Patient Blood Management Survey 205/6 Appendices for Generic Report Appendices Appendix Glossary Abbreviation BCSH HTC ICS KPI NCA NHSBT NOACS PAs PBM PCS POCS RTC TEG TP WTE Meaning British Committee for Standards in Haematology Hospital Transfusion Committee Intraoperative Cell Salvage Key Performance Indicator(s) National Comparative Audit National Health Service Blood and Transplant Novel Anticoagulants Programme Activities Patient Blood Management Postoperative cell salvage Postoperative cell salvage Regional Transfusion Committee Thromboelastography Transfusion Practitioner Whole Time Equivalent
Appendix 2 Trust Response by Region and RBC Use Level Counts Break % Respondents Base Trust Use Level Very High High Moderate Low Very Low Total 6 52 8. 8 27.9% 2.% 2 8.8% 0.7% RTC Region EERTC 5 26.7% 26.7% 6 0.0% 6.7% EMRTC 7 2 28.6% 2 28.6% 2.9% LondonRTC 8 2 66.7% 22. 5.6% 5.6% NERTC 8 7.5% 7.5% 2.5% 2.5% NWRTC 25 8 2.0% 6 2.0% 8 2.0% 2 8.0%.0% SCRTC 8 7.5% 7.5% 2.5% 2.5% SECRTC 9.%.%.% SWRTC 7 6 5.% 6 5.% 2.5% 5.9% WMRTC 5 8 5.% 6.7% 20.0% 20.0% YHRTC 2.% 5 5.7% 5 5.7% 2.%
Appendix Other Reporting Structures Haematology Specialty Board Clinical Cabinet Meeting Reports via our Hospital Transfusion Team to Clinical Services Harm Free Care Group Risk and Safety Group Pathology Steering Group Quality Committee Clinical Standards Sub Committee Clinical Effectiveness Committee Clinical audit and effectiveness committee Trust Risk Management Committee QSOG Clinical Quality Steering Group Currently via Director Of Nursing. Exception reporting to patient safety group Clinical Risk Committee Appendix Additional TP Responsibilities Policy writing and implementation Anaemia management Administrative duties (meetings, data input) Providing clinical support for other staff
Appendix 5 Laboratory Systems in Use Counts Base % Respondents Total Yes WinPath Telepath Apex Labcentre SunQuest Meditech Cerner (Pathnet) GE Healthcare Fordman Computer Systems (LabNet) In House (home built) System Integrated Software Solutions Technidata IBGS Bank Manager EDS Healthcare SwiftLab IPS 8 26% 2 22 5% 6 % 6 % 5 % % % 2 % 0.7% 8 26% 2 22 5% 6 % 6 % 5 % % % 2 % 0.7%
Molis WinPath Enterprise Intersystems Sanguin (BTDS) 0.7% 0.7% 0.7% 0.7% Appendix 6 Process for authorising (don't transfuse a bloodpatient without informing the patient about the risks and benefits of transfusion) Consultant haematologist must say yes Telephone call Based on individual clinical details Patient displaying clinical symptoms Discussion with Medics and Transfusion Practitioners None in place the number of units can be over written The BMS will check with the clinician. This can be escalated to the Haem Consultant or the TP. Blood request is changed on clinician authorisation Discussed with Consultant Haematologist They are not mandatory. The individual BMS will assess the request and act on this info. No process in place Referred to Haematologist Referral to Consultant Haematologist/SpR Second check by BMS Query inappropriate requests are discussed with the prescribing clinician
Appendix 7 Alternative Methods of Data Extraction NHSBT usage and wastage figures provided on a monthly basis, discussed at HTC Blood Track System and Blood Stock Management Scheme (BSMS). PBARS Blood tracking system TERVIA provides information on where blood is transfused. Data collected by our information analyst from the laboratory IT data We also use Lab Info System, COGNOS Searches and Microsoft Excel Manual extraction an importation Reports via the Trust Digital reporting system We use both the lab system data and blood component request questionnaires completed by lab staf Path manager as well as LIMS Path manager Extract data from 'BloodTrack' combined with data from LIMS. Blood Track data A blood product activity for the Trust times per year and directorate usage annually, not why Access database linked to Pathology, Cerner and NHSBT EDN systems Path manager We use crystal reports to extract data from the LIMS ClickView Excel spreadsheets Over 95 % of blood is used in theatres and critical care, data is extracted from electronic systems The performance team have created a formula which links use and wastage to clinical activity Check the register as the data on the IT system is not reliable or easy to extract
Usage by reason for clinical use and Wastage by Location & reason for wastage. We use lab system & electronic medical records Manual traceability tags to report usage by the clinical areas, monthly reports sent We often get data from finance as its all coded Appendix 8 Iatrogenic anaemia reduced frequency of blood sampling specialties Medicine Neonates / paediatrics ICCU PAEDS NICU Jehovah's Witness and paediatrics ICU/Paediatrics ITU, HDU, Neonatal Unit Cardiac, haematology AICU Haematology & ITU Neonatal ICU's ITU and Paediatrics ITU, neonates Neonates Neonatal Unit and Critical Care SCBU and ICU Haematology
Neonatal Currently all minor surgery /surgery Neonates paediatrics Critical care Critical Care Complex PICU Critical care areas but expanding to Trust wide ITU & HDU patients Appendix 9 Use of Thromboelstography (specialties) Theatres Emergency department Obstetric department Cardiac Critical care 2 2 7 22 20 Appendix 0 Cell Salvage Counts Analysis % Respondents Total Use Not Used NA Base 76 5% 25 6% 222 29% Cardiac surgery 88 27 % 2 59 67% Vascular surgery 86 52 60% 5% 0 5% Orthopaedic 89 8 6 2
surgery 9% 7% General surgery 85 56 66% 28 % % Obstetrics 9 80 86% 7 7% 6 6% Trauma 80 7 59% 2 29% 0 Urology 79 2 5% 28 5% 9 % Liver surgery 80 2 5% 8 0% 60 75% Children's surgery 8 7 9 5 55% Appendix Barriers to PBM Lack of involvement from staff due to workloads. Divisions are not cross charged for blood therefore no incentive to reduce use. Change in behaviour to reduce two unit crossmatches to one is difficult. PBM meetings can also be viewed as 'another meeting to attend'. Our Trust no longer has vascular surgery or trauma patients therefore blood use has reduced significantly. No preoperative anaemia policy in place. Single speciality hospital, no haematology dept. Anaemia/IV iron therapy moving forward but may not be cost effective. Also pathology services run by another hospital/sla which impact on trust decision making and quorum of HTC/HTT difficult to maintain Finance, staffing, culture New funding for IV iron, connectivity of IT systems, funding for bedside systems for complete electronic record of the transfusion process, ODP staffing pressures/recruitment to operate cell salvage equipment. Clinical resistance to change Our constraints are getting GP'S actively involved in treating iron deficient anaemia.
engagement from clinicians Staff levels Time and getting people together in one room at the same time as the Transfusion manager and senior staff on Haematology Shift rota It can sometimes be difficult to get policies through the Quality and safety Committee in a reasonable time frame. Lack of staff resources, lack of money, lack of senior board level management support. Reason for request not documented by lab and rationale often not documented in notes Clinician time for sufficient education to change culture, custom and practice PBM is an unfunded central initiative, largely in place already via BB,2,. Much of the activity is reproduced by PBM; regrettably it is unlikely that sufficient resources will be freed up to justify the expansion of the PBM team who have been working at maximal capacity on a historical basis. This process requires financial priming from central NHS to facilitate optimal role out. The Trust are starting to become anxious about the cost of IV Iron even though the saving in the component budget is gratifyingly similar. Challenges of developing and funding a cross speciality, region wide anaemia service. Budgets are 'ring fenced' which causes many hurdles to overcome when offering an overarching service to CCG's/primary/community and secondary care. Convincing senior clinicians that PBM is the way to go. Many are sceptical and content to stay within their comfort zone of advising transfusions. Availability of clinical staff to participate in PBM working party and implement changes in practice. Difficulty accessing lab data. Need champions within the medical staff to drive PBM forward Need to engage with Primary care to address preoperative anaemia etc. Concerns Business case for funding for increased TP hours were rejected. Resources (time, money) Recruiting champions Staff engagement PBM is not a priority in the Trust need higher profile None Historical reluctance to use indication codes. Funding for introduction of TEG and ROTEM. Time constraints for senior doctors. Lack of resource and staff shortages
Time: TP resource, BMS resource, Consultant resource. Funding. Lack of engagement from users (consultants and junior doctors) Time. Trust need to be required to do. Pressures put on all hospital staff with managing patient flow, Trust being in special measure, CQC visits etc. TIME AND RESOURCES Staff Cost Lack of Transfusion Practitioner time to support PBM. Only one TP in very high use hospital Lack of engagement in a large teaching hospital Lack of allocated laboratory staff time to support this programme. Funding Demonstrating cost savings and patient benefit Lack of interest inadequate Transfusion Practitioner support for education and implementation Staffing resources, time, poor IT support Time allocated for education of medical staff Dedicated time for laboratory Staff training in PBM staffing and time Lack of day case space for preop anaemia treatments. Lack of funding for PBM team. time, no admin support, therefore main TP cannot interface with clinicians and a resistance from a fairly static workforce from BMS's through to consultants TP time, departmental and Trust funding, clinical staff support from multidisciplinary areas can be challenging. Protected haematology consultant time. Lack of support and particularly of time. Disinterest of clinicians in their blood spends Lack of admin and data input personnel leading to inability to generate reports to drive change. Lack of IT engagement distracted by other IT projects within the Trust Staffing levels within the laboratory because of pathology Modernisation. Staffing levels within the Trust as a whole Bureaucracy surrounding funding for IV iron Resources (staffing and financial barriers) Funding Majority of TP time spent on training and competency assessment. Current workload
Training and education Empowerment of BMS Staffing IT support Limited time and staff resources Time and Staff resources Changing perceptions and stimulating enthusiasm among all staff. Funding Size of the Trust Funding may not be approved. Resources may not be available, including enough clinician input. Lack of Clinical Engagement Finance; Staffing levels; Resources; Time; Opportunities; Engagement with blood using specialities; Attendance at HTC including no management/nursing representation Indication codes for electronic prescribing of blood. Team approach to PBM HTC members discussing at team meetings and challenging staff. Investigation of wastage/adverse incident/inappropriate transfusion undertaken with clinical teams. The clinical team ensures shared learning occurs. Roles of TP's diverted to BSQR requirements Funding, staffing levels, admin support, support from the Trust Lack of dedicated transfusion practitioner. No real engagement from medics (possibly related to lack of TP). Departmental staffing issues. Staffing IT support Trust mergers Competing Trust priorities and already full agenda Limited budget and resource Staffing issues including increasing staff turnover and use of agency staff Resources need to spend time auditing current practice to produce an action plan for areas to target. Would be helpful to have tools for the paediatric setting as the 'why use 2 when will do' catch line isn't that helpful in paediatrics. Lack of sufficient staff and funding Staff resources and funding Lack of continuous database of transfusion activity. Lack of specific medical support for PBM activity.
Resources, limited face to face education, no permanent Blood Bank manager for years, conflicting Trust priorities Staffing issues: Recruitment and retention, training. Data analysis: Resource availability LIMS system Limited within the current IT systems that are in place no funding for better/improved lab systems! Plus have limited support from IT department (unless something has gone wrong!) All the aspects of PBM implementation cannot be introduced in one go. It s a gradual evolving process in promoting changes in practice and policy Funding is the major constraint most people agree with the appropriate use of blood and blood products. Blood Transfusion is low priority for many directorates would benefit from more powerful representation who can raise profile Clinical involvement in PBM poor in some areas Financial restriction in implementing fully electronic transfusion processes Communication. Time for TP and Doctors/nurses. Finance. Financial currently budgets are being cut and the imperative is to maintain safe service levels. IT systems Trust and Lab interlinking IT systems Access to a data manager and IT support Finances Staffing Constraints Education time for clinical staff difficult, they often find it hard to attend education sessions Accessing appropriate meeting to cascade information regarding PBM Time and money Resources, support from senior trust members including executives and board Buy in by senior clinicians Finance and challenging historical behaviours by clinicians. Lack of patient spaces for day case administration of IV iron. Lack of engagement with the CCGs and therefore lack of funding to support this. Not having enough transfusion team time (particularly as wasting time on admin tasks) Getting appropriate multiprofessional engagement to make PBM projects viable and sustainable poor attendance at TTC/HTCs and other meetings Restructuring of local pathology services provides uncertainty and diverts resources away from daytoday PBM projects No new funding to develop any Trust wide educational initiatives aligned to PBM
clinicians time to support PBM Split role of transfusion practitioners with increased workload from other speciality Both transfusion practitioners have been on long term absence from work independently Lack of engagement from other specialties such as surgery monetary constraints affect projects such as 2 hour ICS cover Staff buy in Clinical Engagement, preconceive notions IOCS IS TIME CONSUMING, Lack of resources time of relevant people, lack of money Difficulties with IT LIMS is difficult to get accurate information from and noone has the dedicated time to learn how to get transfusion information from the LIMS Local intranet is really difficult to navigate to find policies and local guidelines Long drawn out processes to get guidelines and local policies signed off by relevant committees and groups within the Trust Clinician Uptake Clinicians reluctance to take transfusion advice Financial Constraint No higher level support Massive undertaking Lack of compliance for training for those that are giving advice resulting in incorrect advice being given. Lack of clinician continuity Refusal to take advice from BMS Lack of BMS empowerment Funding has prevented implementation Competing clinical priorities. Limited time for TP to do all the demands of the job some weeks I have worked 2 hours over. The main driver at the moment is rolling out electronic tracking. Staffing and IT support Engagement with all clinical staff on a consistent basis Funding, resources, Pathology merger Time to educate the staff Staffing and time Staffing to provide added education Time, access to staff for training, data analyst time to analyse blood usage data and resources to deliver anaemia service Time for HTT to promote theses enthusiasm to use them from other specialities Recent changes in Haematology Consultants. Approval required by too many committees before implementation
Time for people to concentrate on these activities as well as the current roles we have Lack of resources e.g. consultant haematologist time to set up anaemia clinic, difficult recruiting Consultant Lack of transfusion practitioner time Lack of attendance of some clinical colleagues at HTC Changing medical opinion on transfusion triggers and thresholds Laboratory staff lack time to challenge requesting Capacity for outpatient transfusion Resistance from Consultants to having a restrictive transfusion policy. Money, lack of attendance at the HTC. IT integration at the current time, system network availability as have own in house system, time, resources PBM is competing with other NHS England priorities. IT restricts access to information lack of resources e.g. IT and especially a lack of time for the HTT to do all the things within PBM Trust activity and staffing, difficulty in releasing staff for training. Limited resources Poor attendance at the transfusion committee meetings Levels of staffing, time and Clinician and Trust support. Trust do not see blood transfusion as a priority difficult to get all divisions to engage in HTC Involvement and support of PBM committee due to time constraints. Staffing levels. At present there is a vacant full time TP position, and there has been for 6 months. Also there are currently major organisational changes taking place including a TUPE which was completed 2 months ago so focus has been on streamlining processes between the two trusts and building relationships.