• 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.
Transfusion Audit and
Role of Hospital Transfusion Committee
Dr C. Shivaram
Consultant and Head-Transfusion Medicine
Manipal Hospital Bangalore
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
Audit Criteria
• 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
Audit Criteria
Explicit
Measurable
Lab Values
No of units
No of donors
Implicit
Subjective
Medical History
Clinical assessment Diagnosis
Involve Individual Judgement
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
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 .
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.
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.
Objectives of HTC
SAFE
DONOR
• Laying done/Ratifying policies for safe donor selection Ex : Discouraging directed donations .
• Motivating people to donate blood voluntarily
SAFE
BLOOD
• 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.
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.
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
www.manipalhospitals.com
•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
Quality Indicators
According to NABH BB requirement
Blood Donors 2012-2014
12304 12365
11384
10548 106489797
1756 1717 1587
0
2000
4000
6000
8000
10000
12000
14000
2012 2013 2014
Counseled
Donated
Defered
2012 2013 2014
Deferral % 14.3% 13.9% 13.9%
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Adverse donor reaction
ADVERSE DONOR REACTION RATE
2013 2014
144/10468
1.37%
118/9797
1.43%
Introduction of Donor Haemovigilance form for improved reporting
NO SERIOUS ADVERSE REACTION REPORTED
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Percentage of transfusion reactions
Year 2012 2013 2014
No. of
Transfusion
Reactions
42 34 31
No. of
issues
22767 23600 24123
Percentage
of
Transfusion
reaction
0.18% 0.14% 0.13%
1
19
14
9
0 0 0 0
10
14
0
1 1
5
3
15
12
0 0
1 1
2
0
2
4
6
8
10
12
14
16
18
20
2012
2013
2014
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TTI outliers %-Deviations beyond 2SD-NONE
CumulativeTTI Rate : Target less than 1%.
2012
2013
2014
4(0.04%) 5(0.04%) 6
HBSAg 86(0.82%) 50(0.47%) 43
HCV 7(0.07%) 4(0.04%) 0
Syphilis 6(0.06%) 2(0.02%) 2
Malaria 0(0%) 0(0%) 0
Cumulative TTI rate
0.97% 0.57% 0.52%
4
86
7 6
0
5
50
4 2
0
6
43
0 2
0 0
10
20
30
40
50
60
70
80
90
100
HIV HBsAg HCV Syphilis Malaria
2012
2013
2014
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Discard/Wastage rate
Year 2012 2013 2014
No. of units discarded (Date Expiry, Positive units etc)
2847 1958 1588
Total No of units prepared
25614 25558 25711
% of wastage 11.11% 7.65% 6.17%
Wastage Blood Bank Level
Year 2013 2014
Units returned after issue 52 34
Units discarded after return 5 3
Total no. of units issued 23600 24123
% of wastage 0.02% 0.01%
Wastage Ward Level
2847
1958
1588
0
500
1000
1500
2000
2500
3000
2012 2013 2014
No. of units discarded
No. of units
discarded
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Blood usage-Surgical specialties
2816
632
212 135
293 308 229
90 92 194
2197
676
168 238 461 291
178
103 129 238
3184
659
166 244
346 327
188 142 114
387
0
500
1000
1500
2000
2500
3000
3500
CTVS Ortho/Spine General Gastro Neurosurgery OBG Vascular Plastic Urology Onco Surg
2012 2013 2014
10863
(61%)
6814
39% Medical
Surgical
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Blood usage-Medical specialties
1745
2778
1307
232
786
391
1479
3679
1010
281
867 833
1191
4055
1304
247
757
165
0
500
1000
1500
2000
2500
3000
3500
4000
4500
Internal Med Oncology Nephro Cardio Gastro Neuro
2012
2013
2014
10863
(61%)
6814
39% Medical
Surgical
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.
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.
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.
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.
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.
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 .