Establishing & Running An Effective Hospital Transfusion Committee

1. Establishing & Running An Effective Hospital Transfusion Committee Christopher J. Gresens, M.D. VP & Medical Director, Clinical Services BloodSource

2. Transfusion Committees –Objectives • At the conclusion of this presentation, members of the audience will be able to … • Describe how to form and organize an effective transfusion committee, • Define the most important aspects of blood utilization review, • Summarize useful techniques for implementing and managing a successful transfusion committee.

3. Transfusion Committees –Outline Establishing and Running An Effective Hospital Transfusion Committee: Focusing On … • Justification and Organization • Membership and Function • Blood Center Participation • Conflicts of Interest • Blood Utilization Review

4. Transfusion Committees – Outline (Cont.) Establishing and Running An Effective Hospital Transfusion Committee: Focusing On … • Quality Management and Quality Tools • Transfusion Reaction Oversight • Role in Blood Management • Transfusion Guidelines • Implementation and Management

5. Transfusion Committees –Primary Reference The Transfusion Committee: Putting Patient Safety First Edited by Sunita Saxena, MD and Ira A. Shulman, MD

6. 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.

7. Transfusion Committees –I. Justification and Organization A typical transfusion consists of an interdisciplinary process involving as many as 10 steps: • Physician decides to transfuse. • Healthcare worker draws sample for compatibility testing. • Healthcare worker submits sample (with request for blood transfusion) to laboratory.

8. Transfusion Committees –I. Justification and Organization 10 Steps to a Transfusion (Continued): • Laboratorian performs testing. • Laboratorian maintains supply/storage of blood. • Laboratorian selects and issues compatible units. • Healthcare worker picks up blood.

9. Transfusion Committees –I. Justification and Organization 10 Steps to a Transfusion (Continued): • Healthcare worker performs identification checks, starts transfusion, and monitors patient. • Healthcare worker reports (in event of a transfusion reaction or other serious event) case as per requirements. • Laboratorians act on this information to perform transfusion reaction workup, and (in some cases) initiate component recalls, etc.

10. Transfusion Committees –I. Justification and Organization Multidisciplinary Nature of the Committee Because 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.

11. Transfusion Committees –I. Justification and Organization 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

12. Transfusion Committees –I. Justification and Organization 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).

13. Governing Body (e.g., Board) Executive Committee Quality Improvement Committee National Blood Transfusion Service (NBTS) Transfusion Committee Transfusion Committees –I. Justification and Organization Here’s an example of a transfusion committee that is effectively integrated into the hospital’s (and the NBTS’s) organizational structures …

14. 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

15. Transfusion Committees –II. Membership and Function Choosing 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).

16. II. Membership and Function An example of an ideal (though almost never attained) committee membership is as follows …

17. Transfusion Committees –II. Membership and Function The role of the transfusion committee should go beyond just blood utilization review. … to discuss Form 1 Pause…

18. Transfusion Committees –II. Membership and Function Steps 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

19. Transfusion Committees –II. Membership and Function Steps to Establishing Safe Hospital-Wide Transfusion Practices Cont.) STEP 3:Establish a reliable system for performing annual competency and compliance assessments Pause to discuss Form 3

20. Transfusion Committees –II. Membership and Function In 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. Pause to discuss Form 4

21. 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.

22. Transfusion Committees –III. Blood Center Participation 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.

23. Transfusion Committees –IV. Conflicts of Interest One legal definition of conflict of interest is as follows … “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)]

24. Transfusion Committees –IV. Conflicts of Interest • 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.

25. Transfusion Committees –IV. Conflicts of Interest • 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.

26. Transfusion Committees –IV. Conflicts of Interest • 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

27. Transfusion Committees –V. Blood Utilization Review Concurrent vs. Retrospective Blood Utilization Reviews?

28. Transfusion Committees –V. Blood Utilization Review • 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.]

29. Transfusion Committees –V. Blood Utilization Review • 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).

30. Transfusion Committees –V. Blood Utilization Review • 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).

31. Transfusion Committees –V. Blood Utilization Review • 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.

32. Transfusion Committees –V. Blood Utilization Review 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 …]

33. Transfusion Committees –V. Blood Utilization Review 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

34. Transfusion Committees –VI. Quality Management/Tools Transfusion service activities follow two separate paths of workflow: • Blood Component Inventory Management Path: which covers ordering, receiving, managing, and disposing of the component inventory

35. Transfusion Committees –VI. Quality Management/Tools • 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

36. Transfusion Committees –VI. Quality Management/Tools 10 quality system essentials form the backbone of a country’s blood banking standards: • Organization • Resources • Equipment • Supplier and Customer Issues • Process Control

37. Transfusion Committees –VI. Quality Management/Tools Quality System Essentials (Continued)… • Documents and Records • Deviations, Nonconformance's, and Adverse Events • Assessments: Internal and External • Process Improvement through Corrective and Preventive Action • Facilities and Safety

38. Transfusion Committees –VI. Quality Management/Tools Pause to discuss Forms 7 through 9

39. 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. Pause to discuss Form 10

40. 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.

41. Pause to discuss Form 11 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.

42. Transfusion Committees –X. Implementation and Management Planning 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.

43. Transfusion Committees –X. Implementation and 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).

44. Pause to discuss Form 12 Transfusion Committees –X. Implementation and Management 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.

45. Pause to discuss Forms 13-to-17 Transfusion Committees –X. Implementation and Management Planning 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).

46. Transfusion Committees –X. Implementation and Management 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.

47. Transfusion Committees –Summary Today We Focused On … • Justification and Organization • Membership and Function • Blood Center Participation • Conflicts of Interest • Blood Utilization Review

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

49. Transfusion Committees – End Discussion Where do we go from here? What may Global Healing and BloodSource do to assist?

50. 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.