Standard 7 Blood and Blood Products

Clinical leaders and senior managers of a health service organisation implement systems to ensure the safe, appropriate, efficient and effective use of blood and blood products. Clinicians and other members of the workforce use the blood and blood product safety systems.

The intention of this Standard is to:

Ensure that the patients who receive blood and blood products do so appropriately and safely

The blood & blood products governed under Standard 7 include:

Fresh blood products:

Red cells

Platelets

Plasma

Cryoprecipitate

Plasma derived products:

Albumin

Clotting factors e.g. Prothrombinex

Immunoglobulins:

o IVIg (Intragam P, Octagam, Kiovig)

o Hyper immune (Anti D, Hep B, CMV, Tetanus, Zoster)

Recombinant clotting factors:

Advate

Kogenate

Xyntha

NovoSeven

Blood is a vital limited community resource The Australian Red Cross Blood Service collects 900,000 red cell donations per year however it remains an inherently

limited resource – currently only 3% of the Australian population donate blood. In Australia only the donors give their

blood for free - what happens thereafter is not free! The current national price for a unit of red cells is approximately

$402.

Unnecessary & inappropriate wastage A certain level of discards of blood and blood products is both inevitable and appropriate to ensure that products are

available where and when they are clinically necessary. However, there is a proportion of discards of blood and blood

products that is neither inevitable nor appropriate which is defined as wastage.

Inherent risks of transfusion Although Australia has one of the safest blood supplies in the world the use of blood carries inherent risks and there is

strong evidence associating blood transfusion with adverse outcomes including increased morbidity, mortality and

length of stay.

Inappropriate transfusions Reports have shown that a significant number of transfusions are inappropriate and based on ingrained clinician

behaviour rather than current evidence. Patient Blood Management Guidelines aim to reduce inappropriate

transfusions and deliver better outcomes for patients. These have been approved by the National Health and Medical

Research Council (NHMRC) and are supported by all Australian governments.

Why do we need a Standard for Blood & Blood Products?

The Western Health Transfusion Committee.

The Western Health Transfusion Committee is the key committee within Western Health for facilitating and promoting

evidence based best practice in all aspects of transfusion medicine. The Committee members are senior medical staff

from Haematology, Medicine, Anaesthetics, Emergency, Obstetrics and Gynaecology, Critical Care and Surgery, senior

blood scientists, the Day Unit NUM, Quality Manager and the Transfusion CNC.

Transfusion Committee KPIs and Meeting Minutes can be found on the Blood Products/Transfusion Practice page on the

Western Health Intranet.

Monitoring and improving performance.

In accordance with NSQHS Standard 7 the Western Health Blood Transfusion Committee has developed sixteen key

performance indicators and implemented a comprehensive clinical audit program to evaluate practice and identify

potential opportunities to facilitate improvements in patient safety and systems for the safe and appropriate use and

management of blood and blood products.

Transfusion audit reports on MaP

Are accessible via the Clinical Quality Icon.

The audits are conducted retrospectively by the Transfusion CNC. Transfusion episodes are identified from a list of

patients that have had a Blood Prescription form scanned in their DMR in the preceding month (provided by the DMR

team). For this reason, audit reports will always be a month behind e.g. November audit reports are currently available,

December will be available late January.

The reports detail compliance with applicable audit criteria (questions) for each episode rather than the number of

episodes as not all audit criteria e.g. after-hours transfusion will be applicable for every episode. A legend has been added

to each of the reports outlining audit criteria and possible responses.

Details of each transfusion episode can be viewed by clicking on the displayed number.

Key tasks for Health Services

7.1 Health service organisations have systems in place for the safe and appropriate prescribing and clinical use of blood and blood products

7.1.1 Identify, adopt and/or develop policies, procedures and/or protocols which are consistent with national evidence-

based guidelines

7.1.2 Monitor the use of policies, procedures and protocols, and amend them as appropriate

7.1.3 Implement actions to improve consistency of policies, procedures and protocols with national evidence-based

guidelines, as well as compliance with these policies, procedures and protocols.

All Western Health policies and procedures are consistent with national evidence-based guidelines.

Pretransfusion Testing

Requesting Blood and Blood Products

Intravenous Immunoglobulins

Storage Issue and Transport of Blood and Blood Products

Refrigerators and Monitoring Requirements for the Storage of Blood and Blood Products

Coagulation parameters for cirrhotic patients

Consent, Prescribing and Administration of Blood and Blood Products

Management of Patients Who Refuse Blood and Blood Products

Recognition, Management, Investigation and Reporting of Blood and Blood Product Adverse Reactions & Events

Critical Bleeding and Massive Transfusion

GP referral of community based patients requiring transfusion

Emergency Blood Management Plan

On the Western Health Intranet: Policies, Procedure & Forms. Type your query into the search function from this page and you will find what you are looking for.

Where can I find them?

Members of the workforce should be trained in the use of such documents and procedures,

where appropriate.

Investigations audit and/or assessment of practices against national evidence-based guidelines.

7.2 Undertaking a regular, comprehensive assessment of blood and blood product systems to identify risks to patient safety and taking action to reduce risks

7.2.1 The risks associated with transfusion practices and clinical use of blood and blood products are regularly assessed.

7.2.1 The risks associated with transfusion practices and clinical use of blood and blood products are regularly assessed.

7.2.2 Action is taken to reduce the risks associated with transfusion practices and the clinical use of blood and blood

products.

Alignment with Clinical Practice Guidelines. Appropriateness of dose prescribed and transfused. Transfusion given out of hours when not clinically indicated. Documentation of clinical indication. Documentation of consent. Observation recording in accordance with P & Ps.

7.3 Ensuring blood and blood product adverse events are included in the incidents management and investigation system

7.3.1 Reporting on blood and blood product incidents is included in regular incident reports

7.3.2 Adverse blood and blood product incidents are reported to and reviewed by the highest level of governance in the

health service organisation

7.3.3 Health service organisations participate in relevant haemovigilance activities conducted by the organisation or at

state or national level

7.4 Undertaking quality improvement activities to improve the safe management of blood and blood products

7.4.1 Quality improvement activities are undertaken to reduce the risks of patient harm from transfusion practices and the clinical use of blood and blood products

The clinical workforce accurately records a patient’s blood & blood product transfusion history and

indications for use of blood and blood products

7.5 As part of patient treatment plan, clinical workforce accurately documenting:

relevant medical conditions

indications for transfusion

any special product or transfusion requirements

known patient transfusion history

type and volume of product transfusion

patient response to transfusion

7.5.1: Document comprehensive information regarding transfusion of blood and/or blood products in the patient clinical

record.

The following information should routinely be documented:

Product identification

Provision of information

Patient consent or refusal

Indications

Special product requirements

Known patient transfusion history

Compatibility label or report

Type of product

Volume of product

Date and time of commencement

Date and time of completion

Observations

Patient response including any adverse events

7. 6 The clinical workforce documenting any adverse reactions to blood or blood products

7.6.1 Adverse reactions to blood or blood products are documented in the patient clinical record

7.6.2 Action is taken to reduce the risk of adverse events from administering blood or blood products

7.6.3 Adverse events are reported internally to the appropriate governance level and externally to the pathology service

provider, blood service or product manufacturer whenever appropriate

7.7 Ensuring the receipt, storage, collection and transport of blood and blood products within the

organisation are consistent with best practice and/or guidelines

7.7.1 Regular review of the risks associated with receipt, storage, collection and transport of blood and blood products is

undertaken.

7.7.2 Action is taken to reduce the risk of incidents arising from the use of blood and blood product control systems

7.8 Minimising unnecessary wastage of blood and blood products

7.8.1 Blood and blood product wastage is regularly monitored

7.8.2 Action is taken to minimise wastage of blood and blood products

Patients and carers are informed about the risks and benefits of using blood and blood products and about the available alternatives when a plan for treatment is developed

7.9 The clinical workforce informing patients and carers about blood and blood product treatment options, and

the associated risks and benefits

7.9.1 Patient information relating to blood and blood products, including risks, benefits and alternatives, is

available for distribution by the clinical workforce

7.9.2 Plans for care that include the use of blood and blood products are developed in partnership with

patients and carers

7.10 Providing information to patients about blood and blood product use and possible alternatives in a format

that can be understood by patients and carers

7.11 Implementing an informed consent process for all blood and blood product use

Information for patients: the Intranet

The Internet www.westernhealth.org.au

Additional resource for patients: http://www.mytransfusion.com.au/