On March 16th 2007 a third Better Blood Transfusion seminar was held at the Royal College of Anaesthetists. There were 120 participants representing the key users of the transfusion services namely obstetrics, surgery, medicine, haematology and critical care. The UK Blood Services were also represented.
The event was organised on behalf of the Chief Medical Officer (CMO) by the Blood Policy Unit, Department of Health with the support of a small organising committee.
The aims of the third Better Blood Transfusion seminar were:-
- To build on the success of the previous Better Blood Transfusion initiatives.
- To monitor the use and effectiveness of blood transfusion.
- To avoid the unnecessary use of red cell transfusion in medicine.
- To use FFP and platelets transfusions according to guidelines.
- To minimise the risk of haemolytic disease of the newborn and transfusions in maternity patients.
Introduction and overview by UK Chief Medical Officers
Sir Liam Donaldson, CMO in England opened the meeting and chaired the morning session. He gave a brief overview of the background to the original Better Blood Transfusion in 1998, namely emerging data on transfusion errors from SHOT, concerns about blood shortages, inappropriate blood use and concerns about new variant CJD. The second initiative in 2002 focussed on improving transfusion safety and the appropriate use of blood.
He acknowledged that the first two Better Blood Transfusioninitiatives had been successful, but reiterated that further work was needed and that there were other areas of transfusion medicine that now needed to be tackled.
It was reported that there had been an overall reduction in demand for red cells of >15% in the last 5 years. However the decrease in red cell usage has mainly been in surgery, leaving medical use now accounting for about 65% of red cell usage (for many years medical and surgical use were both approximately 50%). The CMO indicated that attention should be focused on reducing inappropriate use in medicine; he highlighted that there is evidence that indicates inappropriate usage of both fresh frozen plasma and platelets.
The devolved administrations were invited to share experiences from their respective countries.
Scotland - The Deputy CMO, Dr Aileen Keel commented on progress with the blood transfusion initiatives in Scotland: -
- The Better Blood Transfusion Practice initiative.
- Implementation of an e-learning package and On-line Recording and Assessment System (ORAS) available to hospitals at www.learnbloodtransfusion.org.uk
- The Scottish Transfusion Epidemiological Database (STED).
- NHS Quality Improvement Scotland – Clinical Standards for Blood Transfusion.
Wales - The Deputy CMO, Dr David Salter shared the results of an audit of implementation of BBT2 in Wales: -
- 83-89% of trusts has an appropriate Hospital Transfusion Committee and Hospital Transfusion Team.
- All but one hospital has a Transfusion Practitioner.
- All hospitals have pre-assessment clinics.
- A cell salvage consumables reimbursement scheme has been established together with a national database.
- There is a mandatory requirement by junior doctors in Wales to complete the www.learnbloodtransfusion.org.uk e-learning package.
- In 2005, a new Advisory Blood Structure was established.
Northern Ireland - The Deputy CMO, Dr Liz Mitchell shared data on the Northern Ireland audit of appropriate use of blood led by Dr Damian Carson and his team using specific criteria for the threshold for transfusion.
Over-transfusion was defined as a transfusion above the agreed threshold for transfusion by more than 2.0 g / dl.
Of 2853 transfusions, 1215 were examined and as a result the following recommendations were made:-
- Optimise Hb before admission (iron deficiency anaemia in particular).
- Check and review Hb prior to transfusion.
- Transfusion should only be considered if the Hb is below the threshold for transfusion, and over-transfusion should be prevented by considering 1 unit transfusions if appropriate.
- Education should be targeted to all grades and specialities of clinical staff in all hospitals.
- Inappropriate transfusion in Northern Ireland has fallen from 20% to 10% and blood use has gone down by 11% in the last 3 years.
Professor Ted Gordon-Smith, retired Chair of the National Blood Transfusion Committee (NBTC), opened the first session reviewing progress of the implementation of the Better Blood Transfusion Health Service Circulars.
Professor Mike Murphy presented a summary of the recent audit of the implementation of Better Blood Transfusion carried out by the NBTC that showed significant progress compared to previous surveys. He highlighted evidence showing the effectiveness of the Better Blood Transfusion initiative, including a reduction of >15% in red cell usage over the last 5 years and a reduction in ABO-incompatible red cell transfusions as reported to SHOT. The infrastructure for transfusion in hospitals has improved with the establishment of Hospital Transfusion Teams, but could be under threat with various Trust financial constraints. This was followed by a report of a UK audit on the number and remit of Transfusion Practitioners. This session, presented by Catherine Howell, concluded by recommending that the role needs to be reinforced, the scope more clearly defined, and that the resource should reflect the size of the Trust.
Related afternoon workshop: Resources required to deliver BBT at hospital level.
Professor Jonathan Potter, newly appointed as Director of the Clinical Effectiveness and Evaluation Unit at the Royal College of Physicians, opened the second session on the power of good quality data. He illustrated this topic by using data from a national stroke audit. He demonstrated how the use of data had improved the number and quality of stroke units, as well as data from myocardial infarction audits that had improved door to needle time. Key to its most effective use is knowing how to present and use data. This was followed by a presentation by Professor Tina Maki from Finland. In her presentation she shared their experience of optimising blood use through the use of benchmarking. Dr Brian McClelland concluded this session by describing the Scottish experience with the Scottish Transfusion Epidemiological Database. He suggested we need better data systems to inform clinicians how to manage patients at risk of transfusion.
Related afternoon workshop: Monitoring the use and effectiveness of blood transfusion (effective use of data).
Professor Lindsay Davies, Department of Health chaired the next session on the new challenges in blood transfusion. She illustrated the current known hazards of transfusion (including incorrect blood given by errors at the bedside and in the laboratory, TRALI and infection), but also suggested there will be other challenges on the horizon that we are currently unaware of. She commented that large amounts of money are spent on reducing the very small risk of transfusion transmitted infection compared to reducing the greater risk of incorrect blood transfusion errors. New challenges highlighted included reducing the risk from blood products containing plasma, the modernisation agenda and multi-tasking in the laboratory. She reiterated that the most effective way to minimise risk was to give blood appropriately.
Dr Neil Soni appraised the audience of the guidelines for the use of platelets and FFP and the challenges in assessing coagulation status to achieve more appropriate use.
Related workshop: Avoidance of unnecessary transfusion in medicine.
Dr Susan Tuck representing the Royal College of Obstetrics and Gynaecology illustrated another new challenge. She highlighted iron deficiency anaemia, high rates of caesarean section, massive obstetric haemorrhage, increased frequency of inter-hospital transfers and errors in the administration of Rhesus-D prophylaxis as some of the challenges in obstetrics.
Related afternoon workshops: Safety and effectiveness of transfusion in obstetrics and avoidance of unnecessary transfusion in surgery.
Dr Adrian Copplestone, Chair of the NBTC, opened the penultimate session to discuss resources needed to achieve Better Blood Transfusion. He spoke about the importance of the role of the NBTC, Regional Transfusion Committees (RTC), Hospital Transfusion Committees and Hospital Transfusion Teams. He highlighted the availability of the new NBTC/RTC section on the www.transfusionguidelines.org.uk website for providing information and communicating good practice. He referred to the vital role of NHS Blood and Transplant, which was then expanded by Peter Garwood, Managing Director of the NBS. The NBS have been, and still are, very committed to supporting Better Blood Transfusion and the safe and appropriate use of blood.
This session was concluded by Professor Adrian Newland, President of Royal College of Pathologists who discussed the modernisation of transfusion services as part of the Pathology Modernisation initiative. He highlighted that the laboratory errors in the 2005 SHOT report amounted to 45% of all ‘wrong blood’ incidents, and suggested that hospitals and the NBS should work together to determine the optimal strategy for laboratory transfusion services.
The final, but arguably the most important session of the day was entitled ‘Putting patients at the heart of Better Blood Transfusion’. This was opened by Dr Shubha Allard who is the Chair of a new NBTC working group set up to improve patient involvement in transfusion issues. Patient involvement is at the heart of NHS modernisation and increasing patient awareness about the safe and appropriate use of blood is key. She gave an overview of a forthcoming National Patient Transfusion Awareness Week (April 23rd - 27th 2007). Jenny Bramhall was the last speaker of the morning. She discussed pre-operative assessment and highlighted areas where intervention was necessary such as the identification and treatment of iron deficiency, the importance of taking a bleeding history and the correct management of Jehovah Witnesses.
The afternoon session was a series of workshops. A summary of the workshops is provided as an appendix.
At the close of the day, William Connon, Head of Blood Policy, Department of Health rounded up with a general summary of the day.
He thanked all participants for their hard work in helping to develop the next series of priorities for 2007 – 2012 and made some additional points about the next steps for Better Blood Transfusion: -
- Reiterating the challenges for the NHS with respect to blood use
- Blood and blood components are a scarce resource.
- Safety issues still remain (patient identification is a key safety issue).
- Empowering the public to understand the risks and choices and that involvement of patients and the public is essential.
- Collaborating to ensure there are appropriate resources to deliver these priorities
- Strengthening the systems set in place by previous Better Blood Transfusion initiatives
- Focusing more effort on the appropriate use of blood in medicine as well as the appropriate use of platelets and plasma
- Collection of data, use of IT and traceability will be key objectives.
- The involvement of NHSBT is fundamental.
A new Better Blood Transfusion Health Service Circular will be published. It will define action points for the objectives generated at this meeting.
William Connon – Head of Blood Policy Unit, Department of Health
Dr Denise O’Shaughnessy – Senior Medical Advisor, Blood Policy Unit, Department of Health
Catherine Howell – Transfusion Liaison Nurse Manager, NHS Blood and Transplant
Dr Shubha Allard – Consultant Haematologist, NHS Blood and Transplant/Barts and The London NHS Trust
Professor Mike Murphy – Clinical Director-Patients, NHS Blood and Transplant
Dr Derek Norfolk – Consultant Haematologist, NHS Blood and Transplant/Leeds Teaching Hospitals NHS Trust
Carol Cantwell – Transfusion Laboratory Manager, St Mary’s Hospital, London