Emergency Blood Products Management Policy

- Managing shortages of Blood and Platelets

Version / 4
Name of responsible (ratifying) Committee / Trust Transfusion Committee
Date ratified / 09 October 2015
Document Manager (job title) / Consultant Haematologist
Date issued / 15 March 2016
Review date / 01 October 2018
Electronic location / PHT Clinical Policy
Related Procedural Documents / Major Incident Response Policy, Blood Transfusion Policy, Pharmacy Guidelines
Key Words (to aid with searching) / Emergency Blood Plan, Blood Shortages, Platelets, Blood Transfusion
Version / Date Ratified / Brief Summary of Changes / Author
4 / 09.10.15 / No changes / R. Corser
3 / 19.04.13 / - / R Corser

CONTENTS

QUICK REFERENCE – Red cell shortages

Quick reference (Appendix B) - Platelet Shortage Plan

1Introduction

2Purpose

3Scope

4Definitions

5Roles and Responsibilities

6PROCESS

7Training Requirements

8References and Supporting Documentation

9Monitoring Compliance

APPENDICES:

Appendix A - Red Cell Shortage Scheme Plan

Appendix B - Platelet Shortage Plan

Appendix C - Indications for Transfusion of Red cells

Appendix D - Platelet indication codes

Appendix E - Platelet Usage Guidance

Appendix F - KEY CARD 1 Emergency Red Cell Stock Contingency Plan

Appendix G - general e-mail message in event of Red cell shortage to all staff

Appendix H - general e-mail message in event of Platelet shortage to all staff

Appendix I - Communication plan in the event of Blood shortages

Appendix J - Guidance for the HTC and HTT during Green phases – where Red cell and Platelet supply is adequate

QUICK REFERENCE – Red cell shortages

Red Cell Shortage Scheme Plan

Quick reference (Appendix B)- Platelet Shortage Plan

1INTRODUCTION

This document is a response to the Chief Medical Officer’s National Blood Transfusion Committee documents outlining plans for Blood and Platelet shortages, issued in January 2010. (See references 1 and 2).

These documents seek to set out a framework for the use of these blood products in times of shortages. The plan may also operate when there are no shortages. It draws upon the work done to ensure appropriate use of Blood products as detailed in HSC 2007/001 Better Blood Transfusion – Safe and Appropriate Use of Blood.

2PURPOSE

The Department of Health requires the Trust should have an Emergency Blood Management Plan (EBMP) in place to ensure that any shortage of blood or platelets are effectively managed, that the Trust continues operating and that patients requiring these products continue to receive them. To prepare for the possibility of a prolonged and or severe shortage of blood there must be a well outlined contingency plan.

3SCOPE

This document affects patients that may require blood products, particularly at times of national shortages. With reference to the paragraph below, in special circumstances, the membership of the groups may need to be varied if key personnel are unavailable. The EBMP plan has been recommended by the Department of Health because of the risk of shortages in the situations mentioned below.

The Trust’s Emergency Blood Management Policymay, depending on the circumstances, be co-dependent with the Major Incident Plan. This situation may occur if a Major Incident exhausts the available supply of blood for transfusion. In this situation the work of the EBMG should not duplicate or contradict the plans of the Major Incident Command and Control Team. The Chair of the EBMG should ensure good lines of communication with Command and Control centre. The EBMG should also refer to the Major Incident Plan for Blood Sciences.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain on-going patient and staff safety’

4DEFINITIONS

Blood Products

Blood products are defined as packed red cells (commonly known as units of blood) or platelets

National Health Service Blood and Transplant (NHSBT)

The NHSBT is the body that manages blood supplies in England. It times of shortages they will notify the Trust’s Blood Transfusion Laboratory of an alert phase.

Alert Phases

There are three phases of the plan for blood and platelet shortages, as declared and defined by the NHSBT:

  • Green: Normal circumstances where supply meets demand.
  • Amber: Reduced availability of blood product for a short or prolonged period.
  • Red: Severe, prolonged shortages.
Patient Categories

The NHSBT defines 3 categories of patient who may need blood product support

Category 1 Patient
  • Active major bleeding
  • Emergency surgery
  • Curative cancer surgery
Category 2 Patient
  • Urgent surgery
  • Palliative cancer surgery
  • Symptomatic anaemia
Category 3 Patient
  • Elective surgery with greater than 20% chance of a 2 unit transfusion
Laboratory Staff

Trained Transfusion registered MLS, Clinical scientists with transfusion training, MLA acting under supervision of registered MLS, Clinical Scientists or medical staff, members of the Haematology medical team.

5ROLES AND RESPONSIBILITIES

National Blood Service (NBS – an arm of NHS Blood and Transplant)

In times of shortage, the NBS will notify the Blood Transfusion Laboratory and declare an alert.

Hospital Emergency Blood Management Group (EBMG)

The EBMG will:

  • Have senior hospital management support from the Chief Executive and Medical Director to make difficult decisions in times of severe shortage of blood products
  • Formulate the local plan for blood shortages
  • Ratify policy and make arrangements to manage blood products appropriately in times of shortage.

(Clinical Staff throughout the hospital must be made aware of the support of these key hospital staff for the decisions made by the HTT in times of Shortage.An agreed email, will be sent at the start of any shortage. (Appendix G & H) This will indicate that the HTT decisions have the support of the Trust at the highest level. Subsequent emails sent once the EBMG has met will indicate the level of support from the Medical director, as per the communication plan. (Appendix I))

Emergency Blood Management Group (EBMG) Representatives:
  • Medical Director (or representative if on leave if an alert is declared)
  • Consultant Haematologist Responsible for Transfusion (or Deputy)
  • Chair of the Hospital Transfusion Committee
  • Chief of Service Trauma, Orthopaedics, Rheumatology and Pain (Musculo-Skeletal)
  • Chief of Service - Theatres, Anaesthetics & Critical Care
  • Governance and Risk Management representative
  • Chief BMS Haematology - Blood transfusion
  • Chief of Service Surgery & Cancer Clinical Service Centre
The Hospital Transfusion Committee (HTC)

The HTC is responsible for the strategic direction of transfusion service at Portsmouth Hospitals NHS trust, including the audit and ratification of blood related procedural documents.

Appendix J outlines operational guidance from the Department of Health to the HTC, to use at times when red cell and platelet supply are adequate

Hospital Transfusion Team (HTT)

The HTT together with key clinical personnel, will manage the local EBM plan. The HTT consists of the:

  • Blood bank manager or Deputy
  • Consultant Haematologist who sits on the Transfusion Committee or deputy
  • Transfusion practitioner
  • Chair of the Hospital Transfusion Committee

Again, Appendix J outlines the operational guidance for the HTT, where red cell and platelet supply is adequate

The HTT will also seek to ensure good transfusion practise and best use of Red cells and platelets at all times through education, clinical polices, and audit. See Appendix J for details.

The Chief Executive

The Chief Executive will, through the Medical Director, to whom she delegates this responsibility, provide senior support in times of severe shortage of blood products

Hospital Duty Manager

If an alert is called out of hours, the Hospital Duty Manager will liaise with the Consultant Haematologist to inform the relevant on-call staff (Appendix F)

Lead Haematologist for Transfusion or deputy

The Lead Haematologist for Transfusion, if on duty will act to approve any products as defined in the plan. If they are on leave then the Consultant Haematologist on duty for the laboratory during the day or the On call haematologist out of hours will act up as deputy.

6PROCESS

The Hospital Transfusion team and Committee seek to promote safe and efficient use of blood products at all times. However at times of shortage the NHSBT may declare an alert restricting the use of specific blood products.

6.1Declaration of the Alert

The NHSBT may declare an Amber or Red Alert, either to all blood groups and products or to specific blood groups or types of product.

When an Alert is declared the NHSBT will communicate this to the Consultant Haematologist with responsibility for Transfusion and also the Blood Transfusion Laboratory. The laboratory & HTT will enact the Emergency Blood Management Plan.

The Flow diagrams – for Red Cells, Appendix A and Platelets, Appendix B summarise the required actions.

The Hospital Duty manager should be contacted out of hours.

6.2Action during Red Blood Cell Transfusion Phases

6.2.1Green Phase Red Blood Cells

  • The HTC and HTT will promote the objectives of Better Blood Transfusion and the appropriate use of blood. Appendix J describes this process in detail.
  • The HTC and HTT will obtain senior management and NHS Trust Board commitment to implement the Emergency Blood Management Plan.

6.2.2Amber Phase Red Blood Cells

The EBMG will decide which categories of patients will have access to blood transfusion.

  • Continuation of elective surgery will depend on blood stock levels.
  • Consideration should be given to reducing the transfusion trigger for transfusions.
  • Cases of actual or potential massive blood loss must involve a Consultant Haematologist to discuss patient management and blood product provision. Massive transfusion policies that allow automatic supply of blood products may have to be partly suspended.
  • All requests for transfusion outside of the agreed indication codes (see appendix G) should be referred to a Consultant Haematologist.
  • Reduction of the reservation period for cross matchedblood to 12 hours wherever possible.

6.2.3Red Phase Red Blood Cells

  • The Transfusion Laboratory manager / deputy will reduce stockholding to the level notified by the NHSBT. This may involve transfer of blood back to the NHSBT
  • The HTT on behalf of the EBMG will reduce usage to the level indicated by NHSBT.
  • Medical assessment of all requests for red cells,will be reviewed by a Consultant Haematologist.
  • Priority for transfusion willbebased on clinical need.
  • Daily review of the blood shortage and its impact on patient care by the EBMG.
  • Laboratory staff via the NBS and local hospital contacts, will share information to use regional stocks more effectively.
  • The HTT will draw up a predetermined policy on dealing with major bleeding to give guidance on when to stop blood component support.This will be ratified by the EBMG. This policy will be ratified at a later date after the formation of the EBMG, and adoption of this EBMP policy.

6.3Action during Platelet Transfusion Phases

6.3.1Green Platelet Phase

See Appendix J

6.3.2Amber Platelet Phase

  • Stocks of platelets, will no longer be held, by the Laboratory, if notified of a Amber phase by the NBS. Only platelets ordered for named patients will be delivered to the Laboratory.
  • Laboratory staff will maximise the use of available platelet units through:
  • The interchangeable use of apheresis and pooled platelets (except for HLA/HPA matched platelets)
  • Not requesting long dated platelets
  • Accepting platelets of a different ABO group (in line with BCSH guidelines)
  • Accepting leucodepleted platelets instead of CMV negative platelets
  • Accepting RhD positive platelets where RhD negative are not available and administering anti-D where applicable.
  • The HTT and Consultant Haematologist will identify possible alternatives to transfusion of platelets
  • Laboratory staff and HTT will reduce platelet usage to categories as identified in communications from the NHSBT.
  • All requests for platelets, will be made by a senior clinician, Specialist Registrar or Consultant level.
  • The Lead Haematologist for Transfusion or deputy will approve all platelet requests. The transfusion laboratory will ask requesting clinicians to page the Lead Haematologist who will confirm the order for platelets with the Transfusion Laboratory

6.3.3 Red Platelet Phase

As in Amber, but platelets will be restricted to category 1 patients only.

  • The request for platelets must now be phoned directly by the nominated Haematology Consultant Haematologist directly to the NHSBT consultants
  • An additional data set for every request for platelets from NHSBT will be needed to include:
  • Patient identifier (hospital number or name)
  • Indication for transfusion
  • Requesting Consultants name
  • Patient category (see Appendix 3) Patient blood group
  • Laboratory staff, (MLS, Consultant Haematologist depending on the question). Will provide information to the NHSBT on request to assist with tracking of units of platelets. If a unit is not used it can then be reallocated to another patient or hospital.

7TRAINING REQUIREMENTS

No specific training is required for Clinicians and staff in general, but advice can always be sought from members of the HTT, HTC or NHSBT as appropriate.

Haematology Medical Staff will have an Update meeting upon the first adoption of the Plan in September 2011 and updates every autumn.

Other Laboratory Staff will be informed of the plan through their regular update meetings.

8REFERENCES AND ASSOCIATED DOCUMENTATION

8.1Internal

  • Blood Transfusion Policy
  • Major Incident Response Policy
  • Pharmacy Guidelines – Use of Platelets

8.2External

  • Chief Medical Officer’s National Blood Transfusion Committee - A Plan for NHS Blood and Transplant and Hospitals to address Red Cell Shortages (DH 109118.)
  • Chief Medical Officer’s National Blood Transfusion Committee - A Plan for NHS Blood and Transplant and Hospitals to address Platelet Shortages (DH 109119)
  • Better Blood Transfusion Safe and Appropriate Use of Blood.4transfusionguidelines.org.uk - BBT HSC 07

9EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our valuesare the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace.

Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.

We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignity

Quality of care

Working together

No waste

This policy should be read and implemented with the Trust Values in mind at all times.

10 MONITORING COMPLIANCE

It is not possible to be prescriptive about how this policy can be monitored in full as the likelihood of any event requiring its use cannot be predicted.

If there is a need to enact the Amber or Red phases of the plan then a review meeting of the EBMG will take place after the emergency is over to see if there are any lessons to be learned.

Monitoring the Green phases of the plan will take place through the remit of the HTC and HTT, by ensuring participation in regular national audits of transfusion and local audits in the laboratory and in clinical areas to ensure good transfusion practise.

If the EBMG recommends any action after an Amber or Red phase then they will report this to the HTC and the Trust governance committee. The EBMG will direct the HTT / HTC or other appropriate groups to act on their behalf.

Change in practice and lessons to be earned will be circulated as appropriate through the Team brief and via the intranet.

.

Appendix A -Red Cell Shortage Scheme Plan
Appendix B - Platelet Shortage Plan


Appendix C -Indications for Transfusion of Red cells
Category 1 / Category 2 / Category 3
These patients will remain highest priority of transfusion / These patients will be transfused in the Amber but not the Red phase / These patients will not be transfused in the Amber phase
Resuscitation R1
Resuscitation of life threatening /on-going blood loss including trauma.
Surgical support
Emergency surgery* including cardiac and vascular surgery**, and organ transplantation.
Cancer surgery with the intention of cure. / Surgery/Obstetrics
Cancer surgery (palliative).
Symptomatic but not life-threatening post-operative or post-partum anaemia.
Urgent*** (not emergency) surgery. / Surgery
Elective surgery likely to require donor blood support (Patients with > 20% chance of needing 2 or more units of blood during or after surgery).
Non-surgical anaemias
Life-threatening anaemia including patients requiring in-utero support and high dependency care/SCBU.
Stem cell transplantation or chemotherapy ****
Severe bone marrow failure.
Thalassaemias (but consider lower threshold).
Sickle cell disease crises affecting organs.
Sickle cell patients aged < 16 with past history of CVA. / Non-surgical anaemias
Symptomatic but not life-threatening anaemia.

* Emergency - patient likely to die within 24 hours without surgery.

** With the exception of poor risk aortic aneurysm patients who rarely survive but who may require large volumes of blood.

*** Urgent - patient likely to have major morbidity if surgery not carried out.