26063 Blood and Transplant Matters (Issue 44) · Penny Richardson Media and PR Manager NHSBT,...

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June 2015 • Issue 45 Information for hospitals served by NHS Blood and Transplant Inside Patient Blood Management (PBM) in Clinical Haematology Conference Resume 4 2014 Survey of Intraoperative Cell Salvage: Equipment and Practice Across the United Kingdom 6 Blood Stocks Management Scheme: Still value after all these years? 8 Harvey’s Gang: Putting Patient Blood Management in the Heart of the Hospital Transfusion Laboratory 10 Involving, Informing and Consenting Patients Receiving Red Cell Transfusion 12 Remote Allocation of Platelets 14 Audit of Antenatal Immunisation with K 16 National Comparative Audit of Anti-D Immunoglobulin Prophylaxis 18 The Introduction of a Regional Road Map to Improve Access to Therapeutic Apheresis Services in the North West of England and North Wales 19 Case Study 22 Haemoglobinopathies and Genotyping 23 The Order of St John Award for Organ Donation 25 CPD Questions 27 Clinical Case Studies 29 Diary Dates 31

Transcript of 26063 Blood and Transplant Matters (Issue 44) · Penny Richardson Media and PR Manager NHSBT,...

Page 1: 26063 Blood and Transplant Matters (Issue 44) · Penny Richardson Media and PR Manager NHSBT, Liverpool Email: penny.richardson@nhsbt.nhs.uk ... less of our product. In this issue,

June 2015 • Issue 45

Information for hospitals served by NHS Blood and Transplant

InsidePatient Blood Management (PBM) in Clinical Haematology Conference Resume 4

2014 Survey of Intraoperative Cell Salvage: Equipment and Practice Across the United Kingdom 6

Blood Stocks Management Scheme: Still value after all these years? 8

Harvey’s Gang: Putting Patient Blood Management in the Heart of the Hospital Transfusion Laboratory 10

Involving, Informing and Consenting Patients Receiving Red Cell Transfusion 12

Remote Allocation of Platelets 14

Audit of Antenatal Immunisation with K 16

National Comparative Audit of Anti-D Immunoglobulin Prophylaxis 18

The Introduction of a Regional Road Map to Improve Access to Therapeutic Apheresis Services in the North West of England and North Wales 19

Case Study 22

Haemoglobinopathies and Genotyping 23

The Order of St John Award for Organ Donation 25

CPD Questions 27

Clinical Case Studies 29

Diary Dates 31

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< 2 Blood and Transplant Matters – June 2015

Editorial Board:

Rob Webster Consultant Haematologist, (Editor) NHSBT, Sheffield Email: [email protected]

Lynne Hodkin Medical Secretary/PA, (Editorial Assistant) NHSBT, Sheffield Email: blood&[email protected]

Denise Watson Regional Lead: Patient Blood Management Team NHSBT, Newcastle Email: [email protected]

James Neuberger Associate Medical Director Organ Donation and Transplantation, Bristol Email: [email protected]

Penny Richardson Media and PR Manager NHSBT, Liverpool Email: [email protected]

John Girdlestone Head of Laboratory Stem Cells and Immunotherapies NHSBT, Colindale Email: [email protected]

Paul Rooney R&D Manager, NHSBT Tissue Services NHSBT, Liverpool Email: [email protected]

Please let us know if the mailing address for your copy of Blood and Transplant Matters is not correct

contact: blood&[email protected]

Next EditionIssue 46 will feature articles on:

• National Survey on the Use of O RhD Negative Blood

• Fetal Genotyping (ffDNA)

• ECMO Support Group

• Wellcome – The Man with the Golden Blood.

If you would like to comment on any of the articles in this edition of Blood and Transplant Matters please email the Editor: [email protected]

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Blood and Transplant Matters – June 2015 3 >

EDITORIALNHS Blood and Transplant

describes itself as a Special Health Authority, dedicated to saving and improving lives through the wide range of services we provide to the NHS. Since joining NHS Blood and Transplant as Chief Executive last summer, I have been seeing first hand and learning from colleagues in their workplaces just how wide that range of services is. I have also been pleased to

meet a great number of people who work in the hospitals that we serve and others who support the vital work that we do.

Our blood service, supplying hospitals in England and North Wales, relies on the generosity of over 6,000 blood donors each day, to make sure we are able to meet the needs of patients. During my first months in post, I have seen how much care is taken of this precious commodity. NHS Blood and Transplant’s Patient Blood Management team works with colleagues in hospitals to help to improve transfusion practice and contrary to most organisations, to encourage our ‘customers’ to use less of our product. In this issue, Andrea Harris reports on the presentations from the Patient Blood Management in Clinical Haematology Conference that took place in Birmingham at the end of 2014.

The Blood Stocks Management Scheme (BSMS) receives data from blood services and hospitals in the UK and the Republic of Ireland, through VANESA, a specialist data management system. Elaine MacRate, BSMS Manager demonstrates how participants are also able to view data and charts on platelets and red cell issues, stock and wastage in real time, allowing them to compare their performance against other participants. She also reminds us that improving inventory management can reduce wastage and save money and that is something to shout about.

Another way of reducing blood use is cell salvage. Members of the UK Cell Salvage Advisory Group report on last year’s survey into Intraoperative Cell Salvage and the recommendations that they have drawn up to help to improve service and practice across the UK.

Emma Copperwaite from Ysbyty Glan Clwyd writes about a novel solution to a platelet supply problem that arose when her hospital’s pathology department was relocated at some distance from their users. This solution has improved service for their users, reduced wastage and made traceability easier. As a declared technophile, I applaud the use of technology that has such a positive impact.

As I looked at the contents for this issue, Harvey’s Gang jumped out at me. In February, as mentioned in the article, I had visited Western Sussex NHS Trust and been welcomed to the Haematology and Blood Transfusion Laboratory by Malcolm Robinson. I had heard first hand about their fantastic Harvey’s Gang initiative. This wonderful scheme involves young patients and their families in an area of their treatment they would not usually see. This initiative has now inspired other hospitals at home and abroad to follow their example.

Every year, the NHSBT audit team together with colleagues from NHSBT and hospitals throughout the UK manage and support a variety of audits. Effective clinical audit can bring about change and improve practice. This issue reports on the results of three audits. The first an audit commissioned by SaBTO assessing the extent to which patients are involved in the decision to transfuse them. The following two relate to ante and post natal care.

Dr Sara Trompeter, a Consultant Haematologist with NHSBT and UCH London, writes about the problems in providing blood and continuing care for highly transfused patients. She tells us how genotyping is now available in NHSBT’s RCI laboratories around the country and talks about the NHSBT’s Haemoglobinopathy Genotyping Initiative.

I have also seen the life saving treatments that our Therapeutic Apheresis Services provides in our units around the country. A team from NHSBT and the North West Regional Transfusion Committee report on their project to improve patient access to these vital services in their region.

Hearing from someone whose life has been transformed by an organ transplant reminds me three people a day will die waiting, as there are not enough organs available. Joyce Herdson was diagnosed with Idiopathic Pulmonary Fibrosis in April 2012 and her story relates how her health deteriorated over the following months. Joyce received a life saving lung transplant on New Year’s Day 2014 and tells us that she will be forever grateful to her donor. If you want to help others after your death, please sign up to the Organ Donor Register and let your family know of your donation choice.

Only about 5,000 people a year die in circumstances where they can potentially donate their organs and with 10,000 people needing a transplant, it is easy to see how vital each donor and donation is. Our final article in this issue, from Dale Gardiner and The Reverend Canon Dr Paul Denby describes how a partnership between the Order of St John and NHSBT led to the creation of a new national award. The Order of St John Award is a unique posthumous award which publically acknowledges and celebrates the generosity of organ donors and their families.

Finally, having started with a sentence describing our purpose, I would like to end with a sentence that states NHS Blood and Transplant’s organisational aim. Our ambition is to be the best organisation of our type in the world. My aim is to help us achieve this.

Ian Trenholm Chief Executive NHSBT, Watford Email: [email protected]

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< 4 Blood and Transplant Matters – June 2015

Patient Blood Management (PBM) in Clinical Haematology Conference Resume

A National Patient Blood Management in Clinical Haematology conference was held on 19th November 2014 at the Hilton Metropole Hotel, National Exhibition Centre, Birmingham. This event was organised and facilitated by the NHS Blood and Transplant (NHSBT) Patient Blood Management (PBM) Practitioner Team.

The conference was opened by Professor Adrian Newland, recently retired Chair of the National Blood Transfusion Committee (NBTC) and Professor of Haematology at Barts and The London NHS Trust. He provided an overview of Patient Blood Management explaining how ‘Better Blood Transfusion’ initiatives have been developed in the UK over the past 16 years. Whilst there have been great advancements in transfusion over this time, with reductions in the amount of blood components transfused, there remains evidence of inappropriate use and unsafe practices. PBM is an international, evidence based, multi-disciplinary approach to optimising the care of patients, who might need a transfusion. In England, PBM recommendations were launched July 2014.

Kate Jones, Head of Practice Development and Innovation from NHSBT, presented Safety First in Blood Donation. She discussed key safety interventions in the blood donation process. NHSBT take 1.8 million donations every year from just 4% of the eligible donor population, and research is ongoing looking at what motivates individuals to donate. All donors undergo a pre-donation health check and haemoglobin screening. The INTERVAL study is looking at frequency of donation. Platelet donors can donate every two weeks (maximum 24 donations in one year) although most donate monthly.

Tony Davies, NHSBT PBM Practitioner and member of Serious Hazards of Transfusion (SHOT), presented Lessons from the 2013 SHOT report. During 2013, 77.6% of all transfusion incident reports were caused by human error, including nine ABO incompatible red cell transfusions.

There were 22 deaths where the transfusion was causal or contributory and 143 reports were associated with major morbidity, including acute transfusion reactions (including anaphylaxis, severe febrile or hypotensive), delayed transfusion reactions, and Transfusion-Associated Circulatory Overload (TACO, especially in patients with contributory factors such as low body weight or renal impairment).

Tony stressed that positive patient identification is critical at every stage of the transfusion process, to prevent errors due to ‘human factors’.

Emma Whitmore, NHSBT PBM Practitioner, then provided an overview of the requirements for patient consent, with a presentation called How informed are you? – patient information and consent. In 2011 the Advisory Committee for the Safety of Blood, Tissues and Organs (SaBTO) published recommendations for patient consent for blood transfusion. In 2012, the Department of Health published ‘No decision about me without me’. Individual choice is a basic human right. Patients should have the right to decide if they want a transfusion and have the risks and benefits explained before the transfusion commences. PBM puts the patient at the heart of decision making and the keys to informed consent are information and communication.

Lorraine Birtwistle, an Advanced Haematology Nurse Practitioner from Manchester, described her experiences of Non-medical Authorisation of Blood Components (NMABC). Amendments to the Medicines Act excluded blood and blood components as medicinal products and removed the legal barriers to nurse authorisation. In 2009, Pirie and Green published a framework supporting the need and rationale for NMABC to be developed and implemented. NMABC is specifically applicable to high use areas such as haematology, where the nurse can assess the patient, make the decision to transfuse, organise and then authorise or prescribe the transfusion, rather than wait for a junior medic who has little or no knowledge of the patient. Implementation of this extended role takes time, especially when ‘on top of your day job’ – it took Lorraine over two years to gain Trust agreement and to have all associated policies in place, followed by training and competency assessment. Benefits include a reduction in waiting times for day patients, better planning of case loads by nursing colleagues, improved liaison between nursing and medical teams, and improved transfusion practice in junior medics following her lead and practice examples.

Dr Marina Karakantza, a Consultant Haematologist from Leeds who has a joint post with NHSBT, presented on Management of Anaemia in Wide Spectrum Myelodysplastic Syndromes (MDS). 98% of MDS patients present with anaemia. 70% of these patients present with mild anaemia. 30% present with severe pancytopaenia, infections, bleeding, fatigue and shortness of breath. Haemoglobin triggers for transfusion vary. Most European centres use Hb 80-85 g/L with no co-morbidities, and 100 g/L with cardiac or pulmonary co-morbidities. The main objective of treating anaemia in MDS patients is not only to relieve symptoms but to improve quality of life and prevent ischemic organ damage. An alternative to

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Blood and Transplant Matters – June 2015 5 >

red blood cell transfusions is Erythropoietin (EPO) with or without granulocyte-colony stimulating factor (G-CSF), which enhances the response to EPO in some patients.

Dr Kate Pendry is a Consultant Haematologist from Manchester, who has a joint post with NHSBT, presented on Red Cell Transfusion Triggers – Management of Acute Anaemia. Dr Pendry challenged the audience to think about “How much is too much?” and “How much is not enough?” when deciding transfusion triggers in the treatment of anaemia. Acute anaemia has a huge number of causes, including Gastro-Intestinal bleeding (overt or occult), post-op bleeding, post-partum bleeding, haemolysis, renal impairment, haematinic deficiency, bone marrow failure, malignancy, sepsis and iatrogenic anaemia (phlebotomy related blood loss). There is not a ‘one size fits all’ solution, and there are multiple factors involved in the decision making process.

Orin Lewis and Beverley de Gale from the Afro Caribbean Leukaemia Trust (ACLT), then provided A Patient and Relatives Perspective. This was a powerful and emotive presentation which promoted the work of ACLT, which was founded by Orin and Beverley when dealing with the shortage of ethnic minority groups donating blood, tissues, organs and bone marrow after their son was diagnosed with leukaemia. They shared Daniel’s story and some of the emotions, challenges and outcomes that his illness had on their lives and, the work that continues in his name as a legacy for others.

Dr Hazel Tinegate, Consultant Haematologist from NHSBT, presented Managing Patients who Experience Transfusion Reactions. Acute Transfusion Reaction (ATR) occur in 1 in 10,000 components transfused in the UK. Incidence varies according to type of component, with platelets having the highest incidence. ATR is the second most reported hazard of transfusion. Signs and symptoms of ATR are multiple and include fever, chills, rigors, hypoxia, dyspnoea, stridor, change in blood pressure, itch, rash, swelling of lips, collapse, shock, change in consciousness, reduced urine output, change in urine colour, nausea, malaise, pain and feeling of impending doom. Different transfusion reactions, as well as other medical conditions, can have many overlapping signs and symptoms, therefore diagnosis can be difficult.

Dr Andrea Harmer, National Head of NHSBT Histocompatibility and Immunogenetics, presented Human Leucocyte Antigen (HLA) Matching for Platelet Transfusions. HLA-selected platelets are directed donations for a named patient. There are different grades of match available, and investigating these can be very time consuming. Full matches are not possible for the majority of patients. In order to ensure the best patient

response, it is important to have good planning, providing NHSBT with as much notice as possible to find the best match. Post-transfusion platelet increment data is vital to help inform future selections. This blood test can be taken as little as 10 minutes after completing the transfusion.

Gillian Powter, Senior Nurse/Research Manager from NHSBT Clinical Trials Unit then presented Assessing Bleeding in Haematology Patients. There is a high prevalence of bleeding in patients with haematological malignancy; 40-50% of patients experience a bleed greater than or equal to World Health Organisation (WHO) Grade 2. Assessing bleeding can be very subjective; one person’s ‘minor’ is another’s ‘significant’. Clinical documentation of patient bleeding is often unreliable. A standardised method of measuring a patient’s bleeding can be useful; removing the differences between assessors. Bleeding assessment forms used in clinical studies could be valuable in daily practice too.

Finally, Dr Janet Birchall, a Consultant Haematologist from Bristol who has a joint post with NHSBT, presented the last presentation of the day National Comparative Audit: Use of Platelets in Haematology (2010). Haematology patients are the largest recipients of platelets accounting for up to 67% of all platelets transfused. This was the largest audit of platelet use ever reported, and identified that 28% of all platelet transfusions audited could potentially have been avoided. This would have resulted in a cost saving of over 16 million pounds. In the five years preceding the audit period platelet demand increased by more than 20%. Following the audit results use has increased by only 2% over the last two years.

Presentations from this conference are available on the NHSBT Hospitals and Science website: http://hospital.blood.co.uk/patient-services/patient-blood-management/

Andrea Harris Patient Blood Management Lead NHSBT, Birmingham Email: [email protected]

References:

Advisory Committee on the Safety of Blood, Tissues and Organs (2011) Patient Consent for Blood Transfusion. https://www.gov.uk/government/publications/patient-consent-for-blood-transfusion

Bolton-Maggs, PHB. (Ed), Poles, A., Watt, A., and Thomas, D. on behalf of the Serious Hazards of Transfusion (SHOT) Steering Group (2014) The 2013 Annual SHOT Report. http://www.shotuk.org/shot-reports/report-summary-supplement-2013/

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2014 Survey of Intraoperative Cell Salvage: Equipment and Practice Across the United Kingdom

Introduction

In 2006, the United Kingdom Cell Salvage Action Group (UKCSAG) was established to help support the wider implementation of cell salvage as an alternative to donor blood and to facilitate a UK approach to its use. The group publishes its outputs through the UKCSAG pages of the UK Transfusion Practice Toolkit. In 2007 an initial survey of Intraoperative Cell Salvage (ICS) practice was launched with a repeat survey in 2010. In 2014 a further survey was carried out. The aims of this repeat survey were:

• To evaluate progress with implementation of ICS.

• To identify remaining obstacles to the implementation and provision of an ICS service.

• To measure the success of the UKCSAG Toolkit.

• To gain an overview of how training for ICS was being delivered and by whom.

• To compare the clinical specialities where ICS is being used in 2014 compared with 2010.

• To help focus future work priorities of the UKCSAG.

Methods

A survey group was established from members of the UKCSAG. Questions were formulated by an iterative process and also based on previous surveys carried out by the UKCSAG. The survey was conducted as an online exercise using SnapSurveys© software, a paper option was also available. Answers to each question have been analysed proportionately (number, %).

Main Findings

137 hospitals from all four countries in the United Kingdom responded to the survey. It identified new trends in ICS implementation. Some areas of practice identified

in the 2010 survey remain a challenge. Key findings in this 2014 survey are:

• The 2010 and 2014 surveys were distributed differently. Accounting for this there has been little change in the number of machines in use.

• 16% of respondents said they outsourced cell salvage services.

• One manufacturer emerged as the most frequently-used machine, and was viewed as providing good support, service and manufacturer-based training.

• Surgery in obstetrics and gynaecology is the most frequent user of ICS with an increase in use in 2014.

• 21% said they did not operate outside normal working hours. This has not changed since 2010.

• Staffing and lack of trained operators are cited as reasons for no out of hours service provision.

• Operating Department Practitioners (ODP) are the main users of ICS equipment.

• There has been a slight increase in the use of Acid Citrate Dextrose (ACD) as an anticoagulant.

• 63% did not suction amniotic fluid (in other words it went into waste suction).

• All ICS operators who actively use equipment, now appear to receive training in a variety of different formats.

• ODPs, ICS Co-ordinators and manufacturers provide the bulk of the training.

• 59% of anaesthetic trainees said they did not receive theory or practical training (no change since 2010).

• 15% said they did not know about the UKCSAG workbook.

• 9% said they did not know about the learnbloodtransfusion e-learning module.

Department of Health (2012) Liberating the NHS: No decision about me, without me – Government Response to the Consultation. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216980/Liberating-the-NHS-No-decision-about-me-without-me-Government-response.pdf

National Blood Transfusion Committee (2014) Patient Blood Management: An Evidence-Based Approach to Patient Care. http://www.transfusionguidelines.org.uk/uk-transfusion-committees/national-blood-transfusion-committee/patient-blood-management

National Comparative Audit (2011) 2010 Re-Audit of the Use of Platelets in Haematology. http://hospital.blood.co.uk/media/26866/nca-platelet_re-audit_report-st_elsewheres_nhs_foundation_trust_2010.pdf

The INTERVAL study http://www.intervalstudy.org.uk/

Green, J., Pirie, L. (2009) A Framework to Support Nurses and Midwives Making the Clinical Decision and Providing the Written Instruction for Blood Component Transfusion. http://www.rcn.org.uk/__data/assets/pdf_file/0003/260832/BTFramework-Finaldraft2505092.pdf

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Blood and Transplant Matters – June 2015 7 >

• 16% said they had no policy for ICS in their organisation.

• 11% were not aware of the UKCSAG competency template.

• Theatres fund the bulk of the cost of ICS.

• Local blood transfusion departments/laboratories funded the cost of the blood.

• Between 50 and 60% of respondents said they did not quality control the machines or the operators. However, this represents a slight improvement since 2010.

Recommendations:

A list of recommendations have been drawn up for key stakeholders:

For Hospitals:

• The requirement for, and provision of ICS should be reviewed/audited by every Hospital Transfusion Committee and be part of the programme for Patient Blood Management/Better Blood Transfusion (PBM/BBT) to be fully integrated into patient care.

• Every hospital providing ICS, must have an up-to-date policy for its use.

• Recording of autologous transfusion, should have the same stringent standards as seen in allogeneic transfusion. The green ICS label (that is available free from manufacturers), or hospitals own equivalent, should be used by all hospitals carrying out ICS. The use of addressograph labels introduces additional risk and should be discouraged.

• Every ICS machine in use should have a service and maintenance contract with the manufacturer, or internal service provider, along with an agreed and documented programme for internal quality control.

• All incidents relating to ICS should be reported to the Serious Hazards of Transfusion (SHOT) scheme. Machine faults should additionally, be reported as per the local hospital policy and reported to the manufacturer at the appropriate stage of this process and via the ‘Yellow card’ system to the Medicines and Healthcare Products Regulatory Agency (MHRA). Guidance on reporting to SHOT is available at: http://www.shotuk.org/wp-content/uploads/SHOT-Cell-Salvage.pdf and guidance on reporting to the MHRA is at: https://yellowcard.mhra.gov.uk/the-yellow-card-scheme/.

• All ICS training received should be competency assessed.

For the UKCSAG:

• The UKCSAG need to raise their profile and do more to advertise the resources available on the Toolkit; it is recommended that they review their terms of reference including governance arrangements and create an annual action plan with time frames and responsibilities.

• All documentation on the ICS Toolkit should be systematically reviewed by the UKCSAG at least once every two years and updated if necessary.

• Further research on ICS is required and should be encouraged and supported by the UKCSAG.

For Blood Services:

• Each of the Blood Service PBM/BBT teams should ensure they have a named contact for cell salvage lead at every relevant hospital in their country and ensure they are provided with regular updates and so forth.

• Blood Services not currently doing so, could consider bulk buying cell salvage equipment and providing it ‘at cost’ or free to hospitals.

For College of Operating Departmental Practitioners and Royal College of Anaesthetists:

• Education and training on ICS should be an integral part of all programmes for ODPs and Anaesthetists.

• All ICS training received should be competency assessed.

For ICS manufacturers:

• Review the feedback in the survey and consider how they can improve the machines, service and support they provide to hospitals.

Karen Shreeve Manager: Better Blood Transfusion Team Welsh Blood Service Email: [email protected]

Rebecca Gerrard National Lead: Patient Blood Management Practitioner Team NHSBT, Liverpool Email: [email protected]

Hannah Grainger Cell Salvage Coordinator: Better Blood Transfusion Team Welsh Blood Service Email: [email protected]

Brian Hockley Data Analyst and Audit Manager NHSBT, Sheffield Email: [email protected]

References:

UKCSAG online resources: http://www.transfusionguidelines.org.uk/transfusion-practice/uk-cell-salvage-action-group

Jones, J, Howell C, 2011. Intraoperative Cell Salvage Survey; UK Report

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Blood Stocks Management Scheme: Still value after all these years?

I have worked in blood transfusion for more years than I would like to admit to, in large hospitals, small hospitals and in the private sector. In all that time I have never met a Transfusion Laboratory Manager who said ‘I really do not care about wastage’.

When blood component wastage is discussed, you generally get one of these replies:

• Our wastage is about the same as everyone elses.

• Yes, we have got wastage but our hospital’s challenges are unique, it cannot be improved.

• We would like to improve it, but we just do not have the time or the staff.

• Wastage? Not here. We do not have any at all.

Which of those categories does your hospital fall into? Perhaps now is the time to review practice and see if you could reduce your wastage. Not just for the donor, because everyone who works in blood transfusion really does value the donor. Perhaps you should consider if the acceptance of a certain level of wastage, is costing your laboratory money. Here, at the start of a new financial year, why not use the Blood Stocks Management Scheme (BSMS) database (VANESA) to demonstrate how even slight improvements in stock management can create ‘cash releasing efficiency’ savings?

Here are some examples of how hospitals that are similar sized, similar specialities and equivalent distance from their centres vary in their wastage levels. These examples use wastage data directly from VANESA,

No worse than others?

Consider three hospitals from the BSMS “Red Cell Usage – Very High” category. This shows Wastage as Percentage of Issues by month, against a cluster of 53 hospitals that are in the same Red Cell – Very high category.

Hospital 1 Hospital 2 Hospital 3

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

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5.0%

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Jan

-14

Feb

-14

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Ap

r-14

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-14

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14

Au

g-1

4

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-14

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Au

g-1

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Jan

-14

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Sep

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No

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c-14

Breakdown:

Red Cells Hospital 1 Hospital 2 Hospital 3

Issues for 2014 (Jan-Dec) (approx) 16,000 14,000 20,000

Total No of Units wasted 650 500 360

Wastage as a Percentage of Issue 4.0% 3.6% 1.8%

You can see there is a difference in wastage, let us look at the categories.

Ah, but we are different

These hospitals all have: Obstetric Unit, Oncology Unit, Orthopaedic Unit, Paediatric Unit, Renal Unit, Teaching Hospital, Casualty, Haemophilia Unit and are “near to Blood Centre” (Delivery Time – Near)

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Blood and Transplant Matters – June 2015 9 >

These are the differences:

Category Hospital 1 Hospital 2 Hospital 3

Adult & Children's Major Trauma Centre ✗ ✗ ✓

Cardio Thoracic Unit ✓ ✗ ✓

Vascular Surgery ✓ ✗ ✓

Liver Transplantation ✗ ✓ ✗

Neurosurgery ✗ ✓ ✓

Perhaps cardiothoracic surgery and vascular surgery are less blood-intensive than liver transplantation or neurosurgery? Perhaps Hospital 3 only looks so good because they are the only trauma centre?

By selecting by category:

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-14

No

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-14

Hospital 1 versus Identical cluster of clinical categories (10 hospitals)

Taking hospital 1, and selecting by relevant clinical categories, reduces the cluster to ten hospitals, but even so the cluster wastage is still lower. Distance to centre doesn’t impact either

0.0%

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Jan

-14

Feb

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Mar

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Ap

r-14

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-14

Jun

-14

Jul-

14

Au

g-1

4

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No

v-14

Dec

-14

Hospital 2 versus Neurosurgery only category (49 hospitals)

Neurosurgery is always a tricky one. The surgeons insist on having blood standing by, but frequently don’t use it. This has changed hospital 2 from being ~2% above the average, to mostly below.

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

4.5%

5.0%

5.5%

6.0%

Jan

-14

Feb

-14

Mar

-14

Ap

r-14

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Sep

-14

Oct

-14

No

v-14

Dec

-14

Hospital 3 versus Adult and Children Trauma Centres (12 hospitals)

By selecting the Adult and children’s Trauma centres as a category, it does change the cluster (the mean is now around 3.5%) but, this hospital is just looking even better now!

BSMS have 13 clinical categories, combined with the other categories (distance from hospital, reservation period and so on). It does reduce the size of the cluster for comparison, but you can add and subtract categories in VANESA when producing these graphs, to get a more meaningful comparison. Beware of reducing cluster size too much, as with smaller numbers in the cluster, you may get outliers skewing the data. The BSMS will soon be distributing a ‘re-registration’ exercise with some different categories to try and improve the benchmarking process.

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< 10 Blood and Transplant Matters – June 2015

We just do not have the staff or time.

The BSMS really cannot help you with this one. There are lots of suggestions about ‘good practice’ and everyone is facing the challenges of less staff and more work these days.

Once you have decided to do something, it has to become an engrained habit, one that cannot be postponed. Here are a few suggestions for your consideration:

• If its a task that no-one likes, could you set up a rota for it? If that person is not in, then could another person do it?

• If you already put short-dated stock in a separate drawer, could it go in there sooner, for example with three days left, rather than one day?

• If a clinician insists on having too many units standing by, you could take it to the Hospital Transfusion Committee every time you meet, to discuss the wastage it causes.

• Could you reduce your stock? The national demand has dropped over the past two years, maybe if you hold less stock, your wastage may reduce.

• Publicise how much you are saving the hospital by this increased vigilance! Reducing wastage from 4% to 3.5% could save Hospital 1 nearly £10,000 per annum.

Summary

It is true that using the BSMS data will not immediately solve your stock management problems. What it can do is either confirm that your hospital practices are well controlled and cannot be improved or it can identify potential for improvement. There are lots of variables, it’s true. These hospitals were selected only to demonstrate the points made; there are hospitals with much higher wastage and those who, unfortunately, don’t report on VANESA at all.

It is important to do what is right for your laboratory and hospital, but reducing wastage and saving money is worth it, especially if you can use the data to prove how well you have done. Remember, these graphs are for red cells only, with adult platelets the costs (or relative savings) are even higher.

So, is the BSMS still value for money? I think so, yes!

Elaine MacRate Blood Stocks Management Scheme Manager NHSBT, Filton, Bristol Email: [email protected]

Harvey’s Gang: Putting Patient Blood Management in the Heart of the Hospital Transfusion Laboratory

The importance of involving and empowering patients as part of the clinical decision making processes, is well documented. With the introduction of the Patient Blood Management (PBM) initiative in England and North Wales in July 2014, they are being given greater emphasis in transfusion practice. Demonstrating this in the transfusion laboratories is not as easy as having a patient attending the laboratory and engaging with laboratory staff outside of the sample tube, is rare indeed.

In 2013 the Haematology and Blood Transfusion Laboratory at Worthing Hospital, part of Western Sussex NHS Trust, (WSHT) was contacted about showing a little boy around the department. He was curious to see where his blood went when it was tested, why it needed to be done so many times, and how it would help the hospital staff to decide what blood he needed as part of his treatment. This simple request became the start of what has become an international PBM initiative to increase the involvement and knowledge of patients and their families, in the laboratory aspects of their transfusion treatment.

In March 2013 Harvey was admitted through Accident & Emergency (A&E) at Worthing hospital, where blood tests̀ that he had a Haemoglobin of 36 g/L. He was diagnosed with Acute Leukaemia, subsequently confirmed as Acute Myeloid Leukaemia, was double Blood Grouped and Antibody screened and had a Blood Group of AB Rh Positive and no atypical antibodies present. He was flagged for Irradiated and Cytomegalovirus (CMV) Negative Blood and Platelets. He was transfused with Red Cells, Platelets and started Chemotherapy and Shared Care with The Royal Marsden Hospital (RMH).

Harvey received a Bone Marrow Transplant (BMT), from his brother Max, who was A Rh Negative, and Harvey subsequently started grouping as A Rh Negative.

Regretfully Harvey rejected the BMT and succumbed to Host versus Graft Disease on 6th October 2014, after a 19 month battle. At his Farewell on 30th October 2014, the family showed a picture of Harvey in the laboratory with Malcolm Robinson (Chief Biomedical Scientist, Blood Transfusion WSHT) whilst on his tour as a “Trainee Scientist” for the day.

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Blood and Transplant Matters – June 2015 11 >

Consultant Paediatrician, Jon Rabbs informed Malcolm that they had seven other critically ill youngsters who wanted to visit the laboratory, as Harvey had so “Harvey’s Gang” was created.

Led by Malcolm, a small group of people made a collaborative and creative effort to make the laboratory tour more memorable for all concerned, including patient, family, paediatric staff, and all the laboratory staff not just haematology and blood transfusion.

Ruth O’Donnell Transfusion Practitioner WSHT bought mini lab coats, Wendy Cottee, Haematology Lead reverse engineered them to handmake more, Emma Whitmore designed and printed certificates of attendance and coined the phrase “Harvey’s Gang” and provided NHS Blood and Transplant Patient Information Leaflets, comic/sticker books, and “Ask me who am I” stickers, LabCold delivered a huge box of penguins, the Serious Hazards of Transfusion (SHOT) sent boxes of pens, Ortho provided rulers and highlighter pens, Malcolm bought sweets and got the trainee scientist badges made, suggested naming the new WSHT Ortho VISION analyser “Harvey” and inviting Harvey’s parents into the laboratory, to launch both machine and initiative, in Harvey’s name.

Harvey’s parents officially launch Harvey’s Gang

Back L-R: Emma Whitmore Patient Blood Management Practitioner NHSBT, Malcolm Robinson WSHT, Jon Rabbs Consultant Paediatrician WSHT, Melanie Holtom Ortho Clinical Diagnostics.

Front row Claire and Richard Baldwin with the memorial photograph of Harvey that hangs in the laboratory next to the machine that bears his name.

Ortho Clinical Diagnostic stopped a board meeting to tell Harvey’s story, and agreed to “name” the first 100 new Blood Grouping analysers, the Ortho VISION, sold into laboratories. They would support them with Harvey’s Gang “kits” so that they too could engage their patients in their laboratories, this includes providing memorial plaques to accompany those machines, and sending the stories of the laboratories and patients to WSHT to add to their records. Harvey’s Gang is now international and so far it has reached Japan. There has been media attention, newspaper, radio and television coverage and Harvey’s Gang continues to grow at WSHT and in the South East Coast region as other Trusts adopt this PBM initiative.

Since then William, age four who has an inoperable Brain tumour has joined Harvey’s Gang, and Ellae Mae a six year old with Chemotherapy treated Acute Lymphoblastic Leukaemia visited, on her last day, hopefully, of Chemotherapy. Regan a ten year old, second stage WILMS tumour visited and Francesca an eight year old little girl with Fanconi Anaemia visited the laboratory on the same days as Ian Trenholm, Chief Executive NHSBT and Huw Williams Director of Diagnostic and Therapeutic Services NHSBT, to see this powerful PBM initiative in action.

All the children have photographs taken in the laboratories and this is added to a history sheet which is kept as part of the record of attendance.

They get a copy of their photo, their certificates of attendance and “goody bags” given to them.

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Involving, Informing and Consenting Patients Receiving Red Cell Transfusion

Between January and April 2014, the National Comparative Audit of Blood Transfusion collected information from 2,784 sets of patient casenotes in 164 hospitals in the UK, and 2,243 patients from 162 hospitals completed a patient survey. This is the largest survey ever undertaken in the UK and was commissioned by the Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO). All patients had received a red cell transfusion.

The purpose of the audit was to assess the extent to which patients are involved in the decision to transfuse them, how well informed they are and how well care records demonstrates the information and consent process.

How Many Patients are Involved in Transfusion Decisions?

Involvement in decision making is different from being given written information or having things explained. Delivering person-centred care means recognising that the patient is a person who has a voice and the right to express an opinion, not someone whose role is to passively receive care offered. Table 1 shows how many patients thought they were involved.

Involved with the decision making

N = 2,243

% N

Yes 56 1,252

To a certain degree 18 407

No 21 462

Cannot remember 5 120

Not stated 0.1 2

The majority felt they were, yet just over one fifth of respondents explicitly felt they had not been involved.

How Many Patients Were Given Information About Transfusion?

Being given information includes being provided with a leaflet or other written matter and/or having transfusion explained by a healthcare professional. This was measured in three ways: whether it is Trust policy to provide information: whether there is a note in care records that information had been provided and whether the patient recalled is being given information. Auditing this was not straightforward because information and explanation can be given to a patient at several points along the patient’s journey through the healthcare system, so patients saying they had none, might have had some previously but, it is safe to assume that if they did, then for those answering “no”, that information made little impact.

93% (131 of 141 sites) of Trusts have a policy which requires staff to inform patients about risks, benefits and alternatives, but only 77% of these, routinely give information to patients.

Perhaps it is surprising that not every Trust considers that patients should be told about transfusion. In trying to gauge the extent to which information is given, we audited the patients’ care records and surveyed patients. Of 2,782 records audited, the provision of information was documented for 19% (519), not documented for 77% (2,133) and not stated for 5% (130). By contrast the table below shows what we found when we asked patients:

Work continues on refining the blueprint of the packs so that others can simply pick it up and implement it in their own Trusts, and applications for grants and funding to ensure that this initiative can be supported as it grows, are underway.

On the donor side, NHSBT is looking to engage donors with Harvey’s Gang and tell donors stories in their local donation centres and sites, along with patient stories from regional hospitals to show where and how donated blood and blood components really do help to save and improve lives every day.

Morale in the laboratory has soared to new heights and as one Biomedical Scientist said “when it’s a really difficult day I look at Harvey’s picture and remember why we do

what we do, it helps me refocus and keep going”. The Laboratory profile has been raised with regular mentions in the Trust newspaper and in the media which has had a positive impact. There is a better understanding of the role the hospital laboratory plays in daily patient care.

Emma Whitmore Patient Blood Management Practitioner NHSBT, Tooting Email: [email protected]

Malcolm Robinson Chief Biomedical Scientist, Blood Transfusion, Western Sussex NHS Hospitals Foundation Trust Email: [email protected]

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Blood and Transplant Matters – June 2015 13 >

Were you given information?

National

% N

Yes 28 631

No 62 1,389

Cannot remember 9 210

Not stated 0.6 13

So there is a discrepancy between what the notes say, and what the patient recalls. This suggests that what the Trust considers as being an adequate means of providing information, may not be as effective as they hope.

Besides providing information, it is important that patients are aware of why they are being offered a transfusion and what the benefits and risks of that transfusion might be. In addition, patients should also be told if there are any alternatives to transfusion but, it is worth bearing in mind that for some patients, there is no satisfactory alternative. We already know that the majority of Trusts require staff to have this discussion, but what do the records say? Documentation that this was done was found in 23% (629) of notes, not documented for 73% (2,043) and not stated 4%. When the patients were surveyed, this is what we found:

Benefits of Transfusion Explained

National

% N

Yes 68 1,534

No 19 434

Cannot remember 11 242

Not stated 1 33

Risks of Transfusion Explained

National

% N

Yes 38 858

No 44 998

Cannot remember 15 343

Not stated 2 44

Alteratives Offered

National

% N

Yes 8 184

No 76 1,714

Cannot remember 12 280

Not stated 3 65

Again, there seems to be a discrepancy between what the notes say and what the patient recalls.

Consent

While there is a general legal and ethical principle that patient consent should be obtained prior to a medical

intervention, SaBTO have issued recommendations re-enforcing the need for valid consent for blood transfusion to be obtained and documented in the patient’s clinical record by the healthcare professional. 85% (120 out of 141 sites) had a policy on consent for transfusion, and in the notes consent was documented for 43% (1192), not documented for 57% (1588), not stated for four. If consent was not documented, there was a note in only 4% of casenotes that the patient was unable to give consent. This is what the patients said:

Were you asked to give consent for transfusion

National

% N

Yes 59 1,333

No 23 508

Cannot remember 16 361

Not stated 2 41

Conclusion

Obtaining valid consent is an implicit part of good patient care in relation to transfusion practice. The SaBTO recommendations on patient information and consent for transfusion are explicitly clear with detailed recommendations.

This audit, while perceived to be challenging, did a have good level of participation enabling us to comment on current UK practice and make recommendations for change. While Trusts overall have policies in place covering key principles, actual practice does not reflect this as shown from the documentation within notes and the feedback from patients and staff. The need to document the indication for transfusion, should be an absolute minimum requirement within hospitals, with the explicit need to communicate this indication to patients supported by discussion of risks, benefits and alternatives. The majority of prescribers currently are junior doctors and, there is an urgent need to strengthen their training not only in relation to obtaining patient consent but, also, appropriate prescribing. There is a need to strengthen the content of training curricula and, also, the delivery of education. Strategies to increase the uptake and use of eLearning modules to support training, needs to be reviewed, with perhaps incorporation into other types of learning, including face to face sessions rather, than as just a stand-alone option.

The audit demonstrates a major discordance between hospital policies and actual practice in particular, around the provision of written information to patients. The development and dissemination of such information, should now be reviewed. Consideration should be given to the incorporation of transfusion information within

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< 14 Blood and Transplant Matters – June 2015

leaflets on relevant specific conditions given to patients to help streamline the provision of information with greater exploration of information technology, to increase patient and health care access.

Overall, the audit highlights the need for a more standardised and structured approach to the process of providing information and, obtaining patient consent, with emphasis on appropriate documentation.

John Grant-Casey National Comparative Audit Manager NHSBT, John Radcliffe Hospital Oxford Email: [email protected]

Shubha Allard Consultant Haematologists NHSBT, Colindale Email: [email protected]

Remote Allocation of Platelets

“Necessity is the mother of invention”. This is something we learn early in our scientific careers. However, it’s not until you encounter this necessity and, develop an idea born from this necessity, that you really understand and appreciated the beauty of this proverb. The necessity was to reduce the distance of platelets from our users and the invention, was remote release of platelets! This is our story…

Glan Clwyd District General Hospital is situated in beautiful North Wales and is currently undergoing a huge renovation to remove asbestos from the older parts of the building. Part of the renovation, was to build a ‘fit for purpose’ Emergency Quadrant, complete with attached theatres and Intensive Therapy Unit (ITU).

As a result of this work, a decision was made to relocate all of Pathology to a purpose built facility out on the back field, to make way for the improved ITU department. We didn’t mind the move as the new building was designed with our service in mind and, has fantastic views of rolling countryside. However, it became evident that we were soon missed by our users – particularly as our old laboratory was very centrally located in the middle of the hospital and provided rapid access to blood products, in emergency cases.

We had previously installed two remote-release fridges in the hospital, allowing remote release of red cells and, these had been working well for us for some time. An army of staff had been trained and, were ‘at the ready’ to collect blood for transfusion. The general opinion of the staff that we had trained, was they liked the ease and flexibility of the system as they were able to determine patient eligibility for themselves, using a Ward Enquiry software module and collect the blood at a time that was convenient to their Patient Care Schedules. The remote release of blood, has quickly become normal practice in our hospital, most likely because it’s a very user-friendly system.

Our main users at the Cancer Centre quickly became familiar with our new address, and during the colder, darker, wetter days (we are in Wales of course!) were not too pleased with the new neighbourhood or the views and as we issue over 125 units of platelets a year we knew there would be trouble ahead! We were soon contacted regarding the changes and during a meeting with the Cancer Centre Matron, it became apparent that the laboratory being away from the main hospital, meant that staff had less time with their patients to deliver the care that they needed. Patients were waiting longer for platelets, staff were becoming displeased with the implications of collecting the platelets from the laboratory and the 30 minute rule for safe return, was almost impossible to enforce. Therefore, we occasionally had to waste platelets. This was the origin of our necessity.

To improve the services we provide to our users, we decided to work closely with our supplier to find a solution... if only there was a way of remotely releasing platelets. We discussed our situation and ideas with them and, together, came up with a plan!

We installed a Locked Platelet Incubator that was fully integrated into our Blood Track System just outside of the Cancer Centre. We used the Plan, Do, Study and Act (PDSA) cycle, to work up the system and develop the software and process. This cycle was repeated until we were completely happy that we had a robust and safe system, which was easy to use when staff were under pressure. Once we got to this final stage of the development process, we finally validated the new system.

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Blood and Transplant Matters – June 2015 15 >

We were also keen to reduce our wastage and to keep it at a minimum, by working with our supplier, we found a way to remotely allocate ABO compatible platelets from the comfort of our new laboratory. After considering many factors and changes, we now have a fully- functional Remote Platelet Incubator, complete with full vein-to-vein traceability. Our traceability is recorded, using a ward fating module. The module works alongside the blood tracking system and allows users to record the arrival of the blood or product onto the ward and also to fate the unit once it has been transfused. This method of fating blood has been very successful in reducing the amount of time we spend on traceability whilst maintaining our compliance levels.

Remote allocation and release of platelets has been live in our hospital since January and has been gaining popularity with the ward staff as it saves them a lot of time that can be better spent with their patients. Because of the positive feedback we have had from our users, we intend to roll out the training to the rest of the hospital, starting with our highest users as priority.

After the successful roll out of our Remote Allocation of Platelets Project, we have completed some further work to develop software, that allows us to remotely allocate ABO compatible red cells to patients too. This is really helpful in ensuring patients receive compatible blood quickly in an emergency and, also, helps keep blood wastage to a minimum. We, also, remotely allocate batched products such as anti-D prophylaxis, albumin and prothrombin complex concentrate.

All these changes have had a positive impact on the running of our hospital, and ensure enhanced patient care, promoting good working relationships with the ward staff. We would very much like to thank our colleagues in the Cancer Centre for their patience whilst we developed this novel system, and for agreeing to partially fund the project.

Glossary:

Blood Track: Is an electronic system used to track all blood product transactions. This system can also monitor temperatures of all integrated locations; keeps track of stock count; records staff training; allows full traceability and alerts the laboratory staff to any problems that occur and the users involved.

Blood Track enquiry: This is a ward function of blood track, which allows all trained users to determine patient eligibility for Electronic Issue (E.I.). If their patient is eligible it will allow the users to see all locations where they can find compatible blood. This function also displays patient blood type and allows users to print off a pick up slip to allow collection from the refrigerators.

Blood Track-Ward fating: This is a function that supports our vein-to-vein traceability. As soon as a blood product arrives on the ward, the user can “arrive” the unit on the blood Track System and then “end transfusion” once transfusion of the product is complete.

Emma Copperwaite Specialist Biomedical Scientist Glan Clwyd Hospital, Betsi Cadwaladr University Health Board (BCHU) Email: [email protected]

Implementation Team (in photo l-r) Steve Ramsey, Emma Copperwaite and Nicola Polley

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Audit of Antenatal Immunisation with K

Background

Anti-K is an antibody directed against the K antigen of the Kell Blood system which has been reported to cause severe extravascular and, occasionally, intravascular haemolysis. Anti-K can be developed in K negative men and women as a result of exposure to the K antigen through a transfusion of K positive blood, pregnancy or transplantation. The literature suggests anti-K is more likely to be caused by previous transfusion, than as a result of the other known exposures (Lee E and de Silva M, 2004.) Therefore, to reduce the incidence of the development of anti-K in women of, or younger than, child-bearing age, must be avoided during transfusion by providing K negative blood. This has been established practice since before the British Committee for Standards in Haematology (BCSH) guidelines in 2006 formally identified it as a requirement.

This audit was undertaken to assess the effectiveness of measures to avoid transfusion of K positive blood to K negative women, and so reduce the incidence of anti-K in women thus determining compliance with the current BCSH guidelines that recommend this practice.

Audit Design

The aim of this audit is to ensure that restrictions surrounding transfusion of K+ blood to women of, or prior to, child-bearing age from the relevant guidelines and policies were applied consistently and that NHS Blood and Transplant (NHSBT) provides components and advice appropriately in these cases.

Two Objectives Were Established:

1. To ensure we provide expert quality of advice to all hospitals regarding the use of K negative units in women of child-bearing age (51 years or less).

2. To provide assurance that our provision of K negative units for hospitals is accurate and appropriate, ensuring that there is always an adequate stock available, to reduce the potential of having to use K positive blood components.

It was decided to use two large referral centres for Foetal Medicine; the Bristol Royal Infirmary (BRI) and the John Radcliffe Hospital (JR), Oxford. The data was collected retrospectively, using a short proforma.

The cases of Anti-K were identified from historical records covering the previous three years. Dr Mamta Chudasama, (SpR) and Professor David Roberts, (Consultant Haematologist) in collaboration with the Laboratory Manager and staff at the JR, completed the proformas to provide the information regarding their antenatal patients with anti-K. The authors, in collaboration with the Laboratory Manager and the Clinical Audit and Effectiveness Team at the BRI completed the same process for cases from the South West.

The data collection, took into consideration the transfusion history of these women; the number, ABO and K phenotype of units transfused at each transfusion episode where records were available. The ABO, Rh and K type of both the mother and father of the sample in question was also collected from existing records where available.

The results were measured against the 2012 BCSH compatibility guidelines pertaining to the use of K negative blood for women of child-bearing age, and reviewed by the Audit Team.

Figure 2: Audit Criterion and possible outcome classifications.

CriterionExpected Level of Performance

Exceptions

No females below age 51 to be given K

positive products

100%

Emergency transfusion where a K

negative product is unavailable

It was then determined whether the sensitisation was due to transfusion of K positive blood and the likelihood of such an event was classified as:

Probable – K positive blood transfused and father K negative

Possible – K positive blood transfused and father K positive

Unlikely – K negative blood transfused or no transfusion and father K positive

Uncertain – Transfusion history uncertain

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Blood and Transplant Matters – June 2015 17 >

Key Findings

Table 1: Performance Level.

CriterionExpected Level of Performance

Actual Level of Performance

No females below age 51 to be given K

positive products

100% 100%

• In no cases was transfusion of K positive blood identified as the definite cause of K alloimmunisation.

• In seven cases, K alloimmunisation by the transfusion of K positive blood was deemed unlikely, as there was no recorded history of transfusion with K positive blood.

• There were two cases where K alloimmunisation by the transfusion of K positive blood was uncertain. In both cases, there is no direct evidence to implicate transfusion as a cause of alloimmunisation and, other possibilities were evident.

• In four cases, K alloimmunisation by the transfusion of K positive blood was probable or possible in transfusion that took place before 2006, when the first BCSH guidelines for this issue were introduced. There were no records of any units being transfused to these patients during the last 15 years and certainly none since 2006 when the current BCSH guidelines, that formally stipulate the need to avoid transfusion of K positive blood to K negative women of childbearing age, came into place.

Table 2: The Transfusion History and Paternal K Phenotype of K Alloimmunised Women

Case Number Transfusion Date of Transfusion

K Phenotype of Transfusion

Paternal K Phenotypes

Outcome (Fig 2)

JR 1 No None N/A NK Unlikely

JR 2 No None N/A NK Unlikely

JR 3 Yes 2013 K neg NK Unlikely

JR 4 Yes 1998 NK NK Possible

JR 5 Yes 1992 NK NK Possible

JR 6 Yes pre 1992 NK K neg Probable

JR 7 Yes 1997 NK K neg Probable

JR 8 No None N/A NK Unlikely

JR 9 No None N/A NK Unlikely

BR 1 No None N/A K pos Unlikely

BR 2 Yes 2009 at North Devon

Not known K pos Uncertain

BR 3 No None N/A K pos Unlikely

BR 4 No None N/A K neg Uncertain

Conclusion

The evidence suggests that no women have been alloimmunised by the transfusion of K positive blood at the JR or the BRI since 2006, when the current BCSH guidelines were implemented. In view of the positive findings, it was recommended that this audit need not be repeated at the BRI or JR until the 2016/17 NHSBT Clinical Audit Programme with consideration being given to employing a prospective audit, examining contemporaneous cases. However, similar studies to review cases at other hospitals, would provide a wider view and, we would be happy to share the audit tool to assist with any such undertakings.

The findings of this clinical audit were shared and discussed with the Reference Service Manager, NHSBT Filton, the Head of Blood Bank, BRI and the Head of Blood Bank, JR. These findings were also shared with the Regional Transfusion Committees, for further dissemination to regional hospital blood banks.

Dawn Tilsley Senior Clinical Audit Facilitator NHSBT, Filton, Bristol Email: [email protected]

Sara Wright Consultant Clinical Scientist Trainee NHSBT, Filton, Bristol Email: [email protected]

References:

BCSH guidelines as follows: http://www.bcshguidelines.com/documents/Compat_Guideline_for_submission_to_TTF_011012.pdf

http://www.bcshguidelines.com/documents/BCSH_FMH_summary_sept2009.pdf

BCSH Guidelines for Blood Grouping and Antibody Testing in Pregnancy 2006 Gooch A, et al Lee, E., de Silva, M. (2004) Transfusion, 44 9S 104A.

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National Comparative Audit of Anti-D Immunoglobulin Prophylaxis

The introduction of anti-D prophylaxis for RhD negative women in the late 1960s resulted in a dramatic reduction of haemolytic disease of the fetus and newborn, due to immune anti-D. Most healthcare workers involved with the care of pregnant women, or the provision of laboratory services to support Maternity Units, will never have seen the devastating effects of this condition on women and their families. The interventions include Post-delivery (PD) prophylaxis for women delivering RhD positive babies, prophylaxis for potentially sensitising events (PSE) during pregnancy and routine antenatal anti-D prophylaxis (RAADP) in the third trimester given to all RhD negative women to prevent sensitisation as a result of silent fetomaternal haemorrhage (FMH).

The 2013 National Comparative Audit (NCA) of anti-D immunoglobulin (Ig) prophylaxis looked at RhD negative women across the whole pathway from booking to delivery – it did not include women who had terminations of pregnancy or early miscarriages. The audit standards were taken from the British Committee for Standards in Haematology (BCSH) and the Royal College of Obstetricians and Gynaecologists (RCOG) anti-D guidelines and the National Institute for Health and Care Excellence (NICE) technology appraisal on RAADP.

Midwives and transfusion staff in 153 UK hospitals with Maternity Units worked together to audit laboratory and maternity records on nearly 6000 RhD negative women booking in September 2012 for delivery in Spring 2013. Overall, the audit showed effective delivery of anti-D Ig prophylaxis.

There are two recommended RAADP regimes – a single 1500 IU anti-D Ig injection at 28-30 weeks gestation, used by 94% of participating sites, and a two-dose regime of at least 500 IU given at 28 and 34 weeks, which is as effective but less popular. 99% of eligible RhD negative pregnant women, received at least one anti-D Ig injection although full compliance (right dose at the right time) with the single dose regime was better compared to the two-dose regime (90% vs.59%).

Post-delivery prophylaxis was given to 98.4% of RhD negative women delivering RhD positive babies and, 91.6% had the right dose at the right time. It is important for a Kleihauer test to be taken from the mother, shortly after delivery to check if sufficient anti-D Ig has been given to cover any fetomaternal haemorrhage (FMH) at birth, and 97% had such a test. The volume of FMH (fetal red cells) was 2mL or less in 88% and in 97% the estimated FMH was 4mL or less. A ‘standard’ 500 IU post-delivery anti-D Ig dose will cover a 4mL FMH and 1500 IU will cover 12mL therefore, additional anti-D Ig was required, where

the standard dose of anti-D Ig was insufficient to cover the estimated FMH. Only 0.5% of women needed additional anti-D Ig to prevent sensitisation.

The strategy to audit maternity and laboratory records, resulted in a good overview of the anti-D Ig given to cover potentially sensitising events in pregnancy, even though this made analysis of the audit data complex and time-consuming. The commonest PSE requiring anti-D Ig, was antepartum haemorrhage (42%) followed by miscarriage and stillbirth (26%) and falls or trauma (19%) with procedures such as amniocentesis, chorionic villus sampling and other in-utero procedures. Anti-D Ig was given to 95.8% of the documented PSEs. It was sometimes difficult to establish the timing of the PSE, so approximately 79% had the injection at the right time but, 96% received the correct dose of anti-D Ig for gestation.

NICE recommend that women give consent to receive RAADP and, it is good practice to counsel RhD negative women about the risks of sensitisation, using written patient information to supplement this. However, only a third of women were documented as having been given information and, only 57% of women had consent documented in their maternity notes.

Continuity of care is important when delivering a complex preventative regime such as anti-D Ig prophylaxis, particularly as there are a number of different professional groups involved. It is important to take the choice of the woman herself into account. The audit showed good compliance with anti-D Ig prophylaxis and there were very few women put at risk of sensitisation. However, it was notable that where women moved from one organisation to another during their antenatal care, or were discharged early following delivery, it was not possible to be sure that appropriate prophylaxis had been given.

There are areas for improvement, and it is recommended that local policies are reviewed, particularly as the new BCSH anti-D Ig guidelines have recently been published1. There are many educational resources available for clinical and laboratory staff (see LearnBloodTransfusion2 and the Serious Hazards of Transfusion scheme3) and excellent patient information leaflets accessible on the NHSBT4 and other Blood Service websites.

As with all National Comparative Audits our thanks go to those who participated! The full audit report can be found on the NCA homepage5.

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Blood and Transplant Matters – June 2015 19 >

Dr Megan Rowley Consultant in Haematology and Transfusion Medicine NHSBT, Colindale and Imperial College Healthcare NHS Trust Email: [email protected]

References:

1 BCSH guideline for the use of anti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn H. Qureshi et al Transfusion Medicine, 2014, 24, 8-20

2 http://www.learnbloodtransfusion.org.uk

3 http://www.shotuk.org

4 http://hospital.blood.co.uk

5 http://hospital.blood.co.uk/audits/national-comparative-audit

The Introduction of a Regional Road Map to Improve Access to Therapeutic Apheresis Services in the North West of England and North Wales

Introduction

Apheresis is a commonly-employed method for the removal of harmful substances and proteins such as antibodies, that drive various disease processes. Different types of therapeutic apheresis modalities exist, such as plasma exchange, leucodepletion, red cell exchange and extracorporeal photopheresis. All therapeutic apheresis (TA) procedures require the use of specially designed machines operated by experienced healthcare clinicians. The medical conditions requiring TA are often unpredictable, severe and frequently require specialist medical and critical care, as well as access to the apheresis procedure itself. Some specialities, such as renal medicine, are regular users of the service, whilst others, such as dermatology and neurology, may have a less frequent need, due to the rarity of diseases. Emergency presentations of medical conditions, such as thrombotic thrombocytopenic purpura (TTP), require prompt urgent assessment of the patient, with rapid diagnosis and commencement of treatment, including TA, to prevent fatalities (BCSH guidelines).

Historically, within the North West of England (NWoE) and North Wales (NW), there was an absence of a standardised referral pathway, for the management of patients requiring therapeutic apheresis (TA). Service delivery was very variable, with some organisations having a comprehensive seven day service either in-house or outsourced with others having a fractured pathway, for the management of patients requiring urgent intervention. This practice was intensified in emergency situations, such as TTP, where delivery of TA is time- critical.

Nationally, variability of service delivery models continues to dominate in practice, often with little collaboration between the different specialities that utilise TA. Whilst

variability exists in the utilisation of in-house services, others contract the expertise of external organisations, such as NHS Blood and Transplant (NHSBT). Good practice is evident in the UK as demonstrated by the large TTP centre at University College London Hospital who accept regional and national referrals for patients with a new diagnosis of TTP, offering a comprehensive service including the diagnostic workup. However, regionally as well as nationally, there remains an absence of comprehensive multi-disciplinary multi speciality services.

As a joint collaborative between the North West Regional Transfusion Committee and NHSBT, a small project team reviewed the current service availability of TA within the NWoE and NW. The findings from a questionnaire survey revealed a lack of clarity about referral pathways for TA with some organisations unable to access a robust service for patients, leading to patient safety concerns.

Method

A retrospective questionnaire (Survey Monkey™) was circulated via email to named clinicians in haematology, renal medicine, dermatology, neurology, cardiology, rheumatology, immunology, endocrine (lipidology) and paediatrics at all hospitals in the NWoE and NW. The questionnaire aimed to identify the regional experiences of TA and highlight any challenges encountered over a 12 months period. Due to poor initial response, a letter outlining the rationale behind the project was sent to Chief Operating Officers of the organisations surveyed, inviting them to encourage completion of the electronic questionnaire by the relevant departments; this was followed simultaneously with a paper questionnaire (with a return envelope) to all non-responders. Although this yielded an additional response, the overall

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< 20 Blood and Transplant Matters – June 2015

response rate was still poor and, as a result, targeted phone questionnaires were conducted to achieve 100% from response from all haematologists in the region. Haematology was singled out, as it was felt they were most likely to have the most insight of the Trusts use of TA services. The data obtained, was entered into an Excel© spreadsheet and analysed internally by a data analyst.

Further intelligence into the regional challenges in accessing TA was obtained via a multi-speciality focus group meeting with Lead Clinicians, Service Users and Managers. This was followed by a one day educational symposium on TA delivered by national experts in the field. The audience was comprised of local service users from different specialities who shared the common challenges in access to TA. Feedback demonstrated the regional appetite for uniformity of practice and standardisation of care.

Results

Responses were analysed from Haematologists, Nephrologists, Rheumatologists, Neurologists and Lipidologists in 27 Trusts from across NWoE and NW. There was at least one response from 23 of the Trusts; 57 respondents in total. Cardiology and Dermatology data was not inputted, as it was felt they did not require the use of emergency TA; Paediatric data will be analysed at a later date separately.

Figure 1: Number of clinicians who reported difficulties gaining access to TA (number = 57).

Difficulty Accessing Apheresis Service?

% Yes % No %Blank

1, 2%

25, 44%

31, 54%

Figure 2: Apheresis Providers for Plasma Exchange in Haematology across North West of England and North Wales (number = 25 ).

Apheresis Providers for Plasma Exchangein Haematology

% NHSBT % In House % Refer out % No response

5, 20%4, 16%

6, 24%10, 40%

The findings of the survey highlighted the absence of uniformity in access to TA. Lack of clarity and variability in access to TA in the NWoE and NW was evident in all the responses. Over 50% of respondents reported absence of a contingency plan if a patient was admitted requiring TA, with over 44% (number = 25) reporting difficulties in gaining access to TA in an emergency (Figure 1). Further variability arose with regards to the delivery of the TA with some service users reporting an in-house service (number = 6, 24%) whilst other referred to outside organisations (Figure 2). This not only highlights patient safety concerns but also the unnecessary stress and work related pressures that can face clinicians during an emergency clinical scenario.

Regional Apheresis Map

It was recognised early that TA provision could be improved by the establishment of regional services, where several hospitals are served by a single service provider. This was anticipated to provide robust access for management of the peaks in referrals and, to provide for flexibility for clinicians to access a service 24/7. In collaboration with Renal Physicians, Haematologists in the region and NHSBT, a regional apheresis roadmap was launched in 2014. The roadmap provides clarity regarding access to TA services for every Trust in the region. In parallel, centralisation of some clinical services such as TTP, has led to clarity and delivery of safer health care. Evaluation of the service will take place, to ensure it is resourced sufficiently in order to have the flexibility and responsiveness required to treat patients who need urgent access to treatment.

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Blood and Transplant Matters – June 2015 21 >

Figure 3: Diagrammatic Representation of Regional Apheresis Road Map for NWoE and NW (service user clicks on the Trust name which reveals a page that explains the referral pathways for the different conditions requiring TA).

ISLE OF MAN

NORTH WALES

CHESHIRE

LANCASHIRE

YORKSHIRE

CUMBRIA

DURHAM

1 2

3

4

5

6

7

8

9

10

11

12

13

14

1516

17

1819

20 21

22

2324 25

26

27

28

29

Conclusion:

The introduction of the regional apheresis map in the NWoE and NW has been a two year project that has required the buy in of stakeholders from different specialties to ensure the introduction of a uniform approach to TA. It is a ‘live’ document and it is anticipated it will undergo further developments as lessons are learned. It is hoped

that this project would serve as a model for other regions of the UK, where similar issues are likely to exist.

The regional apheresis map can be accessed via: http://hospital.blood.co.uk/patient-services/therapeutic-apheresis-services/how-to-make-patient-referrals-to-tas/referrals-in-the-north-west-of-england-and-north-wales/

1 Aintree University Hospitals NHS Foundation Trust

2 Alder Hey Children'S NHS Foundation Trust

3 Blackpool, Fylde and Wyre Hospitals NHS Foundation Trust

4 Central Manchester University Hospitals NHS Foundation Trust

5 Countess of Chester Hospital NHS Foundation Trust

6 East Cheshire NHS Trust

7 East Lancashire Hospitals NHS Trust

8 Lancashire Teaching Hospitals NHS Foundation Trust

9 Liverpool Heart and Chest NHS Foundation Trust

10 Liverpool Women'S NHS Foundation Trust

11 Mid Cheshire Hospitals NHS Foundation Trust

12 Noble'S Isle Of Man Hospital

13 North Cumbria University Hospitals NHS Trust

14 North Wales: Betsi Cadwaladr University Health Board

15 Pennine Acute Hospitals NHS Foundation Trust

16 Royal Bolton Hospital NHS Foundation Trust

17 Royal Liverpool and Broadgreen University Hospitals NHS Trust

18 Salford Royal NHS Foundation Trust

19 Southport and Ormskirk Hospital NHS Trust

20 St Helens and Knowsley Hospitals NHS Trust

21 Stockport NHS Foundation Trust

22 Tameside Hospital NHS Foundation Trust

23 The Christie NHS Foundation Trust

24 The Walton Centre NHS Foundation Trust

25 University Hospital of South Manchester NHS Foundation Trust

26 University Hospitals of Morecambe Bay NHS Trust

27 Warrington and Halton Hospitals NHS Foundation Trust

28 Wirral University Teaching Hospitals NHS Trust

29 Wrightington, Wigan and Leigh NHS Foundation Trust

Dr Samah Alimam Haematology Registrar, North Western Deanery Email: [email protected]

Ms Hannah Scrimshaw Administration Manager, Therapeutic Apheresis Services NHSBT, Birmingham Email: [email protected]

Dr Shruthi Narayan Haematology Specialist Registrar North Western Deanery Email: [email protected]

Ms Catherine Howell Chief Nurse – Diagnostic & Therapeutic Services NHSBT, Filton Bristol Email: [email protected]

Dr Kate Pendry Consultant Haematologist and Clinical Director for Patient Blood Management NHSBT, Manchester Email: [email protected]

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Case Study

I first became aware that I was unwell back in 2008 when, after a bad chest infection, my breathing became laboured. Little things at first, like bending to pick things off the floor or stretching to put washing on the line. My GP couldn’t find anything wrong, but as time went by and my breathing was getting worse, I was sent to the local hospital for

various tests including x-rays and bloods.

However none of the tests detected a problem and my breathlessness was put down to anxiety and age – I was 45 at the time and have never been an anxious person, so I wasn’t totally convinced by this explanation. Eventually after several more chest infections, a greater decline with my breathing and many hospital visits and tests, I was diagnosed with Idiopathic Pulmonary Fibrosis (IPF) in April 2012. I had never heard of the disease and was initially told to search the internet for more information.

IPF is a condition in which scarring is produced on the lungs, in my case for no apparent reason, which causes the lungs to harden and over time decreases the capacity for oxygen. There is currently no known cure and life expectancy is 2.5-5 years. It was explained to me that my only medical hope would be a double lung transplant and I was put on the transplant waiting list, after undergoing all the assessments, in March 2013. My life changed dramatically during this time. I used to be very active raising a family (two boys Lewis now 21 and Luke now 18) with my husband Colin, working part-time as a library assistant, as an Authorised Lay Minister in my local Anglican Church, walking approx five miles daily with our dog and so forth, but with the illness I was on oxygen 24/7 and at times needed a wheelchair to go out. Everything I knew and did stopped, all my hopes and dreams for the future, I felt, were stolen from me and I became totally reliant on other people to help me to do simple tasks such as washing, dressing, cooking. I hated it. I tried hard to stay positive and usually succeeded but some days it was very hard, frightening and overwhelming and as time went on and I still hadn’t received a call from the hospital I would sometimes doubt that the call would come. But the call did come at 5.20 am on New Year’s Day 2014 and threw all our carefully made plans into disarray. Everybody we knew who were on stand-by to take me to the hospital – Colin, our sons, family, friends had all been

celebrating the New Year the previous night and would have been unsafe to drive. I, being my father’s daughter, refused to pay double fare for a taxi on New Year’s Day – so I ended up driving myself with Colin as a passenger to the hospital. The surgery took 13 hours and it wasn’t all plain sailing, there were a few blips but the medical team were fantastic. My surgeon explained afterwards that they had underestimated just how poorly I was and if I had not received the transplant when I did, I would probably not have survived very much longer. Perfect timing and an amazing gift from my donor and family, strangers to whom I will be forever grateful and pray for daily.

I am now ten months post-transplant and everything seems to be going to plan and the hospital are pleased with my progress. Before my operation, when thinking about the future I assumed life would go back to normal after transplant, but realise now that things can never be the same again and we, as a family are building a new ‘normal’.

May 2013

Family Photographs June 2014

September 2014

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Blood and Transplant Matters – June 2015 23 >

Organ donation is so dear to my heart, it saved my life, how can it not be? There are people out there praying for their phone call, for their second chance at life. By going on the Organ Donation Register we all have the opportunity to be the answer to someone’s prayer. Incredible!

Joyce Herdson

Haemoglobinopathies and Genotyping

Patients with haemoglobinopathies are amongst the most highly transfused patient populations over a lifetime. Patients with transfusion dependent thalassaemia will often receive two units every three weeks by ten years old, having started in infancy. For patients with Sickle Cell disease (SCD) the convention is to maintain the HbA > 70% to prevent complications in those who are on a long term transfusion programme. To achieve this, blood can either be given as a ‘top up’ or as an exchange. The exchanges can be manual or automated, the latter using an apheresis machine. A typical example of donor exposure may be a patient with SCD on an automated exchange programme who would have ten units every six weeks, equalling 87 units per annum and a patient with thalassaemia receiving two units every three weeks, equalling 35 units per annum. Heavy donor exposure, particularly in those sporadically transfused, is recognised to cause formation of multiple alloantibodies, thus complicating the provision of compatible blood (Chou, et al 2012). For haemoglobin disorders and especially Sickle Cell disease, the ethnicity and Rh types of the donor population often differ from the patient population, especially in countries where patients are most likely to be on regular transfusion and, therefore, be the most exposed to unfamiliar donor antigens (Singer, et al 2000). Even in populations with similar red cell phenotypes in donors and recipients, there is a high rate of Rh and Kell alloimmunisation (Elhence, et al 2014) Therefore, guidelines for the transfusion of both sickle and thalassaemia patients recommend matching for full RH and Kell antigens (BCSH 1996), though it is being increasingly recognised that this is perhaps not sufficient to prevent a significant proportion of alloimmunisation (Chou, et al 2013). With the advent of methods for high throughput genotyping, including Rh variants, to establish the range of major and minor blood groups for both donors and patients, there is the possibility of extending the blood group match of donors and patients from commencement of the patient’s transfusion life, thus minimising the alloimmunisation risk. Predicting the cost-benefit or indeed feasibility of this, however, requires some understanding of the red cell genotype distribution in the local haemoglobinopathy and donor population. Such data is limited, and results from one country cannot readily be extrapolated to another,

because of the different ethnic mix of both donors and patients in different countries (Matteocci and Pierelli 2014). Another issue regarding alloimmunisation, is that these are lifetime disorders and patients will move from site to site. Furthermore, when one calls an ambulance, the most likely outcome is that they are taken to their local hospital, whereas their haemoglobin disorder and thus their transfusions are managed in a specialist centre. Data from the NHSBT Haemoglobinopathy Survey (not yet published) shows that only half of transfused patients have their full red cell phenotype available at their hospital and that these results are often done locally and, are not immediately available to other hospitals. Those who have not had phenotyping performed and who have received blood in the last three months, will need genotyping in any case, which is most usually sent away with an appreciable time lag, thus a patient may need to receive non Rh and Kell matched blood in extremis. Data from all studies in alloimmunisation in these disorders show that patients are most commonly immunised against Rh and Kell antigens even in countries that have clear guidelines about matching. Severe transfusion reactions, noted by Serious Hazards of Transfusion (SHOT) in their chapters on haemoglobinopathies, note the issue of previously detectable but, no longer detectable, alloantibodies causing catastrophic delayed haemolytic transfusion reactions when patients have attended a different hospital, to where their original antibody was detected.

Provision of blood for this patient population is predicted to grow significantly over time due to a number of factors. Data from the newborn screening programme, shows a consistent significant number of children being born with major haemoglobin disorders (Committee 2013); results of studies of stroke prevention (Adams, et al 1998, Lee, et al 2006) and the observation that patients are now living longer with attendant morbidities that increase the likelihood of the disease severity reaching a threshold for regular transfusions (Reed and Vichinsky 1999) means that an increasing number of SCD patients are maintained on prophylactic transfusion regimens, Another factor is the current older adult cohort with thalassaemia major, is shorter in height due to almost universal hyogonadotrophic

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< 24 Blood and Transplant Matters – June 2015

hypogonadism and iron deposition in early childhood. Now that chelators are available from a very early age, one would expect the current paediatric cohort to be larger once adults, thus having a larger circulating blood volume.

Genotyping for Patients

Genotyping for patients has now been made available in RCI laboratories around the country (Birmingham, Colindale, Filton, Newcastle, Sheffield, Tooting) having previously been available in IBGRL and are in the process of completing all stages of validation. This will allow for a faster turnaround of identification of genotypes in transfused patients. It is possible to process these samples out of hours when clinically relevant.

Haemoglobinopathy Genotyping Initiative (Patients)

NHSBT is undertaking an initiative until the end of June 2016, to provide comprehensive extended genotyping of haemoglobinopathy patient blood groups including Rh D and RHCE varients. The ability to identify variants may be of particular benefit when deciding what blood to give patients and also permits discernment of Rh allo versus autoantibodies in transfused patients. These results are not going to be immediately available, and so in urgent cases, the testing should be requested through the local RCI laboratory. Using an advanced genotyping platform, NHSBT will prospectively genotype as many paediatric and adult haemoglobinopathy patients as possible at no cost to the hospitals. Results will be held on Hematos (the system used by Specialist Services across NHSBT for the collection and management of data relating to the many different areas of testing that are carried out under the Specialist Services’ umbrella) and be accessible through Sp-ICE (SunQuest ICE web browser functionality for Red Cell Immunohaematology (RCI) and Histocompatibility and Immunogenetics (H&I)).

Further information on this project: http://hospital.blood.co.uk/diagnostic-services/red-cell-immunohaematology/haemoglobinopathy-genotyping-initiative/

Genotyping Donors:

This is an ongoing project looking at the technology, feasibility and cost of genotyping donors nationally, with an aim to cover (where necessary) the genotype variants seen in haemoglobin disorders.

Discussion

The rationales for genotyping donors and patients and having this information on a national database are multiple:

• An evidence base to inform transfusion practice and needs of this patient group.

• Timely access to patient – and donor-related information with results available before critical clinical scenarios.

• Reduced workload for laboratory staff and no need for repeated testing as all results available in a central location.

• Improve the quality of NHSBT’s expert medical and scientific support in blood provision.

• Improved compliance with current guidelines.

• Support of blood projection analysis for a hard to resource patient group.

Expansion of antibody data on Haematos would be a further improvement though the issues of NHSBT reporting transfusion results not processed in a NHSBT laboratory would have to be finessed.

Dr Sara Trompeter Consultant Haematologist and Paediatric Haematologist University College Hospital London NHS Foundation Trust and NHSBT Colindale Email: [email protected]

References:

Adams, R.J., McKie, V.C., Brambilla, D., Carl, E., Gallagher, D., Nichols, F.T., Roach,S., Abboud, M., Berman, B., Driscoll, C., Files, B., Hsu, L., Hurlet, A., Miller, S., Olivieri, N., Pegelow, C., Scher, C., Vichinsky, E., Wang, W., Woods, G., Kutlar, A., Wright, E., Hagner, S., Tighe, F. & Waclawiw, M.A. (1998) Stroke prevention trial in sickle cell anemia. Controlled clinical trials, 19, 110-129.

BCSH (1996) Guidelines for pre-transfusion compatibility procedures in blood transfusion laboratories. BCSH Blood Transfusion Task Force. Transfus Med, 6, 273-283.

Chou, S., Jackson, T., Vege, S., Smith Whitley, K., Friedman, D. & Westhoff, C. (2013) High prevalence of red blood cell alloimmunization in sickle cell disease despite transfusion from Rh-matched minority donors. Blood, 122, 1062-1071.

Chou, S.T., Liem, R.I. & Thompson, A.A. (2012) Challenges of alloimmunization in patients with haemoglobinopathies. Br J Haematol, 159, 394-404.

Committee, U.N.S. (2013) Sickle Cell and Thalassaemia: Data Report 2012/13. 60.

Elhence, P., Solanki, A. & Verma, A. (2014) Red blood cell antibodies in thalassemia patients in northern India: risk factors and literature review. Indian Journal of Hematology and Blood Transfusion, 30, 301-308.

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Blood and Transplant Matters – June 2015 25 >

Lee, M.T., Piomelli, S., Granger, S., Miller, S.T., Harkness, S., Brambilla, D.J. & Adams, R.J. (2006) Stroke Prevention Trial in Sickle Cell Anemia (STOP): extended follow-up and final results. Blood, 108, 847-852.

Matteocci, A. & Pierelli, L. (2014) Red blood cell alloimmunization in sickle cell disease and in thalassaemia: current status, future perspectives and potential role of molecular typing. Vox Sanguinis, 106, 197-208.

Reed, W.F. & Vichinsky, E.P. (1999) Transfusion practice for patients with sickle cell disease. Current opinion in hematology, 6, 432-436.

Singer, S.T., Wu, V., Mignacca, R., Kuypers, F.A., Morel, P. & Vichinsky, E.P. (2000) Alloimmunization and erythrocyte autoimmunization in transfusion-dependent thalassemia patients of predominantly asian descent. Blood, 96, 3369-3373.

The Order of St John Award for Organ Donation

Organ donation is one of the greatest gifts one person can give to another. The contributions donors make to society are immeasurable. Annual increases in donation over the past six years are helping so many people, that transplant waiting lists have fallen in number for the first time. These achievements should not be hidden, which is why recognition for such selfless contributions is so important. Donor recognition honours and remembers the gift of donation, and provides the opportunity to promote organ donation to the community.

Recommendation 12 of the 2008 Organ Donation Taskforce report, acknowledged this by calling for, “Appropriate ways should be identified of personally and publicly recognising individual organ donors, where desired. These approaches may include national memorials, local initiatives and personal follow-up to donor families.” Yet, until very recently, there were no national recognition programmes for deceased organ donation in the UK. Any recognition was usually ad hoc, hospital-based, or through the good work of the Donor Family Network. After commencing discussion in 2012, initiated by Mr Terence Foster an Organ Donation Committee Chair, the Order of St John entered into a formal partnership with NHS Blood and Transplant (NHSBT) in 2013, that has led to a new national award to recognise deceased organ donors.

The Order of St John traces its origins back 900 years to the Knights Hospitaller from whom they derive their maxims – ‘Pro Fide, Pro Utilitate Hominum’, ‘For the Faith and in the Service of Humanity’. Today the Order of St John has over 400,000 members worldwide and in the UK, through their subsidiary charity St John Ambulance, is the country’s leading provider of first aid services and, has over 40,000 volunteers.

Many have been honoured in the past by the Order of St John and its membership is multi-faith.

“St John’s focus on primary health care, especially amongst the poorest of the poor, and its capacity to tap the most generous and caring human impulses, gives it a special place in our hearts” Nelson Mandela, Knight Grand Cross of the Order of St John.

As an order of Chivalry of the British Crown the Grand Prior of the Order is always a senior member of the British Royal Family. Currently the Grand Prior is HRH The Duke of Gloucester, cousin to Her Majesty The Queen. The Order of St John is able to institute new awards of recognition and did so with the creation of The Order of St John Award for Organ Donation. This award has been recognized internationally throughout the organisation.

The award offers donors and their families’ public acknowledgment at a level carrying high respect and recognition. The concept of the award was closely modeled on The Elizabeth Cross, posthumously awarded by the Crown to the men and women who have died in military service for their country and, which is presented discreetly to the closest family relatives at local ceremonies.

The posthumous Order of St John Award for Organ Donation, displaying the words ‘add life, give hope’, was presented to 33 representative donor families from around the UK by the TRH The Duke and Duchess of Gloucester on September 18th 2013, at the symbolic first ceremony held at St James’s Palace, London. Following the award launch, all families who indicated they are willing to receive further contact by NHSBT are offered the opportunity to accept the award on behalf of their family member who donated. In 2013, over six hundred families accepted the award by post or more commonly, at local ceremonies throughout the UK, often presided by a Lord-Lieutenant, Her Majesty the Queen’s local representative. In 2014, the number of families accepting was over 800.

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‘It was an amazing day. I felt it was so dignified and yet with a very touching personal feel to it. The fact that everyone was there to honour our loved ones and to feel the compassion from all of you from the NHS and St. John’s was truly wonderful and a day I will remember forever. Also to be in a room with other families who have had the same experience somehow was comforting.’ Anonymous family feedback, 2014.

Preserving human life is the fundamental purpose of The Order of St John and this shared ethos with NHSBT underpins this unique award. We believe it is the only award of its kind in the world, though other countries are watching with interest. Initially the award was only available for deceased organ donors, who donated after April 2012. Following requests by families, whose loved one donated prior to this date, the award is now open for all deceased organ donors who have ever donated in the UK, a heritage of giving, that extends back to the 1970s.

The NHSBT strategy to deliver a revolution in public behaviour, as part of the Taking Organ Transplantation to 2020, will seek to further develop the award ceremonies as high profile annual celebrations of the generosity of donors and their families. The opportunity we now have to offer national recognition delivered locally, acknowledges the altruistic gift made to help others in the midst of personal loss. Even the most experienced Doctors and Specialist Nurses are humbled many times over, by the generosity of donor families. Publically recognising the huge impact behind the small word ‘yes’ is the least we can do.

It might have taken us nearly forty years to get here but finally, through The Order of St John Award for Organ Donation, we are paying tribute to the proud contribution of organ donors and their families, in adding life and giving hope to others.

Dale Gardiner Deputy National Clinical Lead for Organ Donation NHSBT Email: [email protected]

The Reverend Canon Dr Paul Denby MBE JP DL Chancellor of the Priory of England and the Islands The Order of St John

The Order of St John Award

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Blood and Transplant Matters – June 2015 27 >

CPD Questions

1. Patient Blood Management in Clinical Haematology – Conference Resume:

a) ‘Better Blood Transfusion’ initiatives over the last 16 years have almost eliminated inappropriate use of unsafe practices.

b) Four per cent of the eligible donor population actually donate blood.

c) NHSBT take over two million donations every year.

d) In England, Patient Blood Management Recommendations were launched in July 2013.

2. During 2013:

a) Less than 50 per cent of all transfusion incidents were caused by human error.

b) There were no ABO incompatible Red Cell Transfusions

c) There were 22 deaths where transfusion was cause or contributory

d) There were less than 100 reports associated with major morbidity

3. Non-Medical Authorisation of Blood Components:

a) Blood and blood components prescription requires an individual to be a registered medical practitioner.

b) Any nurse can now authorise or prescribe blood for transfusion.

c) Has particular application in all hospital areas.

d) Can lead to reduced waiting times for day patients.

4. Patient Blood Management in Clinical Haematology – Conference Resume:

a) Acute Transfusion Reactions are common, seen in over one in 1,000 components transfused.

b) Post-transfusion increment data is vital to help inform future HLA-selected platelets.

c) There is a low prevalence of bleeding in patients with haematological malignancy.

d) National comparative Audit: use of platelets in Haematology (2010) results have not affected the platelet demand.

5. Intra-operative Cell Salvage (ICS):

a) Surgery in obstetrics and gynaecology is the most frequent user of ICS.

b) Over 90 per cent operated ICS outside normal working hours.

c) All anaesthetic trainees received theory or practical.

d) Over 90 per cent had a policy for ICS in their organisation.

6. Recommendation following 2014 Survey of ICS:

a) No requirement for provision of ICS to be reviewed by hospital transfusion committee.

b) No requirement for every hospital providing ICS to have an up to date policy for it’s’ use.

c) Recording of autologous transfusion should have some stringent standing as seen in allogeneic transfusions.

d) ICS incidents are out with the SHOT Scheme.

7. Blood Stocks Management Scheme: (BSMS)

a) Can immediately solve all stock management problems.

b) Can confirm that your hospital practices are well controlled.

c) Cannot compare similar hospitals.

d) Does not have categories that can be added or subtracted to change comparisons.

8. Harvey’s Gang:

a) Patient Blood Management (PBM) involves only clinical staff.

b) Laboratory visits by patients are to be discouraged.

c) Patient Blood Management can successfully involve the patient.

d) Has resulted in a lowering of laboratory morale.

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9. Involving, Informing and consenting patients receiving Red Cell Transfusion:

a) Most patients felt they were involved in transfusion decision.

b) Under one tenth of respondents explicitly felt they had not been involved.

c) Few Trusts have a policy which requires staff to inform patients about the risks, benefits and alternatives to transfusion.

d) Over half of patients recalled been given information regarding transfusion.

10. Patients recalled:

a) Risks were explained in over 50 per cent.

b) Alternatives were offered in over 50 per cent.

c) Consent was offered in less than 50 per cent.

d) Benefits were discussed in over 50 per cent.

11. National Comparative Audit of Anti-D Immunoglobinopathy Prophylaxis Routine Antenatal Anti-D prophylaxis (RAADP):

a) Less than 50 per cent use a single 1500iu anti-D Ig injection at 28-30 weeks gestation.

b) Less than 80 per cent of eligible RhD negative women received at least one anti-D Ig injection.

c) Full compliance was better with the two-dose regime.

d) Full compliance was better with the single dose regime.

12. Post-Delivery Prophylaxis:

a) Over 99 per cent of RhD Negative women delivering RhD positive babies had post-delivery prophylaxis.

b) Nearly 92 per cent of RhD Negative women delivering RhD positive babies had the right dose at the right time.

c) Volume of fetal cells in FMH was 2 mls or less in 97 per cent.

d) Over 1 per cent of women needed additional anti-D Ig to prevent sensitisation.

13. Potentially Sensitising Event (PSE) requiring Anti-D Ig:

a) Antepartum Haemorrhage represented over 50 per cent of cases.

b) Still birth represented over 50 per cent of cases.

c) 96 per cent received correct dose for gestation.

d) Anti-D Ig was given to over 99 per cent of the documented PSE’s.

14. Therapeutic Apheresis (TA) Services in North West England and North Wales:

a) Over 44 per cent reported difficulties in gaining access to TA in an emergency.

b) Most over 50 per cent refer to NHSBT.

c) Most over 50 per cent was performed in home.

d) Most over 50 per cent refer out but not to NHSBT.

15. Haemoglobinopathies of Genotyping:

Typical donor exposive of a patient with Sickle Cell Disease on an automated exchange programme equals the following number of units per annum.

a) 35.

b) 45.

c) 64.

d) 87.

The CPD Section is a self-assessment exercise which allows readers to evaluate their understanding of each article. The answers are to be found within the articles themselves. Most CPD schemes allow this type of exercise to be eligible for credits as self-directed learning.

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Blood and Transplant Matters – June 2015 29 >

Clinical Case Studies

We have had the following comment:

“Sorry this is a bit late, but I’ve only just had a chance to read the Clinical Case Study in the January 2015 Issue of Blood and Transplant Matters.

I have a couple of Comments

Firstly, the patient’s Hb is given as 8.2g/dL; should this not be 82g/L?

Secondly, with regard to determining the patient’s correct ABO type, there is an old-fashioned test that seems to have gone out of favour, but may help in such a case. This test is the inhibition of anti-A, anti-B and anti-H by the patient’s saliva. Admittedly, the patient has to be a secretor, but there is an 80% chance that he would be, and the ABH substance in the saliva would be purely his own, rather than be contaminated with ABH substance from any transfused blood components. I note the final paragraph states that, “It should be noted that in some individuals the genotype does not reflect phenotype. In addition, PCR for ABO is subject to an error rate and clinical decisions should interpret the results within the clinical context and the serological results.” I agree totally with these comments, and wonder if an inhibition test (at least in 20% of the population) might not be just as safe”.

We totally agree with your comments.

Question 1

A six-year old child was admitted with Hb 90g/L, with antecedent viral infection. Two days later Hb dropped to 62g/L. The bilirubin level, was 40 µmol/l (normal range 2-17 µmol/l) with raised LDH. You are provided with DAT and ABO grouping results. No free antibody detectable by IAT/papain-treated erythrocytes at 37°C. The child was transfused with two red blood cell units. Post transfusion HB level was 94g/L. Two days later Hb dropped to 43 g/L. Again, no free antibody detected, by IAT/papain treated erythrocytes at 37°C on this admission.

1) You are provided with DAT and ABO Grouping results:-

a) Comment on the DAT and ABO grouping findings.

b) What is the likely blood group?

c) How would you confirm the patient’s ABO group?

2)

a) What is the most likely diagnosis?

b) What further laboratory investigations would you carry

out to confirm the diagnosis? Outline the principle of

this test.

3) The child needs further transfusion.

a) What blood would you select?

b) What further measures would you take?

ABO Blood Group Results (Room Temperature 20°C)

Patient’s red cell reaction with:

Patient’s plasma reaction with:

Case No.

Anti-A Anti-B Anti-A,B Anti-A1 A1 RBCs

A1 RBCs

B RBCs

O RBCs

0 5 5 0 5 5 2 2

DAT Results

Polyspecific AHG IgG C3d Control++ - ++ -

Question 2

A 70-year old female patient presented with tiredness. Examination revealed mild sclera icterus. The bilirubin was at 52 (normal range 2-17 µmol/l) and LDH level was 2,049 iu/l (normal range 310-620). Full blood count showed Hb 80g/L, MCV 112 fl and whole blood count 8x109/L with a platelet count of 160x109/L. You were provided with red blood cells indices and ABO grouping, DAT results. Antibody screen by standard IAT at 37°C was negative.

A. Automated Full Blood Count and Red Cell Indices

Patient Normal range

RBC count 0.56 x 109/µl 4.0-5.2 x 109/µl

Hemoglobin 80 g/L 115-155 g/L

Hematocrit 6.4% 35%-45%

Mean Cell Volume 112 fL 77.0-95.0 fL

B. ABO Blood Group Results (Room Temperature 20°C)

Patient’s red cell reaction with:

Patient’s plasma reaction with:

Case No.

Anti-A Anti-B Anti-A,B Anti-A1 A1 RBCs

A1 RBCs

B RBCs

O RBCs

5 0 5 5 2 2 5 2

C. DAT with Warm Washed Cells:

Polyspecific AHG IgG C3d Control+++ - +++ -

1.

a) Comment on Full Blood Count Results?

b) You were asked to repeat Full Blood Count,

how would you proceed?

2.

a) What is the likely blood group?

b) How would you confirm the patient’s ABO group?

3. Antibody screen and identification revealed no free antibody detectable by IAT and papain-treated erythrocytes at 37°C. Based on the DAT results and all the above finding, what is the most likely diagnosis? Give reasons.

4. What further serological investigations would you carry out to determine the possible diagnosis?

5. What are the clinical conditions which may be associated with the above disorder?

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Answers to Clinical Case Studies

Question 1

1. a) DAT by complement only. Reverse grouping reacting with all cell tested at RT (cold antibody).

b) Blood group B with cold antibody.

c) Sample warm washed at 37ºC with saline and repeat ABO typing.

2. a) PCH.

b) Donath - Landsteiner Test.

c) Detection of biphasic antibody.

d) Antibody binds at lower temperature and causes complement activation at 37ºC.

e) IgG antibody with anti-P specificity.

3. a) Select blood group B/Rh matched compatible units.

b) Keep ambient temperature more than 24ºC, to consider using blood warmer.

c) Only very rarely need pp blood.

Question 2

1. a) Spurious indices due to red cell agglutination.

b) Repeat peripheral blood film prepared at 37ºC.

2. a) Blood group A with cold antibody.

b) Sample warm washed at 37ºC with saline and repeat ABO typing.

3. c) CHAD with red cell agglutination at RT providing spurious full blood count results. DAT by complement only.

4. a) Confirmed IgM cold autoantibody by conducting direct saline agglutination at 4ºC, 20ºC, and 30ºC.

b) CHAD is defined as cold auto antibody reacting at or above 30ºC. (High thermal amplitude).

c) studies in general shows high titre at cold temperature and anti-I specificity.

5. a) Acute: Transient (adolescent or young adults).

b) Infection, M pneumonia, infectious mononucleosis.

c) Chronic more than (50 years of age).

d) Idiopathic: Majority.

e) Secondary remainder.

f) Lympho-proliferative disorders.

g) Lymphoma, CLL.

h) Waldenstrom’s Macroglobulinemia.

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Blood and Transplant Matters – June 2015 31 >

Diary Dates

2014Diary Dates2015 20-21 MaySurveillance and Screening of Blood Borne Pathogens22nd International WorkshopLocation: Prague, Czech RepublicFor More information contact:www.isbt.org

21-23 May19th Training Course on Haemopoietic Stem Cell TransplantationLocation: Malaga, SpainFor more information contact:www.esh.org/conferences

3 JuneClinical and Laboratory HaemostasisLocation: The Atrium Conference Centre, Sheffield Hallam University, Howard Street SheffieldFor more information contact:www.b-s-h.org.uk

5 JuneHaematology for PhysiciansLocation: BMA House LondonFor more information contact:www.b-s-h.org.uk

9-11 JuneStem Cells: From Basic Research to BioprocessingLocation: Cineworld: The 02, Peninsula Square LondonFor more information contact:www.b-s-h.org.uk

11-13 June13th International Cord Blood SymposiumLocation: San FranciscoFor more information contact:www.cordbloodsymposium.org

12 JuneEmerging and Re-emerging Infectious DiseasesLocation: EdinburghFor more information contactwww.b-s-h.org.uk

12-15 June19th EHA Annual CongressLocation: Milan, ItalyFor more information contact:www.b-s-h.org.uk

27 June – 1 JulyScotbloodLocation: Stirling Universtiy, ScotlandFor more information contact:www.bbts.org.uk/events

27 June – 1 July25th Regional Congress of the ISBT in Conjunction with the 33rd Annual Conference of the British Blood Transfusion SocietyLocation: LondonFor more information contact:www.isbtweb.org/events-congresses

29 JuneUK NEWQAS for Leucocyte Immunophenotyping Scientific MeetingLocation: Sheffield Hallam University, SheffieldFor more information:www.ukneqas.org.uk

8-10 SeptemberThe 2015 Tissue Engineering CongressLocation: Cineworld: The 02, Peninsula Square, LondonFor more information contact:www.b-s-h.org.uk

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< 32 Blood and Transplant Matters – June 2015

28-29 SeptemberThe Future for Blood and Plasma Donations2nd Global SymposiumLocation: Fort Worth (Dallas), TX, USAFor more information contactwww.bbts.org.uk/events

30 October Red Cell Special Interest GroupLocation: NHSBT Filton Blood Centre, BristolFor more information contactwww.bbts.org.uk/events

10-11 NovemberUK NEQAS (BTLP), BBTS & BSH Joint MeetingLocation: Birmingham Motorcycle MuseumFor more information contactwww.bbts.org.uk/events

1-2 DecemberImproving Access to Plasma and Plasma Products in the Southern African RegionLocation: Stellenbosch (Cape Town), South AfricaFor more information contactwww.bbts.org.uk/events

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Blood and Transplant Matters – June 2015 33 >

Notes

CPD Blood and Transplant Matters

Answers Issue 44

1. D

2. C

3. B

4. C

5. A

6. D

7. B

8. C

9. D

10. A

11. B

12. D

13. B

14. D

15. C

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< 34 Blood and Transplant Matters – June 2015

Notes

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Blood and Transplant Matters – June 2015 35 >

Notes

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Blood and Transplant Matters is prepared and issued by NHS Blood and Transplant, Oak House, Reeds Crescent, Watford, Herts WD24 4QN (Telephone 0114 358 4804)

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