establishing & running an effective hospital transfusion committee christopher j. gresens, m.d....

Establishing & Running An Establishing & Running An Effective Hospital Effective Hospital

Transfusion CommitteeTransfusion Committee Christopher J. Gresens, M.D. VP & Medical Director, Clinical ServicesBloodSource

Transfusion Committees –Objectives

• At the conclusion of this presentation, members of the audience will be able to …

1. Describe how to form and organize an effective transfusion committee,

2. Define the most important aspects of blood utilization review,

3. Summarize useful techniques for implementing and managing a successful transfusion committee.

Transfusion Committees – Outline

1. Justification and Organization

2. Membership and Function

3. Blood Center Participation

4. Conflicts of Interest

5. Blood Utilization Review

Establishing and Running An Effective Hospital Transfusion Committee: Focusing On …

6. Quality Management and Quality Tools

7. Transfusion Reaction Oversight

8. Role in Blood Management

9. Transfusion Guidelines

10. Implementation and Management

Establishing and Running An Effective Hospital Transfusion Committee: Focusing On …

Transfusion Committees – Outline (Cont.)

Transfusion Committees –Primary Reference

The Transfusion Committee: Putting Patient

Safety First

Edited by Sunita Saxena, MD and Ira A. Shulman, MD

Transfusion Committees –I. Justification and Organization

• Transfusion Committee’s Primary Goals

– To provide an objective and accurate assessment of the use of blood and blood components in hospitals, and …

– To make recommendations on all aspects of transfusion medicine in order to promote the highest standards for patient care.


A typical transfusion consists of an interdisciplinary process involving as many as 10 steps:

1) Physician decides to transfuse.

2) Healthcare worker draws sample for compatibility testing.

3) Healthcare worker submits sample (with request for blood transfusion) to laboratory.


10 Steps to a Transfusion (Continued):

4) Laboratorian performs testing.

5) Laboratorian maintains supply/storage of blood.

6) Laboratorian selects and issues compatible units.

7) Healthcare worker picks up blood.


10 Steps to a Transfusion (Continued):

8. Healthcare worker performs identification checks, starts transfusion, and monitors patient.

9. Healthcare worker reports (in event of a transfusion reaction or other serious event) case as per requirements.

10.Laboratorians act on this information to perform transfusion reaction workup, and (in some cases) initiate component recalls, etc.


Multidisciplinary Nature of the CommitteeBecause of the complexity of the transfusion process, it behooves the transfusion committee to have a multidisciplinary structure. This allows for a committee that supports:

– Consistent and standardized transfusion practices, and …

– A transparent process where departments and individuals learn from one another’s successes and failures.


Working Within the Hospital’s Bylaws• The hospital’s bylaws will generally be invoked when

designing the transfusion committee’s:– Structure– Responsibilities– Meeting frequency, and …– Lines of reporting

Other Issues

• Often, the chief medical officer or chief of staff will establish the committee and appoint the chair.

• Meetings should occur as frequently as necessary (but ideally at least quarterly).



Here’s an example of a transfusion committee

that is effectively integrated into the hospital’s (and the

NBTS’s) organizational structures …

Governing Body (e.g., Board)

Executive Committee

Quality Improvement Committee

Transfusion Committee

National Blood Transfusion

Service (NBTS)

Transfusion Committees –II. Membership and Function

• Membership is determined by hospital bylaws, as well as by additional factors, e.g., – Size and type of hospital– Services it provides– Whether or not it has an outpatient

transfusion program

Choosing the ChairpersonChoosing the Chairperson

• The committee chair should have substantial knowledge about transfusion medicine (though it may be desirable to have someone other than the hospital transfusion service (or NBTS) medical director serve as chair – i.e., to reduce the likelihood of any conflicts of interest).


Department Position/Specialty No. of People

Hospital Administration Higher level staff number 1

Hospital Blood bank Both medical director & lab manager

2

NBTS Higher level staff member 1

Biomedical Engineering Engineer 1

Risk Management Higher level staff member 1

Pharmacy Pharmacist 1

Medical Records Higher level staff member 1

Nursing Department Director of Nursing 1

Clinical Services Physician & nurse from each area* 2 x number of areas

*These areas might include pediatrics, obstetrics-gynecology, general surgery, anesthesiology, and internal medicine (even, in some cases, hematology/oncology)

An example of an ideal (though almost never attained) committee membership is as follows …

II. Membership and Function


The role of the transfusion committee should go beyond just blood utilization review.

… to discuss Form 1

Pause…

Transfusion Committees –II. Membership and FunctionSteps to Establishing Safe Hospital-Wide Transfusion Practices

STEP 1: Develop robust policies and procedures, e.g., – Transfusion practice guidelines (developed by NBTS)– Blood utilization review guidelines– Policy for obtaining informed patient consent

STEP 2: Train all staff involved in blood transfusions to follow established policies and procedures

Pause to discuss Form 2

STEP 3: Establish a reliable system for performing annual competency and compliance assessments


Steps to Establishing Safe Hospital-Wide Transfusion Practices Cont.)


Transfusion Committees – II. Membership and FunctionIn many cases, the transfusion committee will implement a blood utilization review program that has two components:

Component 1: Assessment of physician-specific and service-specific blood usage practices.

Component 2: Assessment of institution’s overall blood usage practices.


Transfusion Committees –III. Blood Center Participation

NBTS Medical Director Involvement

When the blood center physician (e.g., the physician from the NBTS) is an active committee member, the hospital may benefit in the following ways:

– It may receive better, more customized consultative services from the blood center physician and his staff.

– It may learn from him/her substantially more about the local (and international) community’s standards of practice.

Ways the Hospital Benefits from NBTS Director Participation (Continued) …– Greater access to continuing medical

education.– And, in short, it should be able to obtain tools

that lead to improved patient care.

Transfusion Committees –III. Blood Center Participation

Transfusion Committees –IV. Conflicts of Interest

“A situation when someone … has competing professional or personal obligations or personal or financial

interests that would make it difficult to fulfill his duties fairly.”

The ‘Lectric Law Library, 2005 [http://www.lectlaw.com/def/c095.htm

(accessed , 2006)]

One legal definition of conflict of interest is as follows …


• Conflicts of interest, in and of themselves, are not inherently unethical; moreover, they’re ubiquitous.

However, …• Serious problems may arise unless

conflicts are:– Identified and disclosed, and then …– Properly addressed.


• Some experts in transfusion medicine believe that the transfusion committee chair should never be chosen from the following two positions:– The hospital transfusion service medical director or …– The blood center (e.g., NBTS) medical director.

• They believe that these medical directors cannot be sufficiently impartial to make truly unbiased decisions.

• This opinion is not, however, universally held.


• Personal relationships often comprise a special kind of conflict of interest, as it can be difficult to criticize (even constructively) a close friend and/or colleague.

Pause to discuss Forms 5 & 6

Transfusion Committees –V. Blood Utilization Review

Concurrent vs. Retrospective Blood Utilization Reviews?


• Advantages of Concurrent Review: – Occurs in real time, so it …– Facilitates meaningful improvements in transfusion

practice.• Disadvantages

– Labor required is intensive and costly, and …– It has the potential to provoke unnecessary confrontation

if not handled well – In cases where the patient is unlikely to be harmed by the physician’s transfusion desires, it may be best to acquiesce and then tackle the matter further at a later time.

– [Note: Concurrent review must never be allowed to delay appropriate patient care.]


• Retrospective Review– Advantages (compared to concurrent review)

• Somewhat less labor intensive, and also ..• Potentially less explosive.

– Disadvantage: Does not allow for proactive intervention (i.e., the cat’s already out of the bag).

– Other Issues• Ideally, retrospective review should occur soon after transfusion

(e.g., the day after), so that the issue is still clear in everyone’s minds.

• This review need not necessarily be 100% inclusive• Representative sampling is usually acceptable (and wise).


• Retrospective Review– Advantages (compared to concurrent review)

• Somewhat less labor intensive, and also ..• Potentially less explosive.

– Disadvantage: Does not allow for proactive intervention (i.e., the cat’s already out of the bag).

– Other Issues• Ideally, retrospective review should occur soon after

transfusion (e.g., the day after), so that the issue is still clear in everyone’s minds.

• This review need not necessarily be 100% inclusive• Representative sampling is usually acceptable (and wise).


• In cases where the review does not find that the standard of care was met, the following may happen:– Transfusing physician may be asked to explain, often in writing,

his/her rationale for the transfusion episode.– Hospital transfusion committee reviews the response.– Any transfusion request that the transfusion committee cannot

justify may be reported to the responsible physician’s chief of service and the medical staff office.

– Rarely, the unjustified incident may have ramifications during the credentialing and staff reappointment process.


Ideally the following categories will be part of the blood utilization monitoring process:

– Ordering practices– Patient identification– Sample collection and labeling– Infectious and noninfectious adverse events– Near-miss events

[Continued …]

Aspects of the Blood Utilization Monitoring Process (Continued)…

– Usage and discard practices– Appropriateness of use– Blood administration policies– The ability of services to meet patients’ needs– Compliance with peer review recommendations


Transfusion Committees –VI. Quality Management/Tools

Transfusion service activities follow two separate paths of workflow:

1) Blood Component Inventory Management Path: which covers ordering, receiving, managing, and disposing of the component inventory

2) Patient Testing Path: Covers activities from the time a lab test is ordered on the medical record through the following:• Sample collection, receipt, and processing• Testing and result review• Reporting of the results• Billing• And provision of follow-up consultations



10 quality system essentials form the backbone of a country’s blood banking standards:

1) Organization

2) Resources

3) Equipment

4) Supplier and Customer Issues

5) Process Control

Quality System Essentials (Continued)…6) Documents and Records

7) Deviations, Nonconformance's, and Adverse Events

8) Assessments: Internal and External

9) Process Improvement through Corrective and Preventive Action

10)Facilities and Safety



Pause to discuss Forms 7 through 9

Transfusion Committees –VII. Transfusion Reaction

Oversight


This is one of the most important functions of the transfusion committee, as the information gleaned from transfusion reaction oversight is essential to preventing and managing future, similar problems.

Transfusion Committees –VIII. Role in Blood Management

• Selected examples of the means by which the transfusion committee can improve blood management are as follows:– Focusing on the preoperative optimization of a

surgical candidate’s hemoglobin levels.– Monitoring and strengthening intraoperative blood

conservation strategies.– Concentrating on useful, well-designed, easy-to-

access physician, nurse, and laboratorian transfusion medicine education programs.

Transfusion Committees –IX. Transfusion Guidelines


Excellent transfusion guidelines may be augmented even further by the development of a transfusion

order form that reflects the guidelines and serves as a helpful practice reminder to ordering physicians.

Transfusion Committees –X. Implementation and

ManagementPlanning Successful Meetings

– Scheduling• This must be started as soon as the committee is

formed.• A yearly schedule may be useful.• Breakfast or lunchtime meetings (with food served)

often promote better attendance.


Management

Planning Successful Meetings– Agendas

• Should include date, time, and location.• Should also include a brief description of

specific issues/items to be discussed (and the name of the person bringing each item forward).

Agendas (Continued) …• Each item should be labeled as either:

– “Action” (i.e., follow-up work required) or …– “Information” (i.e., no follow-up required).

• Meeting handouts should be distributed in advance, along with the agenda, so that members may be prepared to engage in meaningful discussion.



Management


ManagementPlanning Successful Meetings

– Reports• Should be sufficiently detailed, yet also

reasonably brief and easy to interpret.

• A standardized report is preferable (i.e., to allow for simplified tracking of indicators over time).

Pause to discuss Forms 13-to-17

Planning Successful Meetings– After the Meeting

• Distribute meeting minutes as soon as possible (preferably within a week of the meeting).

• Keep the minutes brief yet comprehensive enough for readers who did not attend to understand what took place.


Management

Transfusion Committees –Summary

Today We Focused On …1. Justification and Organization2. Membership and Function3. Blood Center Participation4. Conflicts of Interest5. Blood Utilization Review

Topics of Discussion (Continued) …– Quality Management and Quality Tools– Transfusion Reaction Oversight– Role in Blood Management– Transfusion Guidelines– Implementation and Management

Transfusion Committees –Summary

Where do we go from here?

What may Global Healing and BloodSource do to assist?

Transfusion Committees –End Discussion

Transfusion Committees – Other Notable References

• J.C. Faber. “Expanding the Role of Hospital Blood Banks.” ISBT Science Series (2007) 2: 76-81.

• P. Ouellet. “Hospital Transfusion Committee.” ISBT Science Series (2007) 2: 82-84.

• S. Saxena and I.A. Shulman. “Resurgence of the Blood Utilization Committee.” Transfusion (2003) 43: 998-1006.

To all of our friends/colleagues in the audience…

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Thank You …

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mailto:[email protected]