Clinical Transfusion

11. The Role of Transfusion Committees

Introduction

Transfusion Committees play an important central role in the strategic, operational and reporting lines for transfusion safety, implementation of Patient Blood Management (PBM) initiatives and management of blood supply and use in hospitals. Transfusion Committees can be established locally, for clusters of healthcare providers, across affiliated organisations or for private health establishments, although many Transfusion Committees are based at a hospital level. Transfusion Committees are also know by other names which represent their standing, alignment and key aims. For example they are known as the Hospital Transfusion Committee, Blood Utilisation Committee, Blood User Groups, Trust Transfusion Committee, Divisional Transfusion Committee, Transfusion Committee Group, etc. In England, following the NHS England endorsed PBM recommendations, 94% of Trusts have PBM initiatives included on the standard HTC agenda whist 6% have a separate working group or PBM agenda (15). As all Transfusion Committees have the same overall purpose here in this web page they will be referred to as “HTC”s. The information below focuses on HTCs but the principles are transferable depending on the set up in your local area.

Hospital Transfusion Committees are multidisciplinary groups that have the overarching responsibility to maintain safe hospital transfusion practice.

In some countries the committee is directly responsible for the whole vein-to-vein transfusion process, including implementation of guidelines, training, etc.

In the Netherlands this responsibility is delegated from the Hospital Board of Directors and Medical Board to the HTC.

In Germany, the safety of blood transfusion (a major part of PBM) are the main topics in their quality management system in hemotherapy, first regulated in guidelines. In 1998 the German transfusion law (10) regulated the general aspects of the safety of the blood supply and haemovigilance whereas details are regularly updated in national guidelines (for blood donation and hemotherapy, 11, 12) issued by the German Chamber of Physicians. 

The Structure of HTCs

The members of the group are usually there without remuneration and should be multi-disciplinary and include key stakeholders of both blood utilization and management. Below are typical membership (local countries may require additional roles to be present).

  • HTC Chair - ideally this should be a blood user and preferably not the Consultant Haematologist in charge of blood transfusion.
  • Secretary - HTCs should ideally have administrative support
  • Blood Transfusion Laboratory Manager/Senior Scientists/Clinical Chemist
  • Transfusion Practitioner (or associated role – see Transfusion Practitioner page of the website). The TP often has an additional administrative role as secretary for the committee.
  • Consultant Haematology in charge of blood transfusion
  • Representatives from all clinical areas that use blood
  • Blood supplier representative
  • Hospital Managers
  • Risk and Governance leads
  • Education and Training representative
  • Quality Manager
  • Patient representatives

The HTCs should have reporting lines to the patient safety, clinical governance and senior hospital management committees to ensure any risks identified are accounted for and to allow blood transfusion to remain on the hospital agenda. HTCs should ensure risks are added to Hospital Risk Register (or equivalent system) and an annual report is submitted to relevant committees/managers. A work plan of activity might support the HTC to ensure their work is focused towards the agreed Terms of Reference. The Terms of Reference should be reviewed at set intervals and the membership reviewed. The HTCs usually meet quarterly but in some large user hospitals they meet more frequently. The HTC is usually supported by the Hospital Transfusion Team (HTT) to ensure work carries on in-between meetings. The HTT is usually made up of the Blood Transfusion Laboratory Manager, Consultant Haematologist in charge of blood transfusion, Transfusion Practitioner and Quality Manager for transfusion. In Germany HTCs are mandatory and defined by the guidelines (11). 

They consist of:

  • One chair “transfusion responsible person” (TRP, specialist in transfusion medicine or specialist of a different field with education and expertise in transfusion medicine, minimum 2 weeks of hospitation in transfusion medicine and 16 hour special course “Curriculum hemotherapy”).
  • One “transfusion safety person” for each speciality (TSP, medical doctor, specialist in the respective clinical field with a 16 hour special course “Curriculum hemotherapy” in all aspects of transfusion and the respective quality management).

A “person responsible for quality in hemotherapy (PQH)” has to be nominated for each hospital to the State Chamber of Physicians. PQH control whether the standards are fulfilled, perform self-inspections (with TSP and if possible TRP) and reports in a structured form to the Medical Director of the facility (annual list of potential for improvement in hemotherapy) and the State Chamber of Physicians (annual questionnaire submitted electronically). This person is trained in this for 32 hours (16 hour-special course hemotherapy and 16 hours quality management in hemotherapy). These annual reports of PQH are part of inspections for accreditations and certifications of hospitals and may be also part of risk evaluations (also for insurance purposes). The Chamber of Physicians of the different states evaluate the questionnaires and take action if deficits are reported (such as lack of educated staff), particularly if the same deficits are reported repeatedly. Annually PQH of each state meet at the Chamber of Physicians for exchange of experiences and refreshment of knowledge. Additionally all hospitals have to report their use of blood and plasma derivatives to the Paul-Ehrlich-Institute, which is also addressed for reports in each aspect of hemovigilance (side effects, deviations and near miss events in patients, blood donors and blood processing and distribution). Regularly this data is compiled and published (13). Many hospitals also use critical incident reporting systems to improve quality in every aspect of patient care including hemotherapy.

The Role of HTCs

In many countries it is mandated to have HTCs in place. HTCs have been created in different countries to oversee transfusion activity within their scope. Whereas the approaches used to achieve their goals have varied historically and between nations, their principles are the same (1). A functional HTC, fulfilling its mandate, can be a powerful mechanism to ensure patients receive the safest and most appropriate blood transfusion therapy possible (4). The WHO (2001) recommendations on developing a national policy and guidelines on the clinical use of blood indicate that an HTC ‘should be set up in each hospital to implement the national policy and guidelines on the clinical use of blood and monitor the use of blood and blood products at the local level.’ It goes on to say that the HTC ‘should have authority within the hospital structure to determine hospital policy in relation to transfusion and resolve any problems that have been identified.’

HTCs can be pivotal in ensuring appropriate blood utilization and that best practice standards are followed. Where the primary goal for HTCs are to improve patient safety there is a number of roles they may have (1,2,3,4).

1) Developing systems for the implementation of national guidelines within the hospital – defining blood transfusion policies

2) Monitor the implementation of national guidelines in the hospital and take appropriate action to overcome any factors that may be hindering their effective implementation

3) Liaison with blood transfusion services to ensure availability of required blood and blood components and be aware of the importance of horizon scanning

4) Training and assessment for all staff in the hospital that are involved in the blood transfusion process

5) Monitoring the usage of blood and blood components within the hospital and contribute to benchmarking against others

6) Reducing blood component loss due to time expiry and other wastage reasons – linking into clinical areas where clinical wastage is deemed high

7) Monitoring, reporting and investigating transfusion adverse events and near misses and using these experiences to promote learning

8) Ensure a cycle of clinical audits to check transfusion practice and safety and compliance to national requirements

9) Reduce the number of incidents in which an inappropriate dose of component is given to a patient

10) Disseminating transfusion related information to users including changes to national guidance, audit results and examples of good practice

11) Implementing PBM initiatives – reviewing transfusion alternatives and making recommendations of their use

12) Transfusion governance – be the link with regulatory authorities and agree any submissions and inspection outcomes

13) Reviewing if recall and other quality manual processes work as intended

Some HTC functions and requirements are written into local country legislation and law and compliance attracts a financial premium. 

Effectiveness of HTCs

HTCs are an important part of hospital transfusion safety, practice and appropriate use. Liumbruno and Rafanelli (2012) indicate that according to Italian legislation, a functional HTC should have a major impact on local rates of inappropriate transfusion, as well as on clinical governance, haemovigilance and safety of the transfusion medicine process. Hospital Transfusion Committees and Transfusion Teams, if properly constituted and adequately resourced, can be a powerful force for improving transfusion safety (2). The success of the HTC in improving blood management and reducing inappropriate use of blood have been reported (4). For example the role of the HTC to develop local transfusion policies that impact with a reduction in red cell transfusions after they were introduced (5).

Not only can a functional HTC have a major impact on local rates of inappropriate transfusion (6) they can also be seen as the hub of PBM activity. PBM will require engagement with end-users, managers and other key stakeholders all of whom should be represented at HTCs. To implement a PBM programme of initiatives the first point of presentation may be at an HTC meeting for engagement and approval as well as building partnerships for implementation. The HTC is also an ideal forum to present progress and final results. In some countries, for large projects approval is sought of medical board (representatives of all medical staff).

The HTC is considered the expert group for transfusion in hospital.

In recent years HTC’s are getting more active and are taking more charge in transfusion matters, even if Medical board is not a strong supporter of possible changes in transfusion chain. Without adequate support, resources and real authority the HTC will not be fully functional nor have a strong enough impact on transfusion practice (1).

Challenges for the HTC

Some previous journal papers (4 and 1) highlight that in practice few fully functioning HTCs exist. This is due to the HTCs having a number of challenges that they must overcome to meet their terms of reference and mandates. Some challenges common to HTCs are as below but these vary from country to country: 

1) Attendance (4) – ensuring adequate and consistent attendance is a struggle that most HTCs experience. This may be due to a number of factors including voluntary attendance, timings of meetings, clinical commitments, other meetings and commitments, etc.

2) No central guidance or education for these committees and their chair (4) – the chair is not the transfusion expert and so relies on the transfusion team to provide context and expert information

3) Ongoing professional education of health care professionals involved in transfusion. (1) This may be due to high staff turnover or lack of investment from the trainer.

These challenges can be overcome with resources that are now available (see resources below) and also

1) Increase attendance - senior manager support could be used to highlight the importance of HTC work, secretarial support to find appropriate venues and times.

2) Develop Key Performance Indicators - to ensure hospital and HTC meet requirements. Report regularly in an easy user-friendly manner.

3) Resources and bespoke education - to support the new HTC chair and the other HTC members in their requirements of the role and improved understanding of blood transfusion.

4) Completion of audits to establish progress and use results as momentum for improvement and as comparative to benchmark against others. However, it should be noted that audits have their own challenges.

5) Link in with regional/associated HTCs or other hospitals to share practice.

Resources to Support the Role of HTCs

HTCs will need to remain flexible and continue to become key to clinical areas as practice changes and as new evidence becomes available advise clinical colleagues on the best ways to use blood and blood components to improve and save patient lives. Below are some resources which will support HTCs.

If you have others please contact the ISBT office to get these uploaded.

  1. Appropriateness of blood transfusion and physicians’ education: a continuous challenge for Hospital Transfusion Committees? Liumbruno, GM. and Rafanelli, D. Blood Transfuse. Editorial. 10. Pp1-3 2012
  2. Reducing adverse events in blood transfusion Stainsby, D., Russell, J., Cohen, H. and Lilleyman, J. British Journal of Haematology. 131. Pp8-12. 2005
  3. Developing a National Policy and Guidelines on the Clinical Use of Blood World Health Organisation WHO 2001
  4. Building better hospital transfusion committees for Ontario. Owens, W., Gagliardi, K. and Lauzon, D. Transfusion and Apheresis Science. 46. 323-327. Pp 2012
  5. Can hospital transfusion committees change transfusion practice? Torella, F., Haynes, SL., Bennett, J., Sewell, D. and McCollum, CN. Journal of The Royal Society of Medicine. Vol 95. Pp 450 -452. 2002
  6. The role of hospital transfusion committees in blood product conservation. Haynes, SL. And Torella, F. Transfus Med Rev. 18 (2). Pp 93-104. 2004
  7. The Hospital Transfusion Committee. Guidelines for Improving Practice. Grindon, AJ., Tomasulo, PS., Bergin, JJ., Klein, HG., Miller, JD. And Mintz, PD. JAMA. 253 (4). Pp 540-543. 1985
  8. The hospital transfusion committee: a step towards improved quality assurance. Calder, L. and Woodfield, G. N Z Med J. 104 (921). Pp 427-9. 1991
  9. Resurgence of the blood utilization committee Saxena, S. and Shulman, IA. Transfusion. Vol 43. Pp 998- 1006. 2003
  10. German Transfusion Law: Gesetz zur Regelung des Transfusionswesens (Transfusionsgesetz - TFG) Bundesministerium der Justiz und fur Verbraucherschutz 1998
  11. Querschnitts-Leitlinien (BÄK) zur Therapie mit Blutkomponenten und Plasmaderivaten 4. überarbeitete und aktualisierte Auflage 2014. Herausgegeben vom Vorstand der Bundesärztekammer auf Empfehlung des Wissenschaftlichen The Board of the German Medical Association on the Recommendation of the Scientific Advisory Board (Bundesärztekammer) Vol. 36, No. 6, 2009, ISBN 978-3-8055-9392-2 Bundesaerztekammer
  12. Richtlinien zur Gewinnung von Blut und Blutbestandteilen und zur Anwendung von Blutprodukten (Hämotherapie), Aufgestellt gemäß §§ 12a u. 18 Transfusionsgesetz von der Bundesärztekammer im Einvernehmen mit dem Paul-Ehrlich-Institut. Transfusionsgesetz von der Bundesärztekammer im Einvernehmen mit dem Paul-Ehrlich-Institut Bundesaerztekammer 2010
  13. Hämovigilanz-Bericht Das Paul-Ehrlich-Institut ist ein Bundesinstitut im Geschäftsbereich des Bundesministeriums für Gesundheit 2011
  14. AWMF Arbeitsgemeinschaft der Wissenschaftliche Medizinischen Fachgesellschaften 2016
  15. 2015 Survey of Patient Blood Management Management National Blood Transfusion Committee 2015 Patient Blood Magement Survey
Rachel Moss

Rachel Moss

author

E-mail
United Kingdom

Disclaimer

The content of this resource has been developed and reviewed by members of the ISBT Clinical Transfusion Working Party and should be used at the discretion of healthcare professionals utilising this clinical resource. The authors or the International Society of Blood Transfusion cannot accept legal responsibility for the content of this resource.