Prof. Debasish Gupta

1. Prof. Debasish Gupta Sri ChitraTirunal Institute of Medical Sciences and Technology, Thiruvananthapuram ROLE OF HOSPITAL TRANSFUSION COMMITTEE IN STRENGTHENING BLOOD TRANSFUSION SERVICES

2. HOSPITAL TRANSFUSION COMMITTEE • Hospital Transfusion Committees (HTC) should be created to oversee all aspects of blood and blood product transfusion within individual institution • Every transfusing hospital should have their own HTC • Implement national policy and guidelines on the clinical use of blood • Monitor the use of blood and blood products at the local level

3. Role of Hospital Transfusion Committee • Promotion of Best Transfusion Practices through: • Work inter-departmentally to promote safe and effective transfusion therapy • Monitor hospital transfusion performance by: • Active surveillance (observation audits) of bedside processes related to patient sample collection, blood requests, blood delivery, and bedside administration of blood • Tracking data on key indicators of the transfusion process • Participating in overall program of error/accident reporting

4. Role of Hospital Transfusion Committee Contd. • Recommend and implement approved changes in process of bedside blood administration • Educate staff (nursing, physician) to recognize and report transfusion reactions and disseminate information on hospital guidelines for appropriate blood usage • Provide basic training for new physician staff responsible for administering blood in high usage areas (eg, residents) • Contribute to improving processes for blood utilization review • Implementation of new technology designed to enhance patient safety

5. To ensure “Safe Transfusion Practices” Creation of Hospital Transfusion Committee or Blood Utilization Committee is being promoted all across the world

6. Blood Transfusion - Guidance & Regulations • WHO recommendations • Safe and Adequate blood supply • Clinical transfusion process • Appropriate use of blood • Collection samples, patient ID • Compatibility testing • Administration of blood • Adverse event reporting • Hospital transfusion committee • ‘Better Blood Transfusion Practice’

7. National Blood Policy Objective 5: To encourage appropriate clinical use of blood and blood products. State/U.T. Government shall ensure that HTC are established in all hospitals to guide, monitor and audit clinical use of blood

8. FUNCTIONS OF HOSPITAL TRANSFUSION COMMITTE POLICY & RETURN EDUCATION & COMMUNICATION MONITORING PRACTICE Local Guidelines Data Collection Promote best practices Adverse events Blood Request & Usage Blood Transfusion Protocol National Guidelines Laboratory Wastage & Expiry Clinical Induction Expenditure Training (all staffs involved) MSBOS Hemovigilance Reporting Continuing professional development Dissemination & Review

9. AN EXAMPLE OF AN IDEAL COMMITTEE MEMBERSHIP:

12. “Generally speaking, clinicians receive little or no formal training on the clinical indications for blood transfusion therapies during their time at medical school. HTC can promote best practice by providing continuing professional education and monitoring performance by clinical audit and peer review. Regularly notifying clinicians of their performance is an additional strategy that may improve transfusion practice.”

13. “Unsurprisingly, hospitals have been forced to elaborate strategies to ensure appropriate use of blood products. The hospital transfusion committee (HTC) now plays a pivotal role in this area. This article reviews the development, organization, and function of HTCs in relation to blood conservation and the evidence supporting relevant intervention to ensure appropriate blood utilisation.”

14. “Audits of practice and incident reporting, most notably to national haemovigilance schemes, indicate that poor hospital transfusion practice is frequent and occasionally results in catastrophic consequences for patients. Improvements in practice are needed and depend on a combined approach including a better understanding of the causes of errors; a reduction in the complexity of routine procedures taking advantage of new technology systems, which enforce agreed guidelines and policies; the setting and regular monitoring of performance standards for key aspects of the hospital transfusion process, improved organisation of transfusion in hospitals and staff training; and further research on the safe and effective use of blood and alternatives to donor blood. There needs to be a greater recognition that ‘transfusion safety’ applies to the hospital transfusion process as well as the contents of blood bags and that resources need to be provided for the improvement of transfusion safety and management in hospitals commensurate to their importance.”

17. Where do We stand in Effective Implementation of Hospital Transfusion Committee ?

18. STRENGTHS • National Blood Policy recommends and promotes creation of HTC • Many Transfusing Hospitals have created their own HTC • Significant improvement reported in blood collection, component preparation and appropriate use of blood • Enrolment and Participation in Hemovigilance Programme of India

19. Development of Transfusion policy and guidelines All aspects of the transfusion chain: • Consent for Transfusion • Sample collection • Request procedures (elective and emergency situations) • Checking patient identity • Conducting the transfusion • Monitoring of transfusion – identification and reporting of adverse reactions • Proper documentation • Reporting

20. EMPHASIS OF THE POLICY • On Blood Safety – Adoption of new technology, automation • Appropriateness of blood use • Indication for transfusion of specific component and their dosage • Reservation of blood in advance in special cases • Reduction of Wastage • Responsibilities of all staff involved in transfusion chain • Standards for each activity

21. BLOOD ORDERING Institute with HTC encompasses appropriate and efficient use of blood through: • Development of Maximum Surgical Blood Order Schedule (MSBOS) • Recommends maximum blood order for each procedure • Efficiency of MSBOS is monitored by using C:T ratio • Rationalize blood usage • Reducing risk of outdating

22. BLOOD AUDIT • HTCs promote best practice by monitoring performance through • clinical audit and peer review. • Prescribing practice can be monitored and corrective measures taken • Clinical audit involves evaluation of ongoing practice • Its comparison to set standards; • When such standards are not met, appropriate changes are implemented • Monitoring their effect

23. INVOLVEMENT OF CLINICIANS IN HTC • Defining transfusion policies – International/ National/Local Guidelines • Understanding Management of Transfusion Medicine Unit • Gaining knowledge of Newer technology for blood safety • Advocacy in HTC function Instrumental in: • Integration of Transfusion Medicine into the standard organization of clinical departments • Raising the visibility of the Transfusion Medicine within the hospital.

24. Gaps and Shortcomings in the Programme LACUNAE

25. 1. No directives issued by several State Health Department to the hospitals and Blood Banks for creation of HTC 2. No HTC or Non-functional HTC Stand-alone Blood Banks Blood Storage Centres at FRU District Blood Banks Many transfusing Hospitals 3. No defined Guidelines on HTC by Health Authority

26. 4. Lack of Regular Medical Doctor in Blood Banks to start HTC 5. Inadequate members for the HTC 6. Non-participation or Non-cooperation from clinicians & administration 7. Meetings of HTC are conducted irregularly or infrequently 8. Poor or No action taken on the agendas of the meeting

27. 9. Under-reporting or Non-reporting of Adverse Transfusion Reactions 10. Proper Blood Audit not carried out 11. Lack of training programme on: Bed side transfusion practices Appropriate use of blood/ Rational use of blood Clinical use of blood / Blood components Adverse effect of Blood Transfusion

28. Reasons: Non-participation by clinicians, residents, nursing staff – interest, time Lack of Budget Lack of support from Health sector/ Administration Conflict of Interest

29. Hospital Transfusion Committee at SCTIMST: Our Experience HTC formed in 1995 Held every quarter– 3 times /year Members includes: • One Faculty each from Cardiology, Cardio Thoracic Surgery, Paediatric Cardiac Surgery, Neurology, Neurosurgery, Anaesthesiology • One Faculty from Bio-Medical Technology wing • Nursing Superintendent • Faculty of Transfusion Medicine – Member Secretary • Head of Transfusion Medicine – Chairperson

30. IMPORTANT DECISIONS FROM HTC • Implementation of National Blood Policy • Support of HTC to voluntary blood donation programme of the department • Developed Guidelines for blood transfusion practices • Introduction of Consent Form for patient receiving transfusion of blood & blood products • Regular Auditing of blood and blood components • Introduction of Autologous transfusion in selected clinical cases • Proposal to start Diploma in Blood Transfusion Technology for science graduates (since 1999) • Proposal to start M.D. programme (since 2015)

31. Portfolio Presentation INITIATIVES OF HTC

32. ACADEMIC ACTIVITIES Several Academic activities were conducted regularly: • Rational use of blood • Leuko-reduction of blood and blood products • Massive Transfusion • Appropriate bed side transfusion practice • Autologous transfusion and Blood Conservation • Adverse effect of Blood Transfusion

33. Contn.... Outcome: • 100% blood component usage by clinical departments • Leucodepletion of blood and blood products initiated • Protocols for Massive Transfusion developed • Blood safety measures implemented in all areas of blood services • Autologous transfusion programme introduced

34. Contn.. Studies undertaken: • Assessing the demand of blood and blood products • Maximum surgical blood order schedule • Transfusion Triggers • Blood audit • Adverse transfusion reactions

35. RECENT DEVELOPMENTS • Approval of implementation of NAT for additional blood safety • Reporting of adverse transfusion reaction to HvPI • Clinical trials of indigenous preparation of plasma derivatives by BMT wing - ongoing • HTC supported the complete phasing out of Replacement donors – 100% VBD from 1st October 2016

36. CHALLENGES • 100% attendance of members not achieved • Occasionally rescheduling of Meetings • New Clinical Residents indulge in wrong transfusion practices • Training of New Residents on appropriate transfusion practice • No information on blood units issued outside hospital • Financial issues

37. Improvement in Better Transfusion Practices • Better understanding the cause of errors • Reduction in the complexity of routine procedures • Adoption of new technology • Enforce approved Guideline and Policies • Regular monitoring of performance standards in hospital transfusion process • Improved organization of transfusion • Staff training on regular basis • Research on safe and effective use of blood • Alternatives to donor blood

38. IMPACT OF HTC HTC have a strong impact on better transfusion practice: With adequate Government support With adequate Administrative support With sufficient resources With real authority

39. CONCLUSION HTCs play a key role in blood conservation. • Development of an appropriate transfusion policy • Properly conducted clinical audit • Education of clinicians, nursing staff and other staff • Ensuring appropriate blood usage • Universally accepted transfusion triggers • Implementation of autologous transfusion - Optimize the use of an expensive therapy with limited availability

40. Thank you