NAME : Dr. C.SHIVARAM

Transcription

1 NAME : Dr. C.SHIVARAM DESIGNATION: Consultant & Head Transfusion Medicine, MANIPAL HOSPITAL BANGALORE Honorary Posts: Technical committee member and Principal Asessor -NABH Blood Banks. Member National Haemovigilance Committee and state Convenor Karantaka Invited Member Transfusion Resource Group National Blood Transfusion Council. Honorary Fellow- Society for Regenerative medicine Technical Consultant to State Blood transfusion council, NACO, as resource person for annual training programs.

2 Transfusion Audit and Role of Hospital Transfusion Committee Dr C. Shivaram Consultant and Head-Transfusion Medicine Manipal Hospital Bangalore

3 Transfusion audits An audit is a methodical, defined review of practices and policies to ensure safe and appropriate transfusions. (AABB) A systematic independent examination and review to determine whether actual activities and results, comply with planned arrangements.(naco). An audit is a process of gathering evidence to e aluate ho ell an organisation s processes and procedures match a set of audit criteria. Audits are always carried out against a defined set of criteria

4 Audit Criteria Explicit Measurable Lab Values No of units No of donors Audit Criteria Implicit Subjective Medical History Clinical assessment Diagnosis Involve Individual Judgement Criteria may be as per legal or accreditation needs. Criteria should be tailored to the needs of the hospital. Key medical staff and clinical departments should be involved in their development process. Criteria chosen are initially Liberal and more stringent criteria are adopted later. Review committee(htc) should be flexible and modify them as needed. Criteria may be explicit or implicit or a combination of both

5 Types of Audit Horizontal Vertical Examination Horizontal audit examines one element in a process on more than one item. Ex: Blood donation ( Comprising of counseling, collection, storage,labelling etc) A Vertical audit examines multiple elements in a process, on one item. Ex : Tracing a unit of blood from collection till issue/disposal. An Examination audit examines a person undertaking a test procedure. Comparison with SOP. Understanding of the procedure

6 Standardizing Transfusion Practices Even within the same hospital, transfusion practices vary from one doctor to another for the same procedure/ condition based on the surgeon s/physicians tolerance to anemia or blood counts, rather than the physiological tolerance of the patient. Distribution of blood by the blood centre, both nature and time taken varies from one patient to another even for similar conditions. Administration and monitoring of blood is not always uniform in all wards in a hospital.

7 Transfusion audits and the Hospital Transfusion committee (HTC) plays a pivotal role in removing such anomalies and bringing about standardization of transfusion practices within the institution. Local policies and protocols are developed from national/ international guidelines.

8 Need for Hospital Transfusion Committee Mark Friedman in a study states that lack of knowledge regarding transfusion medicine among clinicians is possibly the major obstacle in making transfusion practices more consistent. HTC- For educating end-users, setting down policies and protocols and promoting safety, efficacy, and efficiency of blood transfusion services. Requirement as per National Blood policy. State and union governments need to ensure that HTCs are established. Requirement of accreditation : Many accreditation agencies like NABH in India, or JCAHO in the United States insist on a HTC. An attempt should be made by HTCs to cover all aspects of transfusion from vein to vein.

9 Objectives of HTC SAFE DONOR SAFE BLOOD Laying done/ratifying policies for safe donor selection Ex : Discouraging directed donations. Motivating people to donate blood voluntarily Review Policies and Protocols for testing/processing blood. Ex Review of newer methods of testing like NAT. Ex Review Processing technologies like leuko -reduction, irradiation and pathogen reduction. SAFE TRANS- FUSION Set down, rational transfusion guidelines, MSBOS and patient identification procedures. Ensuring that right blood goes to the right patient in the right dose based on defined scientific criteria/guidelines.

10 Scope of HTC Scientific and ethical guidelines for the practice of good transfusion medicine, in conformance with nationally/ international accepted criteria modified to suit the local requirements of the hospital. Licensing requirements, administrative issues and financial matters is not the responsibility of this committee.

11 Audit Parameters BLOOD ORDERS/ REQUESTS Units transfused. Patients transfused Units transfused per patient transfused Special components Units returned unused. Transfusion guidelines. MSBOS? DISTRIBUTION OF BLOOD Turnaround time- Definition and calculation Emergency requests. C:T ratios Un-cross matched units. Surgical cancellations due to unavailability of blood. Significant Group/type switches Outdate rate. Wastage rates. Administration and Monitoring Blood issue/delivery errors. Blood administration policies and procedures Transfusion equipments. Special transfusion situations. Compliance with transfusion guidelines. Transfusion reactions. Documentation of Transfusions. Transfusion-transmitted disease. Look-back

12 Quality Indicators According to NABH BB requirement Adverse donor reaction rate Donor Deferral rate TTI percentage Wastage/Discard Rate TAT for blood issues Component QC failures Adverse Transfusion Reaction rate Percentage of components TTI outliers%-no. of deviations

13 Blood Donors Counseled Donated Defered Deferral % 14.3% 13.9% 13.9%

14 Adverse donor reaction ADVERSE DONOR REACTION RATE / / % 1.43% NO SERIOUS ADVERSE REACTION REPORTED Introduction of Donor Haemovigilance form for improved reporting

15 Percentage of transfusion reactions Year No. of Transfusion Reactions No. of issues Percentage of Transfusion reaction % 0.14% 0.13%

16 CumulativeTTI Rate : Target less than 1% (0.04%) 5(0.04%) 6 80 HBSAg 86(0.82%) 50(0.47%) 43 HCV 7(0.07%) 4(0.04%) 0 Syphilis 6(0.06%) 2(0.02%) Malaria 0(0%) 0(0%) 0 Cumulative TTI rate 0.97% 0.57% 0.52% HIV HBsAg HCV Syphilis Malaria TTI outliers %-Deviations beyond 2SD-NONE

17 Discard/Wastage rate Wastage Blood Bank Level Year No. of units discarded (Date Expiry, Positive units etc) Total No of units prepared % of wastage 11.11% 7.65% 6.17% Wastage Ward Level No. of units discarded No. of units discarded Year Units returned after issue Units discarded after return 5 3 Total no. of units issued % of wastage 0.02% 0.01%

18 Blood usage-surgical specialties % Medical (61%) Surgical CTVS Ortho/Spine General Gastro Neurosurgery OBG Vascular Plastic Urology Onco Surg

19 Blood usage-medical specialties % Medical (61%) Surgical Internal Med Oncology Nephro Cardio Gastro Neuro

20 HTC: Constitution Hospital Transfusion Committee (HTC) should have a fair amount of representation from all departments across the hospital. There need not be a bar on the number of members. Desirable to have the heads of the departments or their designees in the HTC. Minimum number (Quorum) to conduct the meeting should be defined-including the nature of members. Surgeon, Physician, Obstetrician, Intensivist, Oncologist, Pediatrician, Nursing representative/quality representative besides Transfusion Medicine specialists are desirable in the committee. Administrative staff, Human resource personnel purchase, Finance staff may be involved as needed as special invitees.

21 Terms of Reference of HTC To set Policy and protocols to ensure adoption of rational transfusion practices. To set down guidelines for Prophylactic and Therapeutic Transfusions (Thresholds levels for transfusion) To examine and ratify all Transfusion Policies in the hospital To review and ratify a procedure for positive patient identification and blood transfusion To design and implement a Hospital Haemovigilance system that is in conformance with the National haemovigilance.

22 Common Minimum Agenda Review quality indicators pertaining to transfusion services. Review of Customer Complaints. Hospital Haemovigilance -Review of Adverse transfusion reaction- Results of audits - Audits may be concurrent or retrospective, horizontal or vertical. Ratify change in process or induction of new processes likely to have a bearing on transfusion.

23 Additional Responsibilities of HTC Policies and protocols for emergency transfusions. Review Protocols for Massive Transfusions. Review protocols for special transfusion situations like AIHA/DIC etc. Review protocols for special needs like IUT/neonatal transfusions. Set and review transfusion/testing protocols for special needs like BMT/Organ transplants.

24 Documentation of HTC Meetings Compendium of policies and protocols specific to the institution and current and valid documents cleared by HTC made available across the hospital. Meeting Notice with Agenda Attendance sheet Minutes of the meeting with timelines and responsibility. Policy decisions taken/ratified. Protocols discussed and accepted. Quality indicators/others issues discussed.

25 Take Home Transfusion Audits and HTC Transfusion audit is a systematic review of institution specific transfusion policies and protocols as laid down by the transfusion service and approved by the HTC. Transfusion audits must cover all aspects from vein to vein and may be horizontal or vertical; prospective, concurrent or retrospective. Audit Criteria may be implicit or explicit or a combination of both. Audit criteria must include Blood orders, Blood distribution, Blood administration and monitoring of transfusions. HTC is a legal and accreditation requirement comprising of all end users of blood, to monitor and ratify new policies and protocols. HTC plays a key role in setting down institutional policies to ensure rational transfusion practices, hospital haemovigilance thereby mitigating risk of transfusion. HTC provides a co-ordinated leadership by a multidisciplinary team of experts.

26 THANK YOU!