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Hello, my name is Ryan Metcalf. I am an Assistant Professor of Pathology at the University of Utah and Associate Medical Director of University Hospital Transfusion Services and ARUP Blood Services along with Medical Director of ARUP Immunohematology Reference Laboratory. Welcome to this Pearl of Laboratory Medicine on “Blood Utilization and Transfusion Committee.”
Transfusion is a high volume activity that interfaces with many hospital services and thus has many stakeholders, such as complex cardiac surgery, solid organ transplant surgery, trauma, hematology/oncology, high-risk obstetrics, critical care, neonatal critical care, and more. Blood transfusion is not without risk: transfusion is actually the most commonly performed procedure in the US and is often considered one of the most over-performed. Ultimately, the Hospital Transfusion Committee is charged with monitoring transfusion practices and adverse events to improve quality and patient safety. In doing so, HTC helps meet regulatory and accrediting body requirements.
Transfusion services are regulated by the Food and Drug Administration (FDA), under which the Code of Federal Regulations (CFR) requires hospitals to have a quality assessment and improvement program that includes transfusion practices. CMS requires this for Medicaid reimbursement. CAP and AABB are accrediting bodies, both of which require review of transfusion practices and adverse events. Many hospitals are also accredited by The Joint Commission, which has similar requirements.
Any formal hospital committee should have a charter to clearly define its purpose, roles & responsibilities, and a framework for accomplishing goals. A typical charter will include the following elements: the committee name, its purpose, members of the committee, definition of a quorum, how often they should meet, committee responsibilities, authorities delegated, criteria for how decisions are made such as voting, measures of success, and approval & reporting to executive committee oversight.
Because there are many hospital services and personnel involved with the transfusion of blood components, HTC membership can be quite large. The committee needs a chair, which can be a transfusion medicine specialist or other physician with knowledge in transfusion medicine. The former has been defined as including eligibility to sit for the American Board of Pathology examination in blood banking/transfusion medicine and being recognized as having consultation expertise in transfusion medicine. Other physician members might include anesthesiologists, surgeons, transfusion medicine specialists, hematologists, critical care physicians, emergency physicians, and obstetricians. Other members might include nurses, transfusion service management & medical laboratory scientists, hospital administration, hospital quality, and risk management representatives. Experts agree that the members in bold on this slide should be included. I recommend erring on having fewer rather than more members in your committee to increase focus and ability to accomplish tasks & goals.
When the HTC meets, it should include a standard review of utilization and quality data. Many HTCs will review the number of type & screens performed, components crossmatched & transfused, component wastage and expiry, and transfusion reactions. Additionally, HTCs may often review rejected samples, FDA-reportable Biological Product Deviations, turnaround times for obtaining blood, nursing blood administration policy compliance, surgical blood ordering appropriateness, C:T and sometimes I:T ratios, and massive transfusion protocol activations. Again, the bolded items represent what is considered important by experts.
Here is a very basic example of a dashboard that might be routinely presented at HTC meetings. Transfusion data are clearly separated by component type. Numbers are tallied each month and throughout the year you can annualize your current data to project how the yearly data will appear. You can then compare this year to previous years.
HTCs can work to ensure institutional policies are known and being followed. Are patients being consented prior to transfusion and is this being documented consistently? Is there a blood refusal policy? Do physicians know when & how to order pretransfusion testing and blood components for transfusion? Other important policies related to transfusion safety include blood administration, MTPs, knowledge of transfusion indications, knowledge of indications for attributes such as irradiation, and the urgency with which blood should be indicated on the order.
Patient Blood Management – or PBM -- and avoiding unnecessary transfusions is often considered a key component of transfusion practices. HTCs may be involved with utilization management, such as prospective clinical decision support alerts to help avoid over-transfusion. The HTC may also oversee preoperative anemia clinic and cell salvage practices. They can discuss and increase awareness surrounding the importance of quickly managing hemorrhaging patients with significant coagulopathy. PBM is broad and may include many other facets including agreed-upon quality metrics and benchmarks.
HTCs may also discuss important changes in practice – whether national standards or local policies have changed. An example of this might include development of a working group with some key HTC members to develop a transfusion protocol for complex cardiac surgery. A newly FDA-approved drug, such as an antidote for direct thrombin inhibitor reversal, should be discussed at HTC because it may impact practices. At a minimum, including items like these on the agenda will increase awareness that could improve patient care.
We have discussed the basic elements of what might be included in HTC meetings, but how might a best-in-class HTC operate? It should regularly have active participation from all members. Hospital leadership should be supportive of the HTC and provide necessary resources. Meeting minutes should be accurate above all else. For sensitive liability issues, excuse those who may not need to be present. It should be clear that teams are aware of policies & procedures, which is reflected in compliance audits. Root cause and corrective & preventive action should be mainstays in dealing with nonconformances and other events. Data presented should be in a standard format.
When change is needed, there is effective training/education and change control. There is a detailed plan for blood shortages due to major disasters.
The six sigma philosophy is the belief that we can be error free. Best-in-class HTCs would also regularly employ established quality tools. A quality management approach might include any of the following tools. For example, a Pareto (or 80:20) chart can be a very useful data-driven tool to identify where you should focus your efforts to rectify a problem, such as plasma wastage. In the example here, nearly 80% of wasted units were wasted due to expiration.
Utilization of most blood components is down over the past several years, particularly for RBCs. If you expect to be in line with national trends of reduced RBCs since we’re now in the era of patient blood management, you can track yearly utilization trends. One strategy is to simply track utilization per year as in the top graph. I prefer an alternative strategy, which is to track utilization per year adjusted for any changes in patient volume and case mix index. This way, you can adjust for any major changes in your hospital related to how busy it is and/or how sick your patients are. Sicker patients tend to require more transfusions.
And finally, we have an example of a nursing blood administration compliance chart. Key elements required by your policies and procedures can be analyzed by hospital service unit. Data in each box would be presented as a percentage compliance and you can define your own benchmark goals. In this example, green is good and red is bad, while yellow is borderline. This hospital should definitely focus on making sure a provider order is present prior to transfusion.
In summary, HTCs are intended to improve transfusion safety in a collaborative manner. They should have a charter and be highly organized while encouraging active participation. HTCs should be data-driven in monitoring transfusion practices. And best-in-class HTCs will apply quality management principles and may use established quality tools.
Slide 16: References
Slide 17: Disclosures
Thank you for joining me on this Pearl of Laboratory Medicine on “Blood Utilization and Transfusion Committee.”