LOUIS ANTHONY O. DELOS REYES, RMT, MDDepartment Head

Department of SurgeryCebu City Medical Center

Hospital Transfusion Committee and

Hospital Tissue Committee

Objectives

• To be able to create Hospital Transfusion Committee

(HTC)

• To define the role and terms of reference in HTC

• To know the members of the HTC

• To know the activities of the HTC

• To know the meeting frequency of the HTC

Overview

• The Blood Matters program (initially BeST – Better Safer Transfusion program) and its advisory committee aims to improve the outcomes in patients requiring blood product transfusion by enhancing the safety and appropriateness of blood and blood product use.

• The Blood Matters Program aims to:

– raise awareness and increase knowledge of transfusion

practice

– monitor and evaluate current practice against guidelines for

the prescribing and administering of blood products

– record and analyse data about incidents, including adverse

events and near misses, to inform policy and procedure

development.

Blood Matter Program

• Transfusion governance

– part of the overall approach to clinical governance in a health

care organisation.

– Clinical governance is a vital leadership issue as an approach

of enhancing quality and safety in health care.

Hospital Transfusion Committee

• To promote and provide the highest standard of quality care for patients receiving blood/blood components and blood products

• Will developed guidelines and policies, audit and using peer review of transfusion practices.

• The HTC meet quarterly and the minutes/actions are recorded accordingly.

• Members

A. Institutional representatives such as:

• Clinicians: surgery, medicine, paediatrics, haematology,

oncology, orthopaedics, O&G, anaesthesia, emergency,

ICU executive management clinical risk

management/quality assurance blood bank (scientist in

charge)nursing other relevant departments such as

pharmacy.

• External representatives such as:

– Philippine National Red Cross

– Blood Service Transfusion Medicine member

– Department of Health

Scope and Duties

• Promote best practice by the use of national/local guidelines.

• Regular review of the Hospital Blood Transfusion Policy

• Participate in both national and local audit examining the blood transfusion process against best practice.

4. Have representative on the Regional Transfusion Committee and receive updated information on the National Blood Transfusion Committee that is disseminated to the HTC

5. There is continuous work with members of the multi-disciplinary team to further enhance best practice by the use of audit and research based practices

6. Promote the education and training of clinical laboratory and support staff involved in blood transfusion.

7. Participate in the Blood Stocks Management Scheme to minimize waste.

8. Manage change that promotes transfusion safety, continuously reviewing practice that links with clinical governance.

9. Participate in the Serious Adverse Blood Reactions and Events (SABRE) and Serious Hazards of Transfusion (SHOT) reporting system as well as the Trust Risk Management clinical incident reporting.

10. Feedback clinical incidents to both the HTC and the specific hospital staff involved. Action incidents accordingly to further minimize risk.

11. Look at alternatives to transfusion and promote the work of the HTC across the Trust.

12. Continually strive to enhance and further develop best practice in the field of Transfusion practice.

Authority

• The Hospital Transfusion Committee is empowered to examine and promote best practice within the

institution to the above scope and duties related to transfusion.

Reporting

• The Hospital Transfusion Committee receives reports from the Hospital Transfusion Team and these are included in the HTC meetings.

• The Deputy Nurse has representation on the group and feedback is given to both the Deputy Nurse and Lead Nurses.

• The work of the HTC is feedback to the Clinical Governance Board.

Key Performance Indicator

• Staff attendance at the meetings will be monitored by the use of registers.

• An Annual Summary report of achievements will be produced at the end of each year and sent to the Clinical Governance Board.

Hospital Transfusion Team (HTT)

• Give feedback on the work of the group

• To manage the day to day business of Blood and Blood Component

Transfusion

• To reduce blood use and increase patient safety

• Meet once a month to discuss and work on issues around the

transfusion process

17

• Consists of the following:

– Clinical Nurse Specialist

– Transfusion Laboratory Manager

– Transfusion Biomedical Scientist

– Consultant Hematologist

Objective

• Assist implementing the actions of the HTC in promoting the highest standard of quality of care for patients receiving blood/blood components and blood products.

Frequency and Attendees of the Meeting

• There may be invited a Hospital Board and Hospital employee’s to the meeting if their input is required regarding specific projects and agenda issues.

• Meetings shall be held every 2 months to HTC

Scope and Duties

• Assist in the implementation of the Hospital Transfusion Committee’s objectives.

• Promote and provide advice and support to clinical teams on the appropriate and safe use of blood.

• Actively promote the implementation of good transfusion practice.

• Act as a resource for training hospital staff involved in the process of blood transfusion.

• Produce an annual report including achievements, action plan for transfusion safety, quality and blood conservation and resource requirements for consideration by senior management at Board level through the HTC.

• Assist in Trust compliance with the Blood Safety and Quality Regulations and future laws and guidelines relating to blood transfusion.

• Implement an action plan for compliance with National Patient Safety Agency initiatives.

Reporting

• The Hospital Transfusion Team reports directly to both Hospital Transfusion Committee’s within the Trust.

• Minutes of meetings and the actions taken will be submitted to the HTC.

Agenda Coverage

• Minor errors

• Major errors and Clinical incidents

• Reports to Serious Hazards of Transfusion (SHOT) and Serious Adverse Blood Related Events (SABRE) at the Medicines and Healthcare Regulatory Authority (MHRA)

• Blood stocks management including wastage

• Blood stocks management including wastage

• Budgetary issues

• Protocol and Standard Operating Procedures (SOP) changes

• Major Accidents

• Training and Education

• Audit

• Autologous Transfusion

• Factor VIIa usage

Other

• Offer advise and assistance on alternative to blood transfusion

• Plans for patients who refuse blood transfusion

Terms of References

• To promote best practice in transfusion medicine

• To monitor usage of blood and components within the hospital review

Blood Services

• Blood Donation– Attracts and retains donors through regular advertising and

marketing campaigns

• Donors and Blood Donations• Testing

– ABO group– Rh group– 5 transmissible infectious diseases

Transfusion Facts

• Blood Types

• Compatibility Testing

Blood Products

• Fresh Whole Blood• PRBC• FFP• Cryoprecipitate• Platelet

Blood Management

• Patient blood management

– Encompasses a holistic approach to the use of blood products

for each individual patient; using the premise of ‘why transfuse’

rather then ‘why not’.

– Carefully balance benefits and potential harm.

– Belief that blood and its components are biological products, the

effects of which are not fully understood, and have the potential

for unwanted consequences.

– Aim of ‘better treatment outcomes’ for the patient.

– To maximize haemoglobin (preoperatively, intra-operatively

and post-operatively); minimise blood loss (including blood

taking) and to use alternatives to blood transfusion where these

are available and feasible.

Consent• Patients have a choice about whether or not to undergo a

proposed procedure or treatment, including transfusion of blood and blood products.

• Purpose: – Provide enough information about the transfusion

care they may receive – promoted and facilitated by WHO.

• Important points– Valid and informed consent process is conducted and

documented.

– Emergency procedures will be undertaken in compliance

with the Guardianship and Administration Act 1986.

– Appropriate substitute consent will be taken when

patients cannot consent for themselves.

– Treating medical practitioner is responsible for obtaining

consent.

– In the case of a Jehovah’s Witness or any other refusal of

treatment, in either adults or children

• Important points to cover when obtaining informed consent: – Explain– Ask– Provide– Document

• Consumer information on consent for transfusion

Clinical Audit• Aims:

– Identify areas for practice improvement; develop and carry out

action plans to rectify or improve care; and then re-audit to

ensure that these changes have the desired effect.

– Compare current transfusion practices with clinical best

practice guidelines.

– If any areas for improvement are identified, practices are

examined and modified where necessary.

Tips for Auditing

• Collect only the essential data

• Maintain and ensure patient confidentiality

• Have clear objectives and aims

• Identify stakeholders that may be affected by your audit and

involve them in discussion

Tips for Auditing

• If required employ a team of people

• Analyse and compare your audit against standards or guidelines

• Make recommendations and develop a plan to implement those

recommendations

• Analyse and compare your audit against standards or guidelines

• Make recommendations and develop a plan to implement those

recommendations

• Re-audit, once recommendations are in place, to assess

improvements

• Talk to your quality/clinical governance department, as they may

have already conducted audits similar to those you are

considering.

Haemovigilance

• Risk management and haemovigilance– Set of surveillance procedures covering the whole transfusion chain (from

the collection of blood and its components to the follow-up of

recipients)

– intended to collect and assess information on unexpected or

undesirable effects resulting from the therapeutic use of labile

blood products to prevent their occurrence or recurrence

• The Blood Matters’ Serious Transfusion Incidents

Reporting (STIR) system

– Is a central reporting system for serious adverse

events involving the transfusion of fresh blood or

blood products including near-miss incidents.

– STIR currently collects data on the following

serious incidents:

• Acute transfusion reaction (ATR)

• Delayed transfusion reaction (DTR)

• Transfusion-related acute lung injury (TRALI)

• Bacterial/other infection

• Transfusion-associated graft versus host disease (TA-GVHD)

• Post-transfusion purpura (PTP)

• Post-transfusion viral infection

• Incorrect blood component transfused (IBCT)

• Wrong blood in tube (WBIT)

• Near miss

National Blood Authority (NBA) – National Haemovigilance Project

• It will report on serious transfusion-related adverse events

relating to fresh components occurring in public and

private hospitals.

• Improve transfusion safety and quality by collecting,

analyzing, and disseminating information on a common

set of adverse events surrounding the transfusion of blood

products.

• The report provides limited data on the types of adverse transfusion events that have been reported in some healthcare reporting systems over the past three to five years.

• It will also be used to assist development of a framework for the future Australian haemovigilance program.

National Blood Supply Contingency Plan (NBSCP)

• It is a document that outlines the risk-management approach taken to assessing the possible problems, governance arrangements and the broad overarching strategies in place to mitigate a supply or demand crisis.

• Aims to improve awareness and ensure appropriate planning is in place for dealing with the impact of a blood crisis in the health sector.

• This document is supported by a range of response annexes to guide key stakeholders in responding to a supply or demand crisis.

• The overarching response involves three levels of

accountability:

– National: covers the roles of national government bodies such

as the NBA and the TGA, in gathering and communicating

information between governments and suppliers and is the link

to broader government emergency management arrangements.

• Operational: covers the role of suppliers in managing required operational activities around collection, manufacture, distribution and interface with the clinical community.

• Clinical: covers the role of clinicians and pathology providers in good communication, managing clinical demand, and approaches to triage to ensure access to products for patients with greatest and most urgent clinical needs.

Classification system available to support clinicians and institutions with their decisions.

• Blood Access Priority 1– Resuscitation– Surgical support– Non-surgical anaemia

• Blood Access Priority 2– Surgery and obstetrics– Non-surgical anaemia

• Blood Access Priority 3– Surgery

• Elective surgery requiring cross-matched red blood cell support of two or more units of homologous donor blood

– Non-surgical anaemia– Other non-urgent medical indications for transfusion– Notes for all priority levels

• All priority levels must consider the following:– Alternatives to transfusion (For example:

erythropoietin, iron therapy, red cell salvage).– A reduction in target post-transfusion haemoglobin.

HOSPITAL TISSUE COMMITTEE

Background

• Hospital Tissue Committee reviews the appropriateness of all surgical procedures performed in the institution, correlating pre- and post-operative surgical diagnoses with pathological findings

• A review of the surgery performed in a hospital or other health care facility. The evaluation is usually made on the basis of the extent of agreement of the preoperative, postoperative, and pathologic diagnoses and on the relevance and acceptability of the diagnostic procedures.

Members• Chief of Hospital• Pathologist- Ex Officio• Representative from Dept. of Surgery• Representative from Dept of OB-Gyne• Representative from Dept. of Ophthalmology• Representative from Hospital Administration• Representative from Nursing Department• Representative from Laboratory Department-

Histopathology Section

Objectives

• To study and report to the staff, or to the Executive Committee of the staff, on the agreement or disagreement among the preoperative, postoperative and pathological diagnoses and on whether the surgical procedures undertaken in the hospital were justified or not.

Purpose

• To study statistics in the Pathology Laboratory Includes the number of submitted tissues, number of apparently missed diagnoses, percentages of normal tissues removed and number of deaths.

• To discuss all cases in which there is inconsistency Includes clinical, operative and pathologic diagnosis, investigation of all cases in which normal tissues were removed and discussion of such cases.

Purpose

• To discuss and study of all deaths.

• To discuss and correct the sub-standard practice of a certain resident physician

METHOD OF PROCEDURE

Review of patient medical history, pathological reports and operative record

Vital information of the patient

Committee Appraisal

Cases presenting inconsistencies or potential deficiencies in desired standards of care

Review of the patients chart

Refer to administrative medical staff committee

Determine the specific pattern of corrections.

accumulating an excessive quantity of cases (sub-standard px care) requiring executive committee examination

Retrieval of committee records

Statistical Report

• The Tissue Committee reviewed 100 operations performed in this hospital during the month of July

• Inconsistency of the surgical operation• Investigate• Correction• Executive Committee for disposition

Thank you!