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Blood Watch Program

Blood Watch - improving transfusion medicine for patients in NSW

Blood Watch is a NSW state-wide transfusion medicine improvement program and its' primary goal is to improve the safety and quality of fresh blood product transfusion in all NSW Public Hospitals.

In keeping with national trends in improvements in transfusion medicine, the Blood Watch program will focus on these six key areas: appropriateness of blood component therapy; reporting of adverse transfusion related events; clinical governance issues; accurate costing of transfusion medicine; ongoing education of health care professionals; and communication of policy to address supply and demand issues.

The Blood Watch program is supported by all NSW Area Health Services and the Australian Red Cross Blood Service.

Blood Myths

Program Overview

Background

There has been significant activity in the "blood arena" in all jurisdictions in Australia especially in regard to the improvement in safety and quality of care around blood and blood products. These activities include (but are not limited to):

The 2005 Report for the Australian Council for Safety and Quality in Health Care - Towards Better Safer Blood Transfusion (Boyce and Brook)
The NSW Blood Transfusion Improvement Collaborative (BTIC) - final report and recommendations of 2003
Restructuring of funding and governance arrangements for blood in Australia with the formation of the National Blood Authority
NSW Health policy (2005_261 and 2005_332) regarding accountability for blood and blood products in NSW and management of fresh blood components

In keeping with National trends in improvements in transfusion medicine, the NSW Department of Health approached the CEC to lead an improvement of safety and quality matters and clinical issues in regard to fresh blood products in NSW.

Who' s Who in Transfusion Medicine?

The National Scenario

The National Blood Authority (NBA) is a statutory agency established to improve and enhance the management of the Australian blood banking and plasma product sector at a national level. From July 1, 2003 the NBA has managed the national purchasing, contracting and supply of blood and blood products on behalf of all Australian Governments.

Governance of Transfusion Medicine within NSW Health

NSW Health has established a Committee - the Blood Products Advisory Committee- to co-ordinate activities for the Department and the National Blood Authority.

Blood Watch- Transfusion Medicine Improvement Program at the CEC

The CEC Blood Watch management team includes:

Ms Bernie Harrison, Director, Quality Assessment Systems & Blood Watch
Ms Carolyn Der Vartanian, Program Leader, Blood Watch
Email: carolynd.dervartanian@cec.health.nsw.gov.au
Ph: 02 9382 7818 Fax: 02 9382 7615
Dr Amanda Thomson, Consultant Haematologist
Email: AThomson@nsccah.health.nsw.gov.au

The management team is guided by the Transfusion Medicine Advisory Committee (TMAC) which meets regularly.

The Program

The CEC convened a Transfusion Medicine Advisory Committee and held a successful planning day in July 2006. All Area Health Services nominated representatives with expertise in transfusion medicine who participated in the development of an operational plan for improving transfusion practice over the next one and three years respectively.

Key performance targets have been developed for the following priority areas:

Appropriateness of transfusion of fresh products
Clinical governance, including the formation of Area Health Service Transfusion Committees
Education strategies through dissemination of key resources through existing professional and educational bodies
Reporting of adverse events through IIMS
Communication between Area Health Services, NSW Department of Health, and the National Blood Authority
Identification of the need for accurate costing models of direct and indirect costs of transfusion medicine.

A two year work plan, based on these key performances, has been developed by the TMAC.

To ensure broad stakeholder support for the program each Area Health Service has nominated a senior clinician who has either a clinical interest or responsibility for transfusion medicine within the AHS who will work with the CEC and their local team.

The CEC funded nine project officer positions for 12 months in 2007 – the majority of which were Clinical Nurse Consultants in Transfusion Medicine. Each Area Health Service also appointed clinical leads (haematologists or anaesthetists) to form project teams with representatives of local pathology providers and blood bank and other key clinical and governance staff, to implement the Blood Watch work plan.

Key Strategies

A comprehensive diagnostic exercise has been undertaken to gain insight into current transfusion prescribing practice. These included the following:

A review of incidents reported in the NSW healthcare reporting system Incident Information Management System (IIMS), relating to blood or blood products. Six hundred and eighty entries for the period July 2005 – June 2006 were reviewed:

mislabelled specimens were the most frequently notified type of adverse transfusion event in the sample (36%);
storage/wastage and or transport issues were the most commonly identified issue which led to 'cold chain' breaks;
53% coded into the blood/blood products incident type were potentially 'misclassifications'.

The Blood Watch teams conducted a comprehensive red cell audit within their major facilities. The results are as follows:

The combined audits included 323 transfusion episodes. Of these, 12.7% of patients were anaemic and had surgery with haemoglobins under 105g/L. The underlying cause of probable iron deficiency anaemia was not investigated or treated pre-operatively.
4% of patients received red blood cell transfusion with Hb over 100g/L which is outside of the NH&MRC/ ASBT Guidelines.
95% of patients had post-operative red cell transfusion with Hb's above 70g/L and of those, 83% received a transfusion without evidence in the medical record of clinical indication for transfusion.
Standard dose for all patients was 2 units however current advice from experts is that a 1 unit transfusion should be followed by an assessment of the patients' symptoms before progressing with a second unit.

A data linkage project was undertaken which links Health Information Exchange (HIE), pathology and blood bank data. This database allows comparison of red cell usage and dosage by DRG and by hospital. These data show the ratio of transfusions which are occurring above the state average and indicate widespread variation in practice.

Comparative data for rural and metro hospitals show that out of the 9 large metro hospitals six of them are prescribing up to 42% above the state average.
In the larger rural hospitals there was a similar finding with five out of six prescribing up to 80% above the state average. It was noted that those hospitals which performed best had a 'quality systems' in place, i.e. clinical governance structures, use of restrictive thresholds, education and data feedback have improved performance in red cell utilisation.
The database has been provided to Area Health Service Transfusion Committees as part of their review and improvement of performance. A new data feed will occur annually.

The CEC, in co-sponsorship with the National Blood Authority, commissioned market research into the prescribing behaviours of senior consultants which included surgeons, anaesthetists and physicians who treat haemodynamically stable patients with normal bone marrow. The research showed the following:

Senior doctors had a high personal confidence in prescribing habits, with a general assumption that they represent best practice. This is often incorrect, yet there is a reluctance to recognise this even when presented with the guidelines.
- Understanding and influencing Blood Prescription, a market research report prepared by Eureka Strategic Research for the Clinical Excellence Commission and the National Blood Authority, Dec 2007

The CEC will develop a communications strategy based on the recommendations of the report.

Change Initiatives and Interventions

A range of interventions and solutions have been put in place by Blood Watch project teams which include:

Education and promulgation of guidelines via the BTIC video and learning guide Appropriate use of Red Cell Transfusion (copies available from the CEC)
Formation of an Area-based Transfusion Committee in all Area Health Services
Audit and feedback – red cell transfusion and platelet transfusion
Implementation of restrictive thresholds in some facilities
Dissemination of ARCBS Lanyard cards (with red cell guidelines) to all facilities
Academic detailing by Blood Watch Clinical Leads
A series of Blood Myths posters was developed in consultation with transfusion experts and disseminated across the State. The purpose of the posters is to debunk some common myths about transfusion, based on the fact that blood is a living tissue transplant and the safety considerations of this are significant yet seriously underestimated.
usly underestimated.(Hyperlink to posters)
Dissemination of ARBCS - BloodSafe Flippin Blood booklets to all AHS.
Development of Area-wide transfusion administration forms within some Area Health Services
Development of Area Standard of Practice for transfusion.
Development of Area-wide policy for blood and blood component transfusion in most Area Health Services.

Future plans – 2008 onwards

The major pieces of work yet to be completed include (but are not limited to):

the development and implementation of a communications strategy for senior clinicians
the roll out of the BloodSafe e-learning program across NSW in April 2008. This program addresses the fundamentals of red cell transfusion, storage and appropriateness
dissemination of a new patient information brochure
education around informed patient consent
updating the Red Cell Relative Use database for 06-07
wide-spread red cell audit in all major facilities by Blood Watch teams in April 2008.

The role of the CEC is to continue supporting the Area Health Services by:

facilitating networking between teams and other jurisdictions,
sharing of best practice
providing centralised support for the development of education resources,
protocol development,
standardised prescription and education documents and forms.

Resources

Links

(In alphabetical order)

Australian Red Cross Service http://www.arcbs.redcross.org.au

Australian Red Cross Blood Service, Information for Clinical Professionals http:www.transfusion.com.au

Australian Council for Safety and Quality in Health Care - http://www.safetyandquality.org

Australian New Zealand Association of Blood Transfusion Professional Association - http://www.anzsbt.org.au

BeST - Better, Safer Transfusion Victoria - http://www.health.vic.gov.au/best

British Blood Transfusion Society - http://www.bbts.org.uk

Canadian Society for Transfusion Medicine - http://www.bloodservices.ca

Institute for Health Care Improvement (IHI) http://www.ihi.org/ihi

NSW Department of Health - http://www.health.nsw.gov.au

National Blood Authority http://www.nba.gov.au/index.htm

National Health and Medical Research Council http://www.nhmrc.gov.au

Serious Hazards of Transfusion (SHOT) http://www.shotuk.org/home.htm

The National Blood Service- UK - http://www.blood.co.uk

World Health Organisation Blood transfusion safety http://www.who.int/bloodsafety/en

Contact Us

For further information or feedback please contact us:

Mailing Address

Clinical Excellence Commission
Blood Watch
Level 3, 65 Martin Place
Sydney NSW 2000

GPO Box 1614
Sydney NSW 2001

Ph: 02 9382 7600
Fax: 02 93827615

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