London Regional Transfusion Committee

London Regional Transfusion Committee London Regional Transfusion Committee Business Meeting 22 nd May 2013 Great Hall St Bartholomew s Hospital MINUTES Present: Abdul Adamu Whittington Hospital Lisa Baldry Great Ormond Street Helen Barber Barnet Hospital Liliana Barbosa HCA International Ruth Black MDHU (Portsmouth) Elizabeth Bergh Kings College Hospital Carol Cantwell St Mary's Hospital Wendy Chase Joint Medical Command HQ Monique Chituku West Middx University Hospital NHS Trust Gavin Cho NWL NHS Hospital Trust Nina Chung The London Clinic Sue Cole Princess Royal University Hospital Clare Denison NHSBT Aman Dhesi NHSBT Ravinder Dosanjh Newham University Hospital Fernando Fegarido Epsom and St Helier Hospital Matthew Free Kings College Hospital Lucy Frith NHBST Vanessa Fulkes Guy's & St Thomas' NHS Trust Sheena Gardner The London Clinic Adrienne Harper Imperial College Healthcare NHS Trust Nicola Henshaw Guy's & St Thomas' NHS Trust Jenifer Heyes Barts and the London NHS Hospital Trust Esther Hill St Anthony's Hospital Amanda Hobson Barnet & Chase Farm NHS Trust Alastair Hunter NHSBT Amanda Joseph The Hillingdon NHS Foundation Trust Dorothy Kasibante HCA Healthcare Megan Lawn Kings College Hospital Sharon Lindo St Mary's Hospital Sue Mallett Royal Free Hospital Helen Marshall DMRC Headley Court Maureen McBrearty University College London Hospitals Stuart McCorkell Guy's & St Thomas' Wendy McSporran Royal Marsden NHS Foundation Trust Vince Michael Kingston Hospital David Mold Chelsea &Westminster Hospital Rachel Moss St Mary's Hospital Dawn Muir MDHU (Portsmouth) Helen Nulty Great Ormond Street Hospital for Children Theresa Ollivierre Charing Cross Hospital Steve Owen Royal Brompton Hospital Rebecca Patel North West London Hospitals Trust Sally Proctor NHSBT Ghulam Qureshi Royal National Orthopaedic Hospital London RTC Mins 22.05.2013 1

Gill Rattenbury Parkside Hospital Mark Reed DMRC Headley Court Robert Reilly Kings College Hospital Sarah Rigg MDHU (Portsmouth) Brian Robertson Guy's & St Thomas' Megan Rowley St Mary's Hospital (ICHNT)/NHSBT Sue Rudd St Helier Hospital Erika Rutherford NHSBT Denis Sellu Ealing Hospital NHS Trust Angela Short Epsom and St Helier Hospital Caroline Subramaniam Central Middlesex Hospital Tracey Tomlinson Hammersmith Hospital James Uprichard St Georges Healthcare NHS Trust Kumar Uthayakumar Hillingdon Hospital Denise Watson NHSBT Richard Whitmore NHSBT Shalinee Wickramasinghe NHSBT Steven Wiltshire St Georges Healthcare NHS Trust Sue Wood NHSBT Rena Yiannacou Whittington Hospital Roslin Zuha St Helier Hospital Apologies had been received from Shubha Allard, Mallika Sekhar, Linda Chapple, Dorothy Kasibante, Louise Tillyer, and Elaine Carter-Leay and Emily Okukenu. Welcome and Introductions GC welcomed everyone to the meeting and informed those present of the health and safety requirements for the building. Minutes of the Last Meeting The minutes from the meeting held on 11th October 2013 were accepted by those present as an accurate record. All actions from these minutes had been completed. If there are any amendments could they please be sent to Sue Wood (SaW) for incorporation. Action: Any amendments to the minutes to be emailed to Sue Wood and Minutes to be put on RTC Website SW NBTC & RTC Chairs Feedback NBTC meeting feedback Gavin Cho gave an update following the NBTC and RTC chairs meeting in April 2013. Topics discussed at the NBTC meeting were as follows: BCSH guidance requiring two blood samples for crossmatch is not intended to compromise patient care. Discussion was had on the effects of the two sample requirement. Each organisation should undertake risk assessment of its own arrangements with a focus on patient identification. Problems with leads and neonates was also highlighted and discussed. NBTC working group is reviewing the NPSA SPN 14 as it did not meet its original requirement. A draft of the first review document has been circulated to Transfusion Practitioners for comment. The RCN has updated the guidance for improving transfusion practice Right blood, right patient, right time and this is available for download on link: http://www.rcn.org.uk/ data/assets/pdf_file/0009/78615/002306.pdf This a straight forward 12 page guide on role of nurses and transfusion standards. The annual SHOT symposium to be held at the Royal College of Medicine in London on 10 July 2013. NBTC Indication Codes for Transfusion have been updated and are available on the website at link: http://www.transfusionguidelines.org.uk/docs/pdfs/nbtc_2014_04_recs_indication_codes_2013.pdf London RTC Mins 22.05.2013 2

NICE guideline on blood transfusion is being developed for 2015. A group is getting together to define, scope and write it. RTC Chairs meeting feedback This meeting updates work and concerns from the other 9 RTC regions. Below are the main topics that were discussed: Concerns were expressed about HTC and RTC attendance. It was thought that this may be economic in origin as Trusts are being squeezed financially. Individuals are being given more work and therefore have less time to be released for meetings. Pathology modernisation has the aim to take laboratories and merge them into a spoke formation. Outside London hospitals are experiencing difficulty in retaining staff due to downsizing and staff leaving. London is currently largely unaffected but it may be a trend which will we see more in the future. The RTC will continue to monitor this change in activity. The NCA medical use of blood results were discussed. One thing these show is that anaemia is not being treated except with blood transfusion. Feedback of London regional results are later on the agenda. BSMS and another RTC region had developed CUSUM charts to monitor platelet orders. The idea is to have an easy way of showing where you have a significant increase in platelets rather than month by month variation. Problems noted were that the charts were difficult to follow. Questions were raised about seasonal variance and discussion followed on how this could be taken into account. The NHSBT BBT team has now been renamed Patient Blood Management (PBM) Team. Rebecca Gerrard is the head of the NHSBT PBM Team. The PBM update will given later in the meeting. A HTC toolkit has been developed. This can be given to HTC Chairs to let them know the role of the HTC and other structures that connect them to other hospitals and the NBTC. Regional Transfusion Committee Staffing Sylvia Hennem and Helen Nulty have stepped down from the London RTT. Gavin Cho thanked both of them for all the help and support they have given during their involvement with the London RTC. There are now two vacancies on the RTT which is the working group of the RTC. GC asked for volunteers to approach members of the RTT to express their interest. Jennifer Heyes (JH) has been offered and accepted the position as PBM Practitioner to work with Clare Denison (currently on maternity leave) to support the London RTC region. Jen is due to start on the 15th July 2013 and Clare is due to return in November 2013. London RTC Budget 2012/13 Budget given: 5,865. Income from sponsorship 4,968. Expenditure on activity (2 RTC business meetings with education afternoon, 1 whole day education day, 2 BMS education days, LoPAG Champions day, 3 TP meetings, 4 TAG meetings): 10,180 End of year balance: 653 under-spent, this was due to non-delivery of printer ink and other stationery. The London RTC has provided numerous meetings and education days with the budget allocation supplemented by sponsorship from various companies. The RTT and RTC thanked all the companies that supported the region. It is expected that the Budget for 2013/14 will be the same and we aim to have a zero balance at year end. Sponsor will be sought to support all meeting. London RTC Mins 22.05.2013 3

RTC Work Plan All items from the RTC work plan are due to be fed back on today s agenda, with the exception of nurse prescribing which will be updated at the next RTC meeting. Future London RTC education meetings are: - 25th October 2013 the PM education topic will be Transfusion and Massive Haemorrhage. - 24th January 2014 a joint London and SE coast whole day education which will be aimed at midwives and is entitled 'Delivering a Safe Transfusion Practice' -BMS education days are under discussion and more details will be sent out by email. London Haematology and Trauma Network Update Megan Lawn gave an update from yesterday's Haematology and Trauma Network meeting. Points covered are as below: Anne Weaver gave an update on Blood on Board with the HEMS team and gave some examples of success stories due to having blood on site of incident. A problem existed where the laboratories did not know if the patient received any transfusions prehospitalisation. There is now a sticker that is used to alert the laboratories that a patient has received a pre-hospitalised transfusion. Outside London, Kent & Surry Air Ambulance has also started to carry blood on board. Angela Green attended the last meeting and said that all was progressing well. One of the problems experienced is the hospital does not have a heli-pad so there are logistical issues to be addressed. SERV is used to deliver to HEMS team. The hospital that supplies the blood does not usually see the patient so is unaware of the patient outcomes. Arrangements are now in place so this information is fed back so the laboratory is aware how important the additional work is. The 4 Major Trauma Centres in London last year (?2011) carried out an audit on Code Red policy using 10 patients each. This year they looked at all cases between Jan-Dec 2012. The data looked at over 200 patients and FFP: RBC ratio. Tranexamic acid usage was also looked at and the code red policy says it should be given. Pre-thawed FFP; emergency departments have wanted pre-thawed FFP for a long time but Blood Transfusion were resistant due to wastage. Oxford Radcliffe hospital trialed pre-thawed FFP and the results were discussed. The results suggested they use A FFP as it matches their patient population by 80%. The 4 MTC in London will look at trialing pre-thawed FFP. Kings will use pre-thawed AB Octoplas, Royal London and St. George's will trial FFP. St Mary's may not trial it as they do not have cardiac on site so it will be more difficult to reallocate the FFP to prevent wastage. A trauma computer system model is being developed to take you step by step through the process to show hospitals how many casualties they can deal with. Individual hospital data can be entered to see results. A Cryo stat study is being carried out to show the affects of early Cryo use. The John Radcliffe hospital and Addenbrookes Hospital have now joined as members so the group is discussing a possible change of name but they will still report to the London RTC. London Platelet Action Group Update Rachel Moss gave the RTC an update for the group. The following points were discussed: LoPAG has a new logo, which was presented to the RTC. LoPAG started by looking at BSMS data with the aim to reduce inappropriate platelet usage and wastage by 10% in the whole RTC region. A platelet champion s day was held. The LoPAG top 10 Tips were surveyed to see usage in hospitals, use if indications codes were discussed, teaching tools to support LoPAG champions to bring London RTC Mins 22.05.2013 4

understanding back into hospitals, a talk from H&I on the importance of HLA PLT matching. Overall feedback from the day was that is was a very useful day. Next steps involve developing a PLT Champions toolkit. The best talk from the PLT champions day was 'PLTs, the basics' and this is now available as a YouTube online talk. Use of algorithms to support appropriate deciding making for the lab and clinical area, use of the PLT App, and the double dose poster and training tools are other items discussed. LoPAG will now look at a champions' day for SpR engagement and submit a BBTS poster to advertise the LoPAG group. It is hoped the LoPAG toolkit will be discussed at the next RTC meeting. Shared Care Document Brian Robertson presented an update on the shared care document. He gave case studies on situations where the use of the shared care document between hospitals would have benefited in better patient blood management. The case studies were discussed. A room round survey was carried out and the audience was asked who uses a shared care form within their trust to communicate to other hospitals. The number of people that responded was noted to be more than the number that used the form at the last RTC business meeting. BR reminded people of the importance of communicating specials requirements of patients who receive shared care and reminded delegates where the London produced documents can be found on the RTC website. Discussion was had on involving and empowering patients to be involved in the aspects of shared care. BR gave an example of the use of a 'special blood' card which can be given to patients to make them feel empowered to show and discuss with clinical staff when they need treatment at another hospital and to close the gap where the shared care document is not used between transfusion laboratories. Use of sharing patient special requirements was also discussed using the NHSBT Sp-ICE system as long as hospitals have allowed their results to be shared. During discussion the audience was asked to let the NHSBT know when they have an IgA deficient patient who has had a transfusion reaction. ACTION: All advise re IgA patient London Transfusion Training Passport Mandy Hobson presented to the RTC with regard to this work activity. It was the first time a work led by the London TP group was presented to the whole RTC. The aim of this work activity was to produce an agreed training passport so that staff movement within London did not lead to unnecessary training being carried out. The group would look at training and not competency assessment. The aim was to get the passport taken up in the Skills for Health (SKF) core skills passport under Blood Components. The group has SFH engagement and they have commented on various versions of the passport. By having a SFH mandated core skills passport it will support transfusion training to be highlighted in trusts by the L&D department and not just being pushed by the TP and HTT. The Passport has been agreed within the London TP group. The next steps will be to get more national agreement on content and approval by RTCs and the NBTC which will make it easier for SFH to take up as a national resource. MH also noted that there will be a talk from SFH in the afternoon education session. London RTC Mins 22.05.2013 5

Integrated Transfusion Services (ITS) Update Lucy Frith, ITS Project Group, presented an update on ITS to the RTC group. The presentation will be available online after the meeting. Below are some points from the discussion: ITS has three sections to it: Stock Management (which was focus of today s talk), Transfusion Innovation and Integrated Supply Planning. Stock management aim is to transform the relationship between NHSBT and hospitals by implementing a new operating model and vendor management inventory (VMI) service for the provision of blood components. This will be based on a collaborative approach towards the setting of stock levels and the adoption of fully integrated working practices between NHSBT and hospitals. Lucy highlighted the risks and benefits of the systems, the high level flow chart of operations and objectives of the stock pilots. Updates on the existing pilots were given: Pilot 1 - Blackpool Victoria Teaching Hospital Trust. The pilot started in summer 2012. Replenishment of red cells and frozen components is planned to commence during April 2013. Pilot 2 - Royal Bournemouth and Christchurch Hospitals Trust. The pilot commenced during November 2012 with replenishment of red cell and frozen components undertaken from end of February 2013. Pilot 3 - Royal Liverpool & Broadgreen The pilot commenced in late 2012. Replenishment of red cells and frozen components has been undertaken from March 2013 Pilot 4 John Radcliffe Oxford, this hospital worked with NHSBT during 2012 to prove the concept of a new stock model and has now moved to a full pilot. In addition desk top modelling is underway with a further 12 hospitals to validate the potential benefits for a wider range of hospitals. Previously due to the Olympics London hospitals were not identified as sites for pilots. St Mary s is now a desk top pilot and discussions were had at the meeting. Lucy presented learning and outcomes of the pilots to date and explained the importance of IT and facilities in early engagement and engagement of the right people to support the ITS relationship. Future work will involve completion of an evaluation of stock pilots for a completed business case to be presented in July 2013 at the NHSBT board meeting with the potential roll out during 2013/14 to other hospitals. Audits & Surveys Megan Rowley gave the presentations and led discussion on the two audit topics. CQC Standard 9 MR made RTC members aware of the CQC standard 9 Management of supply of blood and bloodderived products. This is not a new standard but one that some hospitals were possibly unaware of the need to register. This regulated activity covers the supply of blood, blood components and blood-derived products for transfusion. Supply of these products outside of a provider's regulated activity for example, an arrangement for a large hospital to supply blood or tissue to a smaller one not covered by their Trust would require this regulated activity to be registered. MR also showed a decision tree for 'management of supply of blood and blood derived products' that the CQC have to decide if activity is in scope or outside scope. Discussion was had on various scenarios, such as transfer of blood with patients, supply to wards outside trust but on same hospital location etc. The CQC have been asked for clarification and they replied that the standard is as it stands and it should be interpreted to see if hospitals have to register. It was discussed that registration is a one off activity and cost of this will need to be looked at. Involvement of the CQC lead in hospital will need to occur as it is the Trust, as opposed to Transfusion Team, that should complete compliance. London RTC Mins 22.05.2013 6

Further clarification from CQC by RTC and/or NBTC was discussed and will be further discussed at the London Regional Transfusion Team meeting (RTT). ACTION: RTT to discuss contacting CQC for clarification and NBTC to write to them Highlights of Regional Results from the NCA Medical Use Audit MR presented the region with results from the part 1 medical use of blood audit for the London RTC region. This is available from hospital NCA homepages. Some points of discussion were fall in red cell issues associated with change in surgical practice; is there scope for further reduction by reviewing the use of red cells in medical patients. The audit algorithm that was used to determine if appropriate or inappropriate, age (more older people have the most transfusions), the London region provided 1332 cases for the audit. The audit found a high rate of transfusion in cases with potentially reversible anaemia and transfusion above thresholds recommended by National Indication Codes, Overall 48% of patients were transfused outside standards set by the audit group. Reasons are multi-factorial and require further investigation in phase 2 of the audit which commenced in April 2012 NHSBT Update Erika Rutherford presented the update and informed the meeting of the following: Stuart Penny has been appointed to be the Assistant Director for National Operations Blood Supply. The NHSBT On Time In Full (OTIF) project is looking at improving the supply of Blood Components at the correct time and in full. Ro provisions to the SE have been improved as has LVT availability. An update and reminders were given on the procedure for hospitals and Hospital Services when orders are collected, and also an update on the recall process which is being trialled at Manchester. All hospitals are now ordering on OBOS. 72% of hospitals in London and SE will share results on Sp-ICE and from November NHSBT will selectively switch off hard copy reports with hospital engagement. Al Hunter then updated the RTC on the following points: Closure of Brentwood Stock Holding Unit: following hospital feedback and engagement the decision will remain to close Brentwood as it is but a revised proposal to reduce any clinical risk patients with the creation of a smaller stockholding unit will be presented to the NHSBT board in July 2013. Outcomes from this meeting will be communicated to all hospitals involved. Overnight deliveries following the work during Olympics: progress has been slow and it is hoped that this work can be attached to the Brentwood project. Prudential Ride London: roads will be closed on the 3 and 4 th August for a car free bike ride. Some hospitals may want to engage with the NHSBT to see about changing stock levels as access during the events will be difficult. Kingston Hospital initially appears most likely to be affected. NHSBT will send letters to support working arrangements. NHSBT will not be making any other changes for this event and Blue light emergency deliveries will be given access to hospitals. RTC members were recommended to discuss with local risk planning managers and carry out local risk assessments. More details can be found about the event on: www.prudentialridelondon.co.uk Patient Blood Management Update and RTC Action Plan Gavin Cho gave a brief update on PBM. The RTC had a whole day education day last year and the NBTC PBM working group is developing KPIs and other recommendations. These are not yet available but it is hoped to get the Department of Health signature on them to support its promotion. Any Other Business London RTC Mins 22.05.2013 7

GC thanked all the speakers and those involved in organising the meeting together with the sponsors who support the RTC. Date of next Meeting The next RTC Business and Education day will be an all day event on Friday, October 25th 2013 at 76 Portland Place London W1B 1NT. The meeting closed at 12.15 pm. London RTC Mins 22.05.2013 8