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Transfusion Bulletin

Quality News - Importance of Policy and Guidelines on Clinical Use of Blood

Author(s): Author(s): Dr. Z. S. Bharucha

Vol. 12, No. 2 (2004-08 - 2004-08)

The advent of AIDS has posed a challenge to blood transfusion services, as all concerned have lost confidence in the system following transmission of HIV infection through blood. Careful attention is now required to all aspects of quality to regain the confidence in the safety and efficacy of blood and blood components transfused.

A major change witnessed in the last few years has been that transfusion medicine which has been a laboratory oriented service has now extended into the clinical area with emphasis on patient care. The process of blood transfusion links the community represented by a voluntary blood donor on one end with the recipient on the other. This life saving vein to vein chain requires commitment from not only the blood transfusion service but also the administrators and the prescribers.

The prescribers have a dual responsibility - an obligation to the donors to ensure that their blood donation is used efficiently and to the recipients to ensure safe, reliable and effective transfusion where the benefits outweigh the risks.

The blood transfusion therapy is a supportive therapy and in most circumstances it is required for hematological deficiencies until the primary disease can be corrected. The blood component therapy involves transfusion of various blood components - cellular and plasma derived. It requires a decision making process that is similar to that involved in any other therapeutic intervention. The decision to transfuse requires an accurate diagnosis and its patho-physiology, understanding of consequence of untreated disease, knowledge of available options and potential hazards. The outcome of undertransfusion at times is graver than the unnecessary transfusion However, it is necessary to avoid unnecessary transfusion to prevent or minimize the chances of adverse events.

Correctly used and administered blood components save lives and provide clinical benefit to many patients but morbidity and mortality do occur when there are lapses in the procedures. A quality management concept to achieve a successful and safe transfusion is administration of quality blood component of right type, in right amount, in right way, at right time, to the right patient. An important requirement for this situation is the adequate documentation of the whole transfusion process that also includes the decision to transfuse, patientís consent as well as the clinical outcome of the patient.

The questions to be answered for decision making process

  1. What improvement in the patientís clinical condition am I aiming to achieve?
  2. Can I minimize blood loss to reduce this patientís need for transfusion?
  3. Are there any other treatments I should give before making the decision to transfuse, such as intravenous replacement, fluids or oxygen?
  4. What are the specific clinical or laboratory indications for transfusion for this patient?
  5. What is the time frame of decision making urgent/elective?
  6. What is the hematology defect?
  7. Is a blood component indicated and what component is most appropriate?
  8. What are the risks of transmitting HIV, hepatitis, syphilis or other infectious agent through the blood products that are available for this patient?
  9. Do the benefits of transfusion outweigh the risks for this particular patient?
  10. How should the component be administered and monitored and documented its efficacy?
  11. Is the component easily available?
  12. What other options are there if no blood is available in time?
  13. Will a trained person monitor this patient and respond immediately if any acute transfusion reactions occur?
  14. Have I recorded my decision and reasons for transfusion on the patientís chart and the blood request form?
  15. Is the patient/relative fully informed and consenting to medical decisions?
  16. If this blood was for myself or my child, would I accept the transfusion in these circumstances?

The organizational responsibility

The organizational responsibility for adequate and continuous supply of quality, reliable, safe blood, efficient and effective clinical use of blood as well as implementation of good clinical transfusion practice require a close collaboration between blood transfusion service and the clinicians who are the prescribers.

Key elements to promote these goals

  1. A national policy on CUB with appropriate supportive regulations
  2. National guidelines on clinical use of blood
  3. National Blood Transfusion committee
  4. Hospital Transfusion committees
  5. Training of clinical staff
  6. Availability of alternative options to reduce the need for blood transfusion
  7. Monitoring and evaluation of the programme National Blood Policy

The National Policy on clinical use of blood is possible only if the health authorities are committed and willing to support the programme. The policy should define strategies for effective and appropriate CUB and alternatives to transfusion.

Strategies to be defined under National Blood Policy

  1. A plan to prevent, diagnose and treat the conditions that may need blood transfusion in future, can reduce the need for blood.
  2. Establishment of a blood transfusion service that can provide continuous and adequate supply of safe blood products
  3. Availability of replacement fluids, other pharmaceuticals such as antimalarial, anthelmintics, other nutritional support e.g. iron, B12, folic acid and equipment required to minimize the need for transfusion.
  4. Development of national guidelines.

  5. National Guidelines include
    • sample request form,
    • l maximum blood order schedule (MSBOS) model
    • SOP for all processes
    • information on blood and blood products
    • indications for blood transfusion and
    • information for recipients to help them to give their consent.

  6. Establishment of National Blood Transfusion Committee (NBTC)
    The NBTC is responsible for development, implementation and review of national policy and national guidelines for CUB. Introduction of teaching and training of transfusion medicine programmes could also be the responsibility of this committee.
  7. Establishment of Hospital Transfusion Committee (HTC) at each hospital. The organizational responsibility in a hospital set up can be entrusted to a HTC.
  8. Responsibilities of a Hospital Transfusion Committee

    • To follow national guidelines or develop local guidelines for CUB
    • To develop policies and procedures for blood transfusion in the hospital
    • To monitor and clinically review (concurrently or retrospectively) all blood transfusions to ensure appropriate and correct usage of blood.
    • To recommend corrective actions in transfusion practice
    • To investigate any adverse reactions that follow the blood transfusion and take necessary corrective and preventive action
    • To make arrangements for training of staff based on policies and procedures and CME of clinicians as and when needed.
  9. Education and training of all clinicians and blood bank staff. It is necessary to introduce transfusion medicine as a subject in undergraduate and all postgraduate courses and also for nurses, MLTs and pharmacists.
  10. Development of a plan to monitor and evaluate Monitoring and Evaluation of Clinical Use of Blood`
    • Whether the CUB complies with national guidelines
    • Whether adequate supplies are available
    • Whether systems are in place to ensureeffective use e.g. availability of request forms, MSBOS, system of storage and transport, documentation of process of blood transfusion and reactions if any and SOPS for various processes.
    • A system of audit of CUB enhances the efficacy of transfusion practice.
  11. Introduction of a system of hemovigilance at national or state level may provide a scope to cover the entire transfusion process from donor recruitment to a recipient being transfused.

Hemovigilance

The system of hemovigilance consists of detection, collection and analysis of information regarding untoward and unexpected effects during the vein to vein chain which helps in continuously improving safety of blood transfusion. It acts as a reliable source of information about all untoward effects and gives an opportunity to prevent recurrence by introducing corrective and preventive measures. The adverse effects could be infectious or non-infectious. According to SHOT higher mortality rates were recorded due to clerical errors which indicated importance of documentation. This type of data collection requires a close collaboration and cooperation between blood transfusion service and hospitals. There is a need to develop uniform reporting formats, to ease the analysis. The data needs to remain confidential but provide information that enables traceability, look-back of affected recipients and recall of products involved.


* Ex. Prof. & Head
Transfusion Medicine
Tata Memorial Hospital, Parel, Mumbai.


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