemovigilance system focused on learning from adverse events. SHOT was established in 1996 as a confidential reporting system for significant transfusion-related events, building an evidence base to support blood safety policy decisions, clinical guidelines, clinician education, and improvements in transfusion practice. Recommendations are formulated by an independent steering group drawn from medical royal colleges and professional bodies. Ten years after its inception, SHOT has analyzed 2630 transfusion safety events, published 8 annual reports with recommendations, and presented data nationally and internationally. These recommendations have underpinned key initiatives, in particular the UK Department of Health "Better Blood Transfusion" strategy. SHOT has encouraged open reporting of adverse events and "near-misses" in a supportive, learning culture, vigilance in hospital transfusion practice, and evaluation of information technology to support this process. The importance of education and training has been emphasized. Detailed analysis of events has identified weaknesses in the transfusion chain. A collaborative initiative between SHOT, the Chief Medical Officer for England's National Blood Transfusion Committee, and the National Patient Safety Agency aims to reduce ABO-incompatible transfusions by improving bedside practice. Cumulative SHOT data have documented the decline in transfusion-related graft vs host disease after implementation of leucodepletion and have highlighted transfusion-related acute lung injury and bacterial contamination of platelets as important causes of death and morbidity. The UK blood services have developed strategies to reduce these risks. Future SHOT data will evaluate the success of these and other blood safety improvements.

P25 Overnight Transfusions Expose Patients to Unnecessary Risk and Seldom Facilitate Next Day Discharge

Aims and Objectives The Serious Hazards of Transfusion (SHOT) Committee has highlighted the increased risk of overnight transfusion in its annual reports. The risk arises from the paucity of staff (compared to daytime) to monitor patients and manage complications. The darkness on the ward can also obscure early clinical detection of clinical problems. Additionally, patients receiving the transfusion are prevented from sleeping and others in their bay are disturbed throughout the night. The commonest reason offered for overnight transfusion was to enable patient discharge the following day. After seeking approval from the Hospital Transfusion Committee, we performed two ‘snapshot’ studies to investigate the proportion of all transfusions given overnight. Having established that this was a significant number, fifty sequential overnight transfusions were further examined to see whether they were clinically appropriate and whether the recipients were actually discharged the following day. Evidence base/standards. ‘Overnight’ was defined as between 8 pm and 6 am as these are the times between which nursing and medical staffing levels are at their lowest. Transfusions were judged to be appropriate if they were for patients who:• were actively bleeding• admitted symptomatically anaemic during the night• peri‐operativeMethodology Each morning the Transfusion Practitioner examined the laboratory copies of the transfusion compatibility reports to identify the overnight transfusions. The medical notes for the transfused patients were then consulted for documented evidence as to the appropriateness of each episode according to the criteria above.Results From the two snapshot studies (each of a month), it transpired that, 43% of units of red cells were given to 40% of the patients and 26% of the units to 42% of the patients. This established that the project would be worthwhile. Of the 50 transfusion episodes, there was documentation in the notes of 30 patients (60%) of the need for transfusion. Seven patients (14%) were noted to be symptomatically anaemic and 3 (6%) bleeding. In total 20% of the overnight transfusions were appropriate by our criteria. Next day discharge occurred in five of the 50 patients. Further work was done to investigate possible delays in commencing the transfusions.Recommendations and actions The main action taken was to educate staff that inappropriate overnight transfusions compromised their patients’ care and rarely allowed earlier discharge. This was done through re‐enforcement at induction lectures, the Blood Transfusion Policy and a sign on the blood fridge.

P44 Review of Hospital Transfusion Committee Membership and Attendance in the West Midlands

Introduction Hospital transfusion committees (HTC) are now well established. Over the last 5 years blood usage has declined by 15%. It is now well established that surgical patients utilise less than 50% of red cells despite initiatives to reduce the number of patients waiting for surgery. It was perceived that physicians were under represented on HTCs. As physicians are responsible for an increasing proportion of blood used we decided to quantify attendance at HTCs.Methods Minutes from 18 Trusts’ HTC meetings held in 2005 and 2006 within the West Midlands were reviewed and job title was recorded for members of and those attending their HTC. Sufficient data was available from 14 HTCs to review their last three meetings. The most common posts/departments represented are as follows: Member Members of X % of HTCs Consultant Haematologist 100 Transfusion Practitioner/Co‐ordinator 89 Anaesthetics 89 Blood Bank Manager/Chief BMS 83 Orthopaedics 61 Obs and Gynae 67 Haematology Lab/Pathology Manager 56 Clinical Risk 61 Consultant Surgeon 56 Matron 44 Remaining categories/groups Member Members of X % of HTCs Paediatrics 50 Clinical Governance 39 A and E Consultant 33 Medical Director 33 Physician 28 Director of Nursing (and Midwifery) 28 Theatres/Recovery 22 PCT Representative 22 Quality Manager 17 Clinical Audit 11 ‘Others’ 89 Invitation and Attendance at HTCs by each group Group % of 42 HTCs to which each group was invited % of 42 HTCs to which each group attended C. Haematologist 100 90 TP/Co‐ordinator 79 76 BB Manager 100 88 Anaesthetics 93 69 Clinical Risk 64 31 Clinical Governance 36 19 C. Surgeon 50 21 Obs and Gynae 64 43 Matron 43 21 Haematology Lab 43 29 C. Physician 7 2 Orthopaedics 64 17 Percentage of 14 Trusts with ≥1 attendance in the last 12 months, by group/member Group % of 14 Trusts with ≥1 attendance in the last 12 months C. Haematologist 100 TP/Co‐ordinator 79 BB Manager 100 Anaesthetics 86 Clinical Risk 36 Clinical Governance 29 C. Surgeon 36 Obs and Gynae 64 Matron 36 Haematology Lab 36 C. Physician 7 Orthopaedics 29 Results Conclusions Of medical staff, physicians are members of only 28% of the HTCs. More worrying is that in the period under review for which there was comprehensive data only once did a physician attend an HTC meeting. There is an urgent need to engage more physicians on to the membership of HTCs and to ensure that they attend, review their current practice and disseminate best practice to their colleagues.