Emergency Blood Products Management Policy
- Managing shortages of Blood and Platelets
Version
Name
of
committee
2
responsible
(ratifying)
Trust Governance committee
Date ratified
Document Manager (job title)
Dr Robert Corser, Consultant Haematologist
Date issued
07 December 2011
Review date
August 2013
Electronic location
PHT Clinical Policy
Related Procedural Documents
Major Incident Response Policy, Blood Transfusion
Policy, Pharmacy Guidelines
Key Words (to aid with searching)
Emergency Blood Plan, Blood Shortages, Platelets,
Blood Transfusion
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CONTENTS
QUICK REFERENCE – RED CELL SHORTAGES ...................................................................................3
QUICK REFERENCE (APPENDIX B) - PLATELET SHORTAGE PLAN ...................................................4
1
INTRODUCTION ................................................................................................................................5
2
PURPOSE ..........................................................................................................................................5
3
SCOPE ...............................................................................................................................................5
4
DEFINITIONS .....................................................................................................................................5
5
ROLES AND RESPONSIBILITIES .....................................................................................................6
6
PROCESS ..........................................................................................................................................7
7
TRAINING REQUIREMENTS .............................................................................................................9
8
REFERENCES AND SUPPORTING DOCUMENTATION ..................................................................9
9
MONITORING COMPLIANCE ............................................................................................................9
APPENDICES:
Appendix A - Red Cell Shortage Scheme Plan
Appendix B - Platelet Shortage Plan
Appendix C - Indications for Transfusion of Red cells
Appendix D - Platelet indication codes
Appendix E - Platelet Usage Guidance
Appendix F - KEY CARD 1 Emergency Red Cell Stock Contingency Plan
Appendix G - general e-mail message in event of Red cell shortage to all staff
Appendix H - general e-mail message in event of Platelet shortage to all staff
Appendix I - Communication plan in the event of Blood shortages
Appendix J - Guidance for the HTC and HTT during Green phases – where Red cell and Platelet
supply is adequate
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QUICK REFERENCE – Red cell shortages
Red Cell Shortage Scheme Plan
Green
Phase
Hospitals – ensure appropriate use of
Blood at all times
Make Sure EBMA policy developed
NHSBT notifies Amber
alert
Amber
Phase
Cascade Amber alert and enact
EBMA
Remove spare Blood stocks
NHSBT notifies further
reduction in use of
blood needed
Reduce Blood use
NHSBT notifies Red
phase
Red Phase
EBMAG cascades Red phase
alert
Blood use restricted to Category
1 patients outlined below
NHSBT communicates return to
Amber if shortage becomes less
severe
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NHSBT communicates
return to Green if
shortage is concluded
7-Feb-12
Quick reference (Appendix B)- Platelet Shortage Plan
Green
Phase
Hospitals – ensure appropriate use of
platelets
Make Sure EBMP policy developed
NHSBT notifies Amber
alert
Amber
Phase
Cascade Amber alert and enact EBMA
Remove platelet stocks
NHSBT notifies further
reduction
platelets
needed
Reduce platelet use
NHSBT notifies Red
phase
Red Phase
EBMAG cascades Red phase
alert
Platelet
use
restricted
to
Category 1 patients only
Data collection for platelet use
NHSBT communicates return to
Amber if shortage becomes less
severe
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NHSBT communicates
return to Green if
shortage is concluded
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1 Introduction
This document is a response to the Chief Medical Officer’s National Blood Transfusion Committee
documents outlining plans for Blood and Platelet shortages, issued in January 2010. (See references
1 and 2).
These documents seek to set out a framework for the use of these blood products in times of
shortages. The plan may also operate when there are no shortages. It draws upon the work done to
ensure appropriate use of Blood products as detailed in HSC 2007/001 Better Blood Transfusion –
Safe and Appropriate Use of Blood.
2 Purpose
The Department of Health requires the Trust should have an Emergency Blood Management Plan
(EBMP) in place to ensure that any shortage of blood or platelets are effectively managed, that the
Trust continues operating and that patients requiring these products continue to receive them. To
prepare for the possibility of a prolonged and or severe shortage of blood there must be a well
outlined contingency plan.
3 Scope
This document affects patients that may require blood products, particularly at times of national
shortages. With reference to the paragraph below, in special circumstances, the membership of the
groups may need to be varied if key personnel are unavailable. The EBMP plan has been
recommended by the Department of Health because of the risk of shortages in the situations
mentioned below.
The Trust’s Emergency Blood Management Policy may, depending on the circumstances, be codependent with the Major Incident Plan. This situation may occur if a Major Incident exhausts the
available supply of blood for transfusion. In this situation the work of the EBMG should not duplicate
or contradict the plans of the Major Incident Command and Control Team. The Chair of the EBMG
should ensure good lines of communication with Command and Control centre. The EBMG should
also refer to the Major Incident Plan for Blood Sciences.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may
not be possible to adhere to all aspects of this document. In such circumstances, staff should take
advice from their manager and all possible action must be taken to maintain on-going patient and staff
safety’
4 Definitions
Blood Products
Blood products are defined as packed red cells (commonly known as units of blood) or platelets
National Health Service Blood and Transplant (NHSBT)
The NHSBT is the body that manages blood supplies in England. It times of shortages they will notify
the Trust’s Blood Transfusion Laboratory of an alert phase.
Alert Phases
There are three phases of the plan for blood and platelet shortages, as declared and defined by the
NHSBT:
 Green: Normal circumstances where supply meets demand.
 Amber: Reduced availability of blood product for a short or prolonged period.
 Red: Severe, prolonged shortages.
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Patient Categories
The NHSBT defines 3 categories of patient who may need blood product support
Category 1 Patient
 Active major bleeding
 Emergency surgery
 Curative cancer surgery
Category 2 Patient
 Urgent surgery
 Palliative cancer surgery
 Symptomatic anaemia
Category 3 Patient

Elective surgery with greater than 20% chance of a 2 unit transfusion
Laboratory Staff
Trained Transfusion registered MLS, Clinical scientists with transfusion training, MLA acting under
supervision of registered MLS, Clinical Scientists or medical staff, members of the Haematology
medical team.
5 Roles and Responsibilities
National Blood Service (NBS – an arm of NHS Blood and Transplant)
In times of shortage, the NBS will notify the Blood Transfusion Laboratory and declare an alert.
Hospital Emergency Blood Management Group (EBMG)
The EBMG will:



Have senior hospital management support from the Chief Executive and Medical Director to
make difficult decisions in times of severe shortage of blood products
Formulate the local plan for blood shortages
Ratify policy and make arrangements to manage blood products appropriately in times of
shortage.
(Clinical Staff throughout the hospital must be made aware of the support of these key hospital staff
for the decisions made by the HTT in times of Shortage. An agreed email, will be sent at the start of
any shortage. (Appendix G & H) This will indicate that the HTT decisions have the support of the Trust
at the highest level. Subsequent emails sent once the EBMG has met will indicate the level of
support from the Medical director, as per the communication plan. (Appendix I))
Emergency Blood Management Group (EBMG) Representatives:
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
Medical Director (or representative if on leave if an alert is declared)
Consultant Haematologist Responsible for Transfusion (or Deputy)
Chair of the Hospital Transfusion Committee
Chief of Service Trauma, Orthopaedics, Rheumatology and Pain (Musculo-Skeletal)
Chief of Service - Theatres, Anaesthetics & Critical Care
Governance and Risk Management representative
Chief BMS Haematology - Blood transfusion
Chief of Service Surgery &Cancer Clinical Service Centre
The Hospital Transfusion Committee (HTC)
The HTC is responsible for the strategic direction of transfusion service at Portsmouth Hospitals NHS
trust, including the audit and ratification of blood related procedural documents.
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Appendix J outlines operational guidance from the Department of Health to the HTC, to use at times
when red cell and platelet supply are adequate
Hospital Transfusion Team (HTT)
The HTT together with key clinical personnel, will manage the local EBM plan. The HTT consists of
the:
 Blood bank manager or Deputy
 Consultant Haematologist who sits on the Transfusion Committee or deputy
 Transfusion practitioner
 Chair of the Hospital Transfusion Committee
Again, Appendix J outlines the operational guidance for the HTT, where red cell and platelet supply is
adequate
The HTT will also seek to ensure good transfusion practise and best use of Red cells and platelets at
all times through education, clinical polices, and audit. See Appendix J for details.
The Chief Executive
The Chief Executive will, through the Medical Director, to whom she delegates this responsibility,
provide senior support in times of severe shortage of blood products
Hospital Duty Manager
If an alert is called out of hours, the Hospital Duty Manager will liaise with the Consultant
Haematologist to inform the relevant on-call staff (Appendix F)
Lead Haematologist for Transfusion or deputy
The Lead Haematologist for Transfusion, if on duty will act to approve any products as defined in the
plan. If they are on leave then the Consultant Haematologist on duty for the laboratory during the day
or the On call haematologist out of hours will act up as deputy.
6 PROCESS
The Hospital Transfusion team and Committee seek to promote safe and efficient use of blood
products at all times. However at times of shortage the NHSBT may declare an alert restricting the
use of specific blood products.
6.1 Declaration of the Alert
The NHSBT may declare an Amber or Red Alert, either to all blood groups and products or to specific
blood groups or types of product.
When an Alert is declared the NHSBT will communicate this to the Consultant Haematologist with
responsibility for Transfusion and also the Blood Transfusion Laboratory. The laboratory & HTT will
enact the Emergency Blood Management Plan.
The Flow diagrams – for Red Cells, Appendix A and Platelets, Appendix B summarise the required
actions.
The Hospital Duty manager should be contacted out of hours.
6.2 Action during Red Blood Cell Transfusion Phases

6.2.1 Green Phase Red Blood Cells
The HTC and HTT will promote the objectives of Better Blood Transfusion and the appropriate
use of blood. Appendix J describes this process in detail.
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
The HTC and HTT will obtain senior management and NHS Trust Board commitment to
implement the Emergency Blood Management Plan.
6.2.2 Amber Phase Red Blood Cells
The EBMG will decide which categories of patients will have access to blood transfusion.








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


Continuation of elective surgery will depend on blood stock levels.
Consideration should be given to reducing the transfusion trigger for transfusions.
Cases of actual or potential massive blood loss must involve a Consultant Haematologist to
discuss patient management and blood product provision. Massive transfusion policies that allow
automatic supply of blood products may have to be partly suspended.
All requests for transfusion outside of the agreed indication codes (see appendix G) should be
referred to a Consultant Haematologist.
Reduction of the reservation period for cross matchedblood to 12 hours wherever possible.
6.2.3 Red Phase Red Blood Cells
The Transfusion Laboratory manager / deputy will reduce stockholding to the level notified by the
NHSBT. This may involve transfer of blood back to the NHSBT
The HTT on behalf of the EBMG will reduce usage to the level indicated by NHSBT.
Medical assessment of all requests for red cells,will be reviewed by a Consultant Haematologist.
Priority for transfusion willbebased on clinical need.
Daily review of the blood shortage and its impact on patient care by the EBMG.
Laboratory staff via the NBS and local hospital contacts, will share information to use regional
stocks more effectively.
The HTT will draw up a predetermined policy on dealing with major bleeding to give guidance on
when to stop blood component support.This will be ratified by the EBMG. This policy will be
ratified at a later date after the formation of the EBMG, and adoption of this EBMP policy.
6.3 Action during Platelet Transfusion Phases
6.3.1 Green Platelet Phase
See Appendix J
6.3.2 Amber Platelet Phase
 Stocks of platelets, will no longer be held, by the Laboratory, if notified of a Amber phase by
the NBS. Only platelets ordered for named patients will be delivered to the Laboratory.
 Laboratory staff will maximise the use of available platelet units through:
o
o
o
o
o




The interchangeable use of apheresis and pooled platelets (except for HLA/HPA
matched platelets)
Not requesting long dated platelets
Accepting platelets of a different ABO group (in line with BCSH guidelines)
Accepting leucodepleted platelets instead of CMV negative platelets
Accepting RhD positive platelets where RhD negative are not available and
administering anti-D where applicable.
The HTT and Consultant Haematologist will identify possible alternatives to transfusion of
platelets
Laboratory staff and HTT will reduce platelet usage to categories as identified in
communications from the NHSBT.
All requests for platelets, will be made by a senior clinician, Specialist Registrar or Consultant
level.
The Lead Haematologist for Transfusion or deputy will approve all platelet requests. The
transfusion laboratory will ask requesting clinicians to page the Lead Haematologist who will
confirm the order for platelets with the Transfusion Laboratory
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6.3.3 Red Platelet Phase
 As in Amber, but platelets will be restricted to category 1 patients only.
 The request for platelets must now be phoned directly by the nominated
Haematology Consultant Haematologist directly to the NHSBT consultants
 An additional data set for every request for platelets from NHSBT will be needed to
include:





Patient identifier (hospital number or name)
Indication for transfusion
Requesting Consultants name
Patient category (see Appendix 3) Patient blood group
Laboratory staff, (MLS, Consultant Haematologist depending on the question). Will
provide information to the NHSBT on request to assist with tracking of units of
platelets. If a unit is not used it can then be reallocated to another patient or hospital.
7 Training Requirements
No specific training is required for Clinicians and staff in general, but advice can always be sought
from members of the HTT, HTC or NHSBT as appropriate.
Haematology Medical Staff will have an Update meeting upon the first adoption of the Plan in
September 2011 and updates every autumn.
Other Laboratory Staff will be informed of the plan through their regular update meetings.
8 References and Supporting Documentation
8.1 Internal



Blood Transfusion Policy
Major Incident Response Policy
Pharmacy Guidelines – Use of Platelets
8.2 External



Chief Medical Officer’s National Blood Transfusion Committee - A Plan for NHS Blood and
Transplant and Hospitals to address Red Cell Shortages (DH 109118.)
Chief Medical Officer’s National Blood Transfusion Committee - A Plan for NHS Blood and
Transplant and Hospitals to address Platelet Shortages (DH 109119)
Better Blood Transfusion Safe and Appropriate Use of Blood.4transfusionguidelines.org.uk BBT HSC 07
9 Monitoring Compliance
If there is a need to enact the Amber or Red phases of the plan then a review meeting of the EBMG will
take place after the emergency is over to see if there are any lessons to be learned.
Monitoring the Green phases of the plan will take place through the remit of the HTC and HTT, by
ensuring participation in regular national audits of transfusion and local audits in the laboratory and in
clinical areas to ensure good transfusion practise.
The HTC reports to the Trust Governance committee annually.
If the EBMG recommends any action after an Amber or Red phase then they will report this to the HTC
and the Trust governance committee. The EBMG will direct the HTT / HTC or other appropriate groups
to act on their behalf.
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Change in practice and lessons to be earned will be circulated as appropriate through the Team brief
and via the intranet.
It is not possible to be prescriptive about how this policy can be monitored in full as the likelihood of any
event requiring its use cannot be predicted.
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Appendix A -Red Cell Shortage Scheme Plan
Green
Phase
Hospitals – ensure appropriate use of
Blood at all times
Make Sure EBMA policy developed
NHSBT notifies Amber
alert
Amber
Phase
Cascade Amber alert and enact
EBMA
Remove spare Blood stocks
NHSBT notifies further
reduction in use of
blood needed
Reduce Blood use
NHSBT notifies Red
phase
Red Phase
EBMAG cascades Red phase
alert
Blood use restricted to Category
1 patients outlined below
NHSBT communicates return to
Amber if shortage becomes less
severe
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NHSBT communicates
return to Green if
shortage is concluded
7-Feb-12
Appendix B - Platelet Shortage Plan
Green
Phase
Hospitals – ensure appropriate use of
platelets
Make Sure EBMP policy developed
NHSBT notifies Amber
alert
Amber
Phase
Cascade Amber alert and enact EBMA
Remove platelet stocks
Reduce platelet use
NHSBT notifies further
reduction
platelets
needed
NHSBT notifies Red
phase
Red Phase
EBMAG cascades Red phase
alert
Platelet
use
restricted
to
Category 1 patients only
Data collection for platelet use
NHSBT communicates return to
Amber if shortage becomes less
severe
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NHSBT communicates
return to Green if
shortage is concluded
7-Feb-12
Appendix C -Indications for Transfusion of Red cells
Category 1
These patients will remain
highest priority of transfusion
Resuscitation R1
Resuscitation of life threatening
/on-going blood loss including
trauma.
Surgical support
Emergency surgery* including
cardiac and vascular surgery**,
and organ transplantation.
Cancer surgery with the intention
of cure.
Category 2
These patients will be transfused in
the Amber but not the Red phase
Category 3
These patients will not be
transfused in the Amber phase
Surgery/Obstetrics
Cancer surgery (palliative).
Symptomatic but not lifethreatening post-operative or postpartum anaemia.
Urgent*** (not emergency) surgery.
Surgery
Elective surgery likely to
require donor blood support
(Patients with > 20% chance
of needing 2 or more units of
blood during or after surgery).
Non-surgical anaemias
Life-threatening anaemia
including patients requiring inutero support and high
dependency care/SCBU.
Stem cell transplantation or
chemotherapy ****
Severe bone marrow failure.
Thalassaemias (but consider
lower threshold).
Sickle cell disease crises
affecting organs.
Sickle cell patients aged < 16
with past history of CVA.
Non-surgical anaemias
Symptomatic but not lifethreatening anaemia.
* Emergency - patient likely to die within 24 hours without surgery.
** With the exception of poor risk aortic aneurysm patients who rarely survive but who may require large volumes of blood.
*** Urgent - patient likely to have major morbidity if surgery not carried out.
**** Planned stem cell transplant or chemotherapy should be deferred if possible.
Indication Codes
In times of shortage use of these indication codes may help to clarify which blood products support
should be allowed.
Code
Indication
R1
Acute blood loss – no specific haemoglobin level
R2
Peri-operative transfusion – non cardiovascular patient – Hb less than 7 g/dl
R3
Peri-operative transfusion – known CVD or risk factors for this – Hb less than 8 g/dL
R4
Critical Care – Hb more than 7 g/dl or 8 g/dl in the elderly or with CVD
R5
Post Chemotherapy – no evidence base but Hb 8 - 9 g/dl
R6
Radiotherapy Hb more than 10 g/dl
R7
Chronic Anaemia to prevent symptoms – individual approach depends on symptoms
O Negative blood
In times of shortage then O negative blood should be reserved for Women childbearing age. Men and
Women, who are unable to bear children, should be given O positive red cells.
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Appendix D- Platelet indication codes
Bone marrow failure
P1.
P2.
P3.
To prevent spontaneous bleeding when the platelet count <10 x 109/l.
To prevent spontaneous bleeding when the platelet count <20 x 109/l in the presence of additional
risk factors for bleeding such as sepsis or haemostatic abnormalities.
To prevent bleeding before invasive procedures. The platelet count should be>50 x 109/l before
lumbar puncture, epidural anaesthesia, insertion of intravascular lines, transbronchial and liver
biopsy, and laparotomy, and be>100 x 109/L before surgery in critical sites such as the brain or
the eyes.
Critical care/surgery
P4.
P5.
P6.
P7.
Massive blood transfusion. The platelet count can be anticipated to be <50 x 109 /l after 1.5-2 x
blood volume replacement. Aim to maintain platelet count >50 x 109 /l.
Bleeding, not surgically correctable and associated acquired platelet dysfunction e.g. postcardiopulmonary bypass, post use of potent anti-platelet agents such as Clopidogrel.
Acute disseminated intravascular coagulation (DIC) in the presence of bleeding and severe
thrombocytopenia.
Inherited platelet dysfunction e.g. Glanzmann'sthrombasthenia with bleeding or as prophylaxis
before surgery.
Immune thrombocytopenia
P8. Autoimmune thrombocytopenia, in the presence of major haemorrhage.
P9. Post-transfusion purpura, in the presence of major haemorrhage.
P10. Neonatal allo-immune thrombocytopenia, to treat bleeding or as prophylaxis to maintain the
platelet count >50 x 109 /l.
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Appendix E- Platelet Usage Guidance

Category 1 patients are those with the greatest clinical need for platelet support and therefore should
be given priority when considering allocation of platelets.

Category 2 and 3 patients should be given lower priority. The use of platelets should be considered
as one element in the overall management of these patients.

Use should be guided by the clinical condition of the patient and laboratory/near patient testing.
Category 1
(Patients to be treated in Red
Phases)
Category 2
(Patients to be treated in Red and
Amber Phases)
Massive haemorrhage & Critical care
Massive transfusion for any condition
including obstetrics, emergency
surgery and trauma, with on-going
bleeding, maintain > 50 x 109/L. Aim
for >100 x 109/L if multiple trauma or
CNS trauma
Critical care
Patients resuscitated following massive
transfusion with no on-going active bleeding,
maintain > 50 x 109/L
Bleeding in the presence of
sepsis/acute DIC, maintain >50x
109/L.
Transfusion triggers for invasive procedures
Invasive monitoring or biopsy work, maintain
platelet count > 50 x 109/L
General surgery maintain count > 50 x 109/L
Operations in critical sites such as brain or
eyes maintain > 100 x 109/L.
Bone marrow failure
Prophylactic transfusion for thrombocytopenia
(platelet count < 10 x 109/L) in patients who
are not infected and haemodynamically stable.
Consider support if platelet counts is<20 x
109/L for patients at higher risk of bleeding.
Bone marrow failure, and immune
thrombocytopenia
Active bleeding associated with
severe thrombocytopenia or
functional platelet defects
Category 3
LOW PRIORITY
Surgery
Elective, non-urgent surgery likely to
require platelet support for
thrombocytopenia or congenital/
acquired platelet defects
Surgery Urgent but not emergency surgery for
a patient requiring platelet support
Neonates
Neonatal allo-immune
thrombocytopenia or severe
thrombocytopenia in an otherwise
well neonate, platelet transfusions
are required when the platelet count
falls to between 20 - 30 x 109/L.
Higher target levels should be
maintained if extremely low birth
weight or unwell/bleeding or Intracranial haemorrhage suspected /
confirmed.
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Appendix F- KEY CARD 1 Emergency Red Cell StockContingency Plan
If the plan is implemented there will be a number of key roles, which will be highlighted on Key Cards
with designated actions that must be followed.
Chief BMS, Haematology or Acting Deputy
On receiving AMBER or RED Alert undertake the following
Forward the Fax received from the National Blood Transfusion Service to:
Medical Director
Consultant Haematologist
Emergency Action 2 Out of Hours inform the following people who are on-call
Consultant Haematologist
Hospital Duty Manager
The Hospital Duty Manager will liaise with the Consultant Haematologist to inform the relevanton-callstaff from the
list below
Senior A & E Consultant
Consultant - DCC Critical Care
Consultant - MAU
Consultant General Surgery
Consultant Obstetrics & Gynaecology
Consultant Orthopaedics
Consultant Paediatrics
Night Practitioner - Senior Nurse Bleep holder
Emergency Action 3
Delegate a staff member to check the current blood stock level - will need regular updates
All unused blood returned to stock 24hrs from request.
Reservation may be reduced to cover duration of surgery only.
Help with adherence to MSBOS and provide regular updates to EBMG Team
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APPENDIX G – general e-mail message in event of Red cell shortage to all staff
Shortage of Red Cell Supply - information for all staff.
Portsmouth Hospitals NHS trust has been informed by the National Blood Service that there are
shortages of some blood products.
The Trusts Emergency Blood Shortage management group (EBMG) will arrange to meet and activate
the Emergency Blood Shortage management Policy(EBMP) available on the internet to ensure the
best use of Red Cells.
Staff requesting Blood productsmust include information so that the patient can be assigned to one of
three nationally recognised Patient categories.This helps to assess the urgency forRed cell
transfusion support – see table below.
It is also essential that staff making requests include their contact details on the request form in order
to optimize communication with the Transfusion Laboratory.
This plan has the support of the Medical Director.
Further emails will be circulated with any specific actions once agreed by the EBMG
Patient Categories:
Category 1
Category 2
Category 3
Active major bleeding
Emergency surgery
Urgent surgery
Curative cancer surgery
Palliative cancer surgery
Life-threatening anaemia
Symptomatic anaemia
Elective surgery with >20%
chance of 2 unit transfusion
APPENDIX H – general e-mail message in event of Platelet shortage to all staff
Shortage of Platelet Supply - information for all staff.

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Portsmouth Hospitals NHS trust has been informed by the National Blood Service that there are
shortages of platelets.
The trusts Emergency Blood Shortage management group (EBMG) will use the Emergency Blood
Shortage management Plan available on the internet to ensure the best use of platelets. For full
details see Appendix E of the plan.
It is also essential that staff making requests include their contact details on the request form in order
to optimize communication with the Transfusion Laboratory.
Requests for platelets must come from a Senior Clinician - Speciality Registrar 3 level or above , or
Consultant. You will be directed to speak with a Haematology Consultant for authorisation of your
request.
Further emails will be circulated with any specific actions once agreed by the EBMG
This plan has the full support of the Medical Director.
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Appendix I - Communication plan in the event of Blood shortages
1.1
1.2
1.3
1.4
1.5
1.6
Introduction
If blood supplies available from the National Blood Service fall to a critical level, a message will be
sent to the Blood Transfusion Laboratory.
An action card (Appendix F) will detail the procedure to the transfusion laboratory staff who would
receive the message.
As soon as possible an Emergency Blood Management Group (EBMG) will meet to discuss the
management of the shortage.
The routine care for patients in the hospital may be significantly affected. This may cause public
concern when the shortage is reported in the media. Shortages of red cells are likely to result in
cancellation of routine operations.
This appendix to the EBMP is designed to ensure that all required information is widely distributed,
efficiently and to appropriate members of staff. It will inform Trust employees and educate them
about their responsibilities, and what action they need to take, in the event of shortages.It will also
help to inform patients and the local community.
2 Internal Communications
2.1 As soon as the blood shortage status has been declared, either of Red Cells or Platelets,The
Communication’s team will be asked to send an e-mail message (see appendix G or H)to all staff
informing them of the change in status. The only general action at this stage is the requirement for
cross match requests to categorize the patient group – see Appendix C.
2.2 As soon as the EBMG has met and the likely implications of the shortage have been discussed,
communications department should arrange for an e-mail to be sent to all Consultants and Head
Nurses/Matrons informing them of the situation and the likely consequences.
2.3 Senior members of staff receiving this e-mail are responsible for cascading the information to their
teams.
2.4 Information communicated to the staff should include details of the emergency, its likely duration
and action to take if real or potential problems are identified.
2.5 A message should be posted on the PHT intranet homepage indicating a move to the Amber or
Red phase, with a link to this PHT Emergency Blood Management Policydocument and to a Blood
Status Report from the EBMG.
2.6 Any messages will include statements such as the “Medical director has given his approval to this
communication”.
3 External Communications
3.1 In the first instance, a press release should be issued containing details of the problem, actions
taken and likely consequences of the actions and advice to patients who think that their operations
may be affected. This should include a contact telephone number for enquiries.
3.2 If a large number of enquiries are received, consider implementing a Telephone Enquiries Policy
which involves commissioning NHS Direct to act as the telephone answering service. If this
agreement is implemented, a script will need to agreed by the EBMG and given to NHS Direct.
3.3 Enquiries from the public will be directed to the Communications Team.
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Appendix J - Guidance for the HTC and HTT during Green phases – where Red cell and Platelet
supply is adequate
This Appendix details actions undertaken by the Hospital Transfusion committee and Team to ensure
good practice and governance in Blood Transfusion.
Guidance for Green Phase of Plan




The Trust will enable membership and functioning of the Hospital Transfusion Committee (HTC) and
Hospital Transfusion Team (HTT) including staffing and resources
The HTC and HTT will ensure that there are blood transfusion policies for the effective use of donor
blood products in place, which are implemented and monitored. Monitoring will be by participation in
National and Local audits as directed by the HTC.
The Trust will provide education and training to all staff involved in the process of blood transfusion.
This education will be included in the induction programmes for relevant new staff.
The HTT and HTC will promote co-operation between hospital blood transfusion laboratories from
other Trust to utilise regional blood stocks more effectively, within legal and regulatory limits.
The HTC and HTT will ensure the appropriate use of blood and the use of effective alternatives in
every clinical practice where blood is transfused





By implementing existing national guidance on the appropriate use of blood and alternatives.
Ensuring that guidance is in place for the medical and surgical use of red cells, and other blood
components such as platelets and fresh frozen plasma.
The Blood transfusion Laboratory will implement regular monitoring of blood stocks to ensure
minimum wastage. The HTC and HTT will participate in National audit of usage of red cells, platelets
and fresh frozen plasma in all clinical specialities. These audits are on a 3-year cycle. The HTC will
also encourage Local audit in clinical areas where blood usage is high to ensure best practise.
The HTC / HTT will educate and support blood transfusion laboratory staff to ensure that appropriate
clinical information is provided with requests for blood transfusion.
The HTC will ratify and establish local protocols so blood transfusion laboratory staff are empowered
to ask clinicians about the reason why a patient needs a transfusion,so it is appropriate and meets
trust guidelines.
Securing appropriate and cost-effective provision of blood transfusion and alternatives in
surgical and obstetric care








The HTC and HTT will ensure that pre-operative assessment of patients for planned surgical
procedures identifies problemsbefore admission allowing the investigation and treatment of anaemia
and the optimisation of haemostasis.
Through the HTC and HTT anappropriate, agreed list of indications for transfusion,will be produced.
This will be in collaboration with key clinical specialities. The HTC should implement and monitor
these. The MSBOS – maximum Surgical Blood Ordering Schedule is an example.
The HTC through the HTT will develop a blood conservation strategy including the use of point-ofcare testing for haemoglobin concentration and haemostasis and alternatives to donor blood such as
peri-operative cell salvage and pharmacological agents such as anti-fibrinolytics and intravenous
iron.
Ensure that the blood conservation strategy is implemented.
Ensure the establishment of procedures for the identification and management of maternal anaemia
in particular with correction of iron deficiency in the antenatal and postnatal period.
The hospital will ensure the safe and appropriate use of platelets.Laboratory staff will assess platelet
requests, to see if they meet Trust guidelines. A Consultant Haematologist approval may be sought
for any platelet request that is outside this guidance.
Aspirin or other drugs affecting platelet function should be stopped prior to surgery in time to allow
platelet function to recover.
Emergency Blood Management Plan (EBMP), for Green, Amber and Red phase of a platelet
shortage will ensure consistent action in hospitals to platelets transfusion and minimise waste.
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





Regular clinical audit will take placeagainst agreed guidelines. From this there will be feedback to
reduce inappropriate use, implementation best practice, and to minimise wastage. Re-audit will
monitor effectiveness of audit.
Investigate how to implement the use of National Codes for Transfusionso that every request for
platelets comes with an indication.
Ensure there are up to date transfusion protocols/transfusion thresholds for all transfusions.
Education and training sessions for staff of all levels, including induction and regular updates.
Transfusion guidelines formulated and included in the Junior Medical Staff induction.
Hospital wide education of existence of EBMP
Participation in the Blood Stock Management Scheme. Transfusion Laboratory Manager to develop
links with local hospitals to permit movement of stock between sites.
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Checklist for the Review and Ratification of Procedural Documents and
Consultation and Proposed Implementation Plan
To be completed by the author of the document and attached when the document is submitted for ratification: a
blank template can be found on the Trust Intranet. Home page -> Policies -> Templates
CHECKLIST FOR REVIEW AND RATIFICATION
TITLE OF DOCUMENT BEING REVIEWED:
1
2
Title
Yes
Is the title clear and unambiguous?
Yes
Will it enable easy searching/access/retrieval??
Yes
Is it clear whether the document is a policy, guideline, procedure,
protocol or ICP?
Yes
4
5
Is there a standard front cover?
Yes
Is the document in the correct format?
Yes
Is the purpose of the document clear?
Yes
Is the scope clearly stated?
Yes
Does the scope include the paragraph relating to ability to comply,
in the event of a infection outbreak, flu pandemic or any major
incident?
Yes
Are the definitions clearly explained?
Yes
Are the roles and responsibilities clearly explained?
Yes
Does it fulfill the requirements of the relevant Risk Management
Standard? (see attached compliance statement)
Yes
Is it written in clear, unambiguous language?
Yes
Evidence Base
Is the type of evidence to support the document explicitly
identified?
Yes
Are key references cited?
Yes
Are the references cited in full?
Yes
Are associated documents referenced?
Yes
Approval Route
Yes
Dissemination and Implementation
Is a completed proposed implementation plan attached?
7
No
Review Date
Is the review date identified?
6
Yes
Process to Monitor Compliance and Effectiveness
Are there measurable standards or KPIs to support the monitoring
of compliance with the effectiveness of the document?
7
Yes
Content
Does the document identify which committee/group will approve it?
6
COMMENTS
Introduction
Are reasons for the development of the document clearly stated?
3
YES/NO
N/A
Yes
Equality and Diversity
Is a completed Equality Impact Assessment attached?
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APPENDIX A
cont……
Checklist for the Review and Ratification of Procedural Documents and
Consultation and Proposed Implementation Plan
CONSULTATION AND PROPOSED IMPLEMENTATION PLAN
Date to ratification committee
Groups /committees / individuals involved in the
development and consultation process
HTT – Jo Hickey Transfusion Practitioner
HTC
Sheena King
Is training required to support implementation?
For Blood Transfusion Staff & Haematology
Medical Staff
If yes, outline plan to deliver training
Internal Transfusion training programme will have
a meeting to discuss this plan
Haematology Medical Staff to have update
September 2011
Outline any additional activities to support
implementation
Individual Approval
If, as the author, you are happy that the document complies with Trust policy, please sign below and send the document,
with this paper, the Equality Impact Assessment and NHSLA checklist (if required) to the chair of the committee/group
where it will be ratified. To aid distribution all documentation should be sent electronically wherever possible.
Name
Dr Robert Corser
Date
27th July 2011
Signature
Committee / Group Approval
If the committee/group is happy to ratify this document, would the chair please sign below and send the policy together with
this document, the Equality Impact Assessment, and NHSLA checklist (if required) and the relevant section of the minutes
to the Trust Policies Officer. To aid distribution all documentation should be sent electronically wherever possible.
Name
Date
Signature
If answers to any of the above questions is ‘no’, then please do not send it for ratification.
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APPENDIX B
EQUALITY IMPACT ASSESSMENT
To be completed by the author of the document and attached when the document is submitted for
ratification: a blank template can be found on the Trust Intranet. Home page -> Policies -> Templates
Equality Impact Screening Tool
To be completed and attached to any procedural document when submitted to the appropriate
committee for consideration and approval.
Stage 1 - Screening and Scoping
Date of assessment
8th of June 2011
Department
Clinical Haematology – Surgery and Cancer / Clinical Support Services – Pathology – Blood
Sciences
Name and Job title of person responsible for assessment
Dr Robert Corser
Policy / Function
Emergency Blood Management plan
Aims and objectives of policy/function
To give a framework to manage blood shortages
Who is involved in the assessment?
Myself
Who should benefit from the policy/function provided?
Any patient that needs blood, Laboratory Staff, Clinical staff
The following questions should be
considered during the screening
process.
Yes/
No
1
What evidence is there already held on the
impact on different groups? Complaints,
surveys, reports, summarise the main
points
2
What evidence is there to show the
policy/function is meeting people’s
requirements
3
Can this assessment be linked to an
existing or planned function/policy review
4
Explain
Not
aware
of any
Similar policies in other trusts, DH
guidelines
No
New policy
Assess how the policy/function meets
different needs. (e.g age, gender, race,
disability, sexual orientation, religion/belief
Situations where we may need blood
products occur at all ages and to all
creeds, It tries to conserve blood at all
times and prevent harm if blood products
are in short supply
Does the policy/function contribute to
equality, diversity and human rights?
If yes – identify how
We must make sure that we use
resources well and if these are in short
supply for example, protect the human
rights of patients by avoiding procedures
where blood could be required. It gives a
framework for what to do if blood is in
short supply. In a fair and equitable way
5
If no – could it?
Yes
6
Are there any obvious barriers to different
groups accessing the aims of the
No
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policy/function? (e.g. age, gender, race,
disability, religion)
7
If you have identified potential
discrimination, are the exceptions valid,
legal and/or justified?
No
8
What could be changed to reduce /remove
the barriers
NA
9
Is there any other information, which could
influence making improvements to the
policy/function? e.g. from partner
organisations
No
Does the policy/function affect one group less or more favourably than another on the basis of

10
No
Race
 Ethnic origin (including gypsies and
travellers)
No

Gender
No

Religion or belief
No
 Sexual orientation including lesbian,
gay and bisexual people
No

Age
No

Disability - learning disabilities,
physical disability, sensory
impairment and mental health
problems ,e.g dementia
No
Does this policy/function affect individual
human rights?
If the answer to any of the above questions
is yes, a full impact assessment is required,
go on to stage 2. If no, the EIA is
completed,
NA
Stage 2
11
12
13
14
Consult formally on the policy/function
procedure and any options with relevant
stakeholders (using a range of accessible
and appropriate methods and venues.)
This could involve a survey, focus groups
or the use of consultants, depending on the
level of impact.
Publish results of assessments. Develop
actions / improvements and set as
objectives ( action plan form)
Include objectives in the service equality
action plan and report to the Equality and
Diversity Committee and Divisional Review
Once the final option is chosen, the
outcomes must be monitored regularly to
check for unexpected adverse impacts
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If the answers to any of the above questions is ‘yes’ you will need to complete a full Equality Impact
Assessment (available from the Equality and Diversity website) or amend the policy such that only an
disadvantage than can be justified is included. If you require any general advice please contact staff in
the Equality and Diversity Department on 02392 288511
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