Establishing & Running An
Effective Hospital
Transfusion Committee
Christopher J. Gresens, M.D.
VP & Medical Director, Clinical Services
BloodSource
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
Establishing and Running An Effective Hospital
Transfusion Committee: Focusing On …
1.
2.
3.
4.
5.
Justification and Organization
Membership and Function
Blood Center Participation
Conflicts of Interest
Blood Utilization Review
Transfusion Committees – Outline (Cont.)
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
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.
Transfusion Committees –
I. Justification and Organization
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.
Transfusion Committees –
I. Justification and Organization
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.
Transfusion Committees –
I. Justification and Organization
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.
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.
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
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).
Transfusion Committees –
I. Justification and Organization
Governing Body (e.g., Board)
Executive Committee
Here’s an example of a
transfusion committee
that is effectively
integrated into the
hospital’s (and the
NBTS’s) organizational
structures …
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
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).
II. Membership and Function
An example of an ideal (though almost never
attained) committee membership is as follows …
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)
Transfusion Committees –
II. Membership and Function
The role of the transfusion committee should go beyond just blood
utilization review.
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
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
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
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.
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.
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)]
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.
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.
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
Transfusion Committees –
V. Blood Utilization Review
Concurrent vs.
Retrospective Blood
Utilization Reviews?
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.]
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).
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).
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.
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 …]
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
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
Transfusion Committees –
VI. Quality Management/Tools
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
Transfusion Committees –
VI. Quality Management/Tools
10 quality system essentials form the
backbone of a country’s blood banking
standards:
1)
2)
3)
4)
5)
Organization
Resources
Equipment
Supplier and Customer Issues
Process Control
Transfusion Committees –
VI. Quality Management/Tools
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
Transfusion Committees –
VI. Quality Management/Tools
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.
Pause to discuss Form 10
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-toaccess 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.
Pause to discuss Form 11
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.
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).
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.
Pause to discuss Form 12
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).
Pause to discuss Forms 13-to-17
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.
Transfusion Committees –
Summary
Today We Focused On …
1.
2.
3.
4.
5.
Justification and Organization
Membership and Function
Blood Center Participation
Conflicts of Interest
Blood Utilization Review
Transfusion Committees –
Summary
Topics of Discussion (Continued) …
–
–
–
–
–
Quality Management and Quality Tools
Transfusion Reaction Oversight
Role in Blood Management
Transfusion Guidelines
Implementation and Management
Transfusion Committees –
End Discussion
Where do we go from here?
What may Global Healing and
BloodSource do to assist?
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.
Thank You …
To all of our friends/colleagues in
the audience…
Chris.Gresens@BloodSource.org