The National Motorcycle Museum, Birmingham, was the venue for the annual joint meeting of two leading UK blood transfusion organisations, and attracted an impressive audience of some 250 transfusion scientists, practitioners and clinicians. Since joining forces over recent years to host their annual meetings, UK NEQAS BTLP and the BBTS Blood Bank Technology SIG have benefited from shared overheads and higher attendances.
The theme of the day was the current scope of transfusion laboratory practice and the tools required to meet changing demands in informing and coordinating the response to clinical situations in which transfusion knowledge and expertise is invaluable. Three key areas explored over the day were therefore ‘education’, ‘communication’ and ‘empowerment’, which, according to Ann Benton, UK NEQAS Steering Committee, all impact greatly on the transfusion community and the services it provides.
Reducing laboratory errors
The UK Transfusion Laboratory Collaborative, of which UK NEQAS and BBTS are both stakeholders and active participants, released its recommended minimum standards for hospital transfusion laboratories in 2009. Presenting an update and overview on the implications of these recommendations for hospitals, Bill Chaffe, East Kent Hospitals blood transfusion coordinator and Collaborative spokesman, announced that all NHS trust chief executives should have received a copy of the standards and hopefully would be drawing up an action plan to meet them.
Bill explained how the Collaborative’s recommendations are intended to encourage effective and appropriate use of technology and staff in hospital transfusion laboratories within the framework of current legislative requirements. When adopted, these recommendations will help hospital trusts achieve the minimum standards of proficiency and practice set by the Health Professions Council (HPC) and as required by the UK Blood Safety and Quality Regulations (BSQR), with the aim of achieving a 50% reduction in blood transfusion laboratory errors by 30 September 2012.
Outlining how evidence collated from two recent national surveys of UK transfusion laboratories had formed the basis for the Collaborative’s recommendations, Bill revealed that the surveys had yielded some alarming findings – over 50% of transfusion laboratories are below ideal staffing levels, over 50% of staff have no formal transfusion qualifications, and, more worrying still, 25% of all staff working in transfusion laboratories have no documented transfusion training. As 30% of all reported transfusion errors originate within the transfusion laboratory, with a high proportion occurring outside core hours, Bill considered that the Collaborative’s main recommendations in the three key areas of ‘staffing’, ‘training’ and ‘technology’ must be adopted sooner rather than later. Furthermore, with the Collaborative’s recommendations due to gain Department of Health gateway reference, giving them ‘real teeth’, trust chief executives will be forced to act on them.
Next, UK NEQAS BTLP deputy scheme manager Jenny White examined the opportunities for education and training in transfusion laboratory practice by outlining the various qualifications pathways that can be undertaken to help achieve the Collaborative’s recommendations. Jenny explained how all unsupervised lone workers should now be appropriately qualified, but conceded that attaining this could be an expensive and time-consuming process both for the laboratory and the individual. These pathways include IBMS- and BBTS-recognised transfusion qualifications, but the Collaborative acknowledges that laboratories must now begin working towards the recommendations on training, as they will not happen overnight.
There are also recommendations for the minimum qualifications required for the lead biomedical scientist taking overall responsibility for the transfusion laboratory. Resources such as NHS Blood and Transplant (NHSBT) scientific and technical training courses, distance-learning and attendance at educational meetings can all assist in this area by providing ongoing continuing professional development as required for Health Professions Council (HPC) registration.
Maintaining post-qualification competence is another key area for individuals to consider, specifically by those staff not based permanently in a blood bank. In the interactive discussions that followed, Jenny explained how competence could be assessed using a programme of ongoing annual training for those staff participating in transfusion activities both within and outside core working hours.
Bill and Jenny concluded that the Collaborative’s recommendations provide an excellent opportunity for laboratories to reduce their errors and improve patient safety; however, resources must be found to support them as failure to do this would result in laboratories running the risk of future BSQR non-compliances.
Power to the people
Extension of practice, communication and staff empowerment was the theme of the next session. First, transfusion practitioner (TP) and former biomedical scientist Karen Madgwick presented a revealing glimpse of her role at North Middlesex Hospital. According to Karen, communication can sometimes be a scary process, quoting George Bernard Shaw, who famously said that the single biggest problem with communication is the illusion that it has taken place. Karen outlined the importance of communication in her role as a TP, where, with the support of her consultant haematologist, she has become a key contact for transfusion-dependent patients, directly advising on their management and care.
Empowerment of the laboratory was explored next by head biomedical scientist Ken McLoughlin. He outlined some effective strategies for challenging clinicians that he and his colleagues had employed at the Ulster Hospital near Belfast. “First, you must get a seat around the table at the hospital transfusion committee (HTC) to interact with your clinical colleagues,” he stated, and then outlined how this input was the initial catalyst for what followed. A 2005 regional audit of transfusion practice identified that many inappropriate transfusions were being undertaken, and allowed a mandate for new regional transfusion guidelines to be agreed, the centerpieces of which were a ‘Regional Rulebook for Transfusion’ and a standard transfusion request form for the whole of Northern Ireland.
Additionally, since January 2009, all staff in Northern Ireland have been required to be National Patient Safety Agency (NPSA) Right Patient, Right Blood-compliant. Clinicians must think carefully before ordering blood components as the laboratory now has the power to challenge or query their requests. However, laboratory staff must never be confrontational or prevent the release of blood components, instead, dealing with ‘offenders’ retrospectively.
Ken concluded by saying that empowerment was an educational process for all stakeholders and that he was proud of the achievements of his colleagues across Northern Ireland, which had led to patient transfusion rates 15% below the European average.
Changing transfusion behaviour and practice was also explored by consultant haematologist Simon Stanworth, who examined the knowledge gap between what the evidence says and what actually happens. “Many patients receive care that is unnecessary or, worse still, do not receive the correct care,” he claimed, stating that treatment variation such as occurs with ‘postcode prescribing’ can often occur. The solution is to learn from other fields (eg psychology) to apply behavioural therapy to change transfusion practice by incorporating systematic reviews and clinical trials. “Evidence-based medicine should be complemented by evidence-based implementation,” he concluded, but conceded that there is still a huge challenge ahead if we are to change transfusion practice in a cost-effective way.
NEQAS update
The value and importance of external quality assurance (EQA) data in transfusion laboratories was the basis of the presentation by Clare Milkins, NEQAS BTLP scheme manager. Clare outlined how EQA data had provided a powerful tool to demonstrate that laboratory processes are working correctly and in consensus with each other. Furthermore, unlike internal quality assurance testing, which mainly focuses on reproducibility, EQA can demonstrate any inherent weaknesses in the system. This can provide evidence for guidelines and manufacturers, thereby providing the impetus for change.
“Are we getting the most out of BTLP data?” asked Clare, recalling how a 2001 anonymous questionnaire on transfusion practice revealed widespread activities such as collaboration between laboratories and multiple testing of material using different techniques or additional analysers. Clare suggested possible reasons for these non-routine practices, such as the misunderstanding of the true purpose of EQA, and pressures on laboratories not to be penalised by regulatory bodies such as Clinical Pathology Accreditation (CPA) and the Medicines and Healthcare products Regulatory Agency (MHRA).
“It’s not the errors that are the real issue, it’s the responses you take following them,” Clare stated, and she urged all participants to treat EQA material as if it were a clinical sample, otherwise the data obtained are effectively invalid. Clare also reminded participants that by registering with the UK NEQAS BTLP scheme they had also signed up to abide by the JWG Conditions of Participation relating to EQA exercises.
On the topic of questionnaires in general, Clare explained their significance in providing important data to allow valuable comparisons between laboratory methodologies and subsequent trend analysis. Unfortunately, however, since the introduction of web-based results entry in 2008, the previous high return rates for paper-based questionnaires had fallen markedly to below 60%. Therefore she urged all participants to make greater efforts to return future questionnaires.
Clare rounded off her NEQAS update by highlighting recent complaints received, which mainly related to the quality of EQA material and to website data entry procedures, both of which are currently under review.
Antenatal care
The final session of the day examined the responsibilities of the transfusion laboratory in coordinating the care of pregnant women in relation to alloimmunisation. Setting the scene with a district general hospital (DGH) perspective on antenatal screening, blood bank manager Steve Tucker outlined the efforts to date that had been made nationally, which aim to ensure that severely affected births are now extremely rare. Clear guidelines on the monitoring of pregnant women and the frequency of antibody testing had been integral in this, as was good communication and coordination between the laboratory, clinicians and midwifery teams.
Steve considered that DGH laboratory staff are integral to this process as they provide a key link between care providers and external services, forming the natural conduit through which patient information flows and provides the ability to monitor the actions taken. However, Steve acknowledged the key role of the reference laboratories in antenatal testing.
Mark Williams, a reference laboratory manager for the Leeds and Newcastle Blood Centres, continued the theme by providing a blood centre perspective. highlighting in particular the value of antibody titration as a diagnostic tool in antenatal care in predicting the severity of haemolytic disease of the newborn (HDN). In his talk, Mark covered the pros and cons of automated techniques versus titration methodology and outlined how a new titration score project using card technology is currently underway in Newcastle.
Vicky Woodhead, lead biomedical scientist for Leeds and Bradford antenatal services then described how her laboratory had developed an in-house antenatal testing service. She outlined how initial teething problems had been solved, resulting in a successful three-way partnership between laboratory, clinicians and midwives that was beneficial to patients.
The final speaker of the day was Sailesh Kumar, a consultant in fetal medicine at Queen Charlotte’s and the Chelsea and Westminster Hospital, considered the fetal alloimmunisation problems from the ‘sharp end’. In collaboration with his colleagues, Dr Kumar manages all cases of fetal haematological disorders referred to her unit, performing a wide range of diagnostic and therapeutic procedures, including fetal blood sampling and intrauterine transfusion (IUT).
Dealing specifically with the problems posed by red cell and platelet alloimmunisation during pregnancy, Dr Kumar outlined the success achieved by anti-D prophylaxis since its introduction in the 1970s, which had greatly reduced the incidence of HDN mortality.
Focusing on the current management of at-risk HDN cases during pregnancy, Dr Kumar highlighted how procedures such as paternal genotyping, non-invasive DNA testing and ultrasound monitoring all helped to predict levels of fetal anaemia and the need for intrauterine transfusion.
Pathology in Practice thanks UK NEQAS BTLP and the BBTS Blood Bank Technology SIG for their assistance in preparing this report