Better Blood Transfusion 3

1. Better Blood Transfusion 3 Derived from a presentation by Dr Shubha AllardBarts and the London NHS Trust & NHSBT

2. Background • 1st Better Blood Transfusion initiative (BBT1) launched 1998 • concerns regarding sufficiency and increasing cost of blood • safety issues highlighted by SHOT reports • awareness of possibility of vCJD transmission.

3. Recommendation From March 1999 all Trusts should have HTCs • History • Intended to improve transfusion practice in hospitals • But poorly attended by key users eg surgeons, anaesthetists • No ‘teeth’ to change poor practice

4. BBT2 • Donor Blood is a limited resource • Threat to blood supply from vCJD • Impact excluding transfused people as donors? • ?50% donor loss if prion test available? • Risks – SHOT • Variation in usage

5. Better Blood Transfusion HSC 2002/009 • Replaced HSC 1998/224 • Ensure BBT integral part of NHS care • Make blood transfusion safer • Avoid unnecessary use of blood • Better information patients and public • Development of Hospital Transfusion Team • Lead consultant for transfusion • Transfusion practitioner • Transfusion laboratory manager

6. Rationale for Better Blood Transfusion 3 • Safety and appropriate use of donor blood • Ensuring use is appropriate and that alternatives are available • Important public health and clinical governance issues. • Falling number of donors leading to issues of security of supply • exclusions • (vCJD testing)

7. Rationale for Better Blood Transfusion 3 • Variation in use of blood nationwide: • Good progress in reducing red cell usage • 16% in last 5 years • Mainly seen in surgical setting • Need to look at other clinical specialities • Medicine accounting for 60% of red cell usage • Reductions not seen in FFP or platelet use • Safety In Obstetrics • Evidence base for Transfusion

8. -1.21% -0.90% -1.40% -5.88% -4.36% -2.88% 2.22 2.19 2.17 2.14 2.02 1.93 1.87 Red Cell Demand in England & N Wales 2000/01 – 2006/07 2.30 2.20 2.10 2.00 Million red cell units 1.90 1.80 1.70 1.60 2000\01 2001\02 2002\03 2003\04 2004\05 2005\06 2006/07

9. ABO incompatible transfusions

10. Site of primary error in ‘wrong blood events’ (SHOT, 2005)

11. New challenges and regulatory demands • Clinical Pathology Accreditation • Blood Safety and Quality Regulations • Compliance/ inspection MHRA • NPSA Safer Practice Notice • Competency testing all staff involved with transfusion • Agenda for Change • Cost cutting/ lack of investment/ poor IT

12. BBT3 Health Service Circular published November 2007 • Ensure that Better Blood Transfusion is an integral part of NHS care • Make blood transfusion safer • Avoid the unnecessary use of blood and blood components in medical and surgical practice • Improve the Safety of Blood Transfusion in Obstetrics • Increase Patient and the Public Involvement in Better Blood Transfusion • Monitoring of the arrangements for Better Blood Transfusion and their effectiveness • External support required to ensure the delivery of Better Blood Transfusion

13. Ensure Better Blood Transfusion is integral part of NHS care • Addressed to all trusts providing blood transfusion • Primary Care Trusts (PCTs) • Strategic Health Authorities should ensure robust BBT arrangements

14. Make Blood Transfusion Safer • Adequate staffing of laboratories, inc out of hours • Training and competency of lab staff • Participation in national accreditation schemes • Adverse event reporting SHOT,SABRE-timely feedback, lessons learnt to users • Patient Identification, NPSA • Competency assessment of all staff (NPSA SPN) • Audits key steps in transfusion process

15. Avoidance of unnecessary transfusion in medicine • Ensure • guidance in place for use of red cells, and other components eg platelets, FFP for all clinical specialities • indications for transfusion are in place, implemented and monitored • regular monitoring and audit usage of red cells, platelets and FFP in all clinical specialities

16. Avoidance of unnecessary transfusion in surgery • Ensure mechanisms for • Pre-operative assessment • investigation and treatment of anaemia • optimisation of haemostasis • Use of effective alternatives to donor blood • appropriate use of peri-operative and post-operative cell salvage • Blood conservation strategy

17. Further potential savings on red cell use in medicine and surgery Audits ~15–20% inappropriate use • See N Ireland audit • Regional audits • See Clinical Audit pages on www.transfusionguidelines.org.uk Optimising pre-op assessment and cell salvage • National survey of cell salvage

18. Establish procedures for identification and treatment of maternal iron deficiency anaemia Anti D training in hospital and primary care Training and competency of transfusion laboratory staff Compliance with NICE guidance Ensure systems for Traceability of Anti D guidelines Obstetric Transfusion and Iron Study (OTIS) ?National Comparative Audit Anti-D Safety & effectiveness in obstetrics

19. Ensure timely information made available to patients indication for transfusion any alternatives available Informing patients re importance of wrist bands and correct identification NBTC Patient Involvement Group Patient Info Specialist Societies NHS Choices Website Royal College of Physicians Open Day 5th July 2008 RCPath Pathology Week Transfusion 7th Nov 2008 Increase patient and public involvement in Better Blood Transfusion

20. Monitoring Use and Effectiveness • Monitoring Use and Traceability • Monitoring use of blood and components • Traceability – Blood Safety & Quality Regulations • Audit • Tx in multidisciplinary audit and CPD • National Comparative Audit • Blood Stocks Management Scheme

21. Implementation of BBT3 • Promoting an ongoing education programme is essential. • DH needs to actively support use of www.learnbloodtransfusion.org.uk (particularly with Deaneries) • The outputs from IBMS project re laboratory staffing levels is important. • DH needs to endorse this work • NBTC AuditAudit of Implementation of BBT3 planned for Nov 2008

22. Economic EvaluationPossible savings • Appropriate use blood & components • ~90% of Trusts have policies for red cell Tx • However 30% do not for blood components • Platelets • ~200,000 units pa @ Unit cost of ~£200 • and FFP

23. National Comparative Audit of platelet use - 2007

24. Intensive care Study of Coagulation • 29 adult ICUs in UK • 1930 admissions • 34% abnormal coagulation during ICU stay (INR >1.5) • Of these 37% received FFP • Bleeding 51% • no bleeding 33% • Procedure 15% • Further 3% of all admissions (n=56) received FFP with normal coag results

25. Use of Data • Demonstrating cost savings by reducing blood use is key • Can help support appointment of TPs • Better data on blood use by speciality and by clinician may help improve practice. (STED) • Quarterly comparative data from the Blood Stocks Management Scheme • SHA's should receive regular activity reports from RTCs • Current English blood use per 1000 capita could be broken down into regions.

26. Resources to deliver BBT3 Key issues at Trust level • executive accountability. • Resources for HTT to function in-line with national professional guidance. External support: • NHSBT support for HTC and HTT network/ Contingency planning and shortages • NBTC and RTCs supporting HTCs and HTTs • Organisations supporting research DH Better Blood Transfusion Toolkit. (2004) www.transfusionguidelines.org.uk