12. The Role of Transfusion Committees

Blood Management/Hospital Transfusion Committees (or equivalent) are multidisciplinary groups that have the overarching responsibility to maintain safe hospital transfusion practice.

BMC’s can be established; locally, for clusters of healthcare providers, across affiliated organisations, or for private health establishments, although many BMC are based at hospital level. BMC are also known by other names, which represent their standing, alignment and key aims. For example, ‘Hospital Transfusion Committee’, ‘Blood Utilisation Committee’, ‘Blood User Groups’ to name a few.

The direct responsibility of the committee may vary. Some BMC’s will be directly responsible for the whole transfusion chain from donor to patient whilst others may be responsible for the activities within the hospital setting.

There are countries where the safety and responsibility of transfusion is governed by law and government regulated (2, 3, 4).

The Structure of HTCs

The members of the committee may be multi-disciplinary and include key stakeholders involved in the transfusion process and may include members who are external to the hospital setting. Typical BMC membership may include, but not limited to:

executive management
governance/quality/clinical risk management
representatives of major providers PBM practices/users of blood and blood products: surgery, medical, paediatrics, haematology, oncology, orthopaedics, obstetrics and gynaecology, anaesthetics, emergency/trauma, ICU
nursing
consumer/patient representative
others that may be relevant either ongoing or from time to time are IT specialists, pharmacists, bioethicists and perfusionists
Transfusion Laboratory/Blood bank Manager/Senior Scientist
Consultant Hematologist
Transfusion Practitioner
Education and Training (as required)

Committee roles:

BMC Chair - ideally a health care professional who is regularly involved in supporting transfusion for patients (other than Consultant Haematologist in charge of blood transfusion according to country requirements) to help engage different disciplines.
Secretarial/administrative support
Transfusion Practitioner (or associated role – see Transfusion Practitioner chapter) will often play a key role in facilitation of the committee and often lead on activities required following the meeting.

The committee should have an agreed Terms of Reference, which should be reviewed at set intervals. Membership may also need to be reviewed as staff change. Ideally, the committee meets quarterly, however some BMC meet more frequently in larger organisations.

The BMCs should have defined reporting lines within their organisation.
In some countries, BMCs are mandatory and defined by the guidelines (3) that outline specific roles, responsibilities and education that is required.

The Role of BMCs

A key responsibility of BMCs is to bring together a multidisciplinary group of professionals who share the interest of PBM and transfusion risk management. The primary role of an BMC is to provide an active forum for communication between staff directly involved in clinical and laboratory-based PBM and blood transfusion activities, to provide solutions, feedback and education in relation to identified problems, and to ensure that PBM/transfusion practice accords with best practice and aligns with national standards.

BMCs have been created in different countries to oversee transfusion, and blood management activities within their scope. Whereas the approaches used to achieve their goals have varied historically and between nations, their principles are the same (5). A functional BMC, fulfilling its mandate, can be a powerful mechanism to ensure patients receive the safest and most appropriate blood transfusion therapy possible (4). The WHO (2001) recommends that an BMC ‘should be set up in each hospital to implement the national policy and guidelines on the clinical use of blood and monitor the use of blood and blood products at the local level.’ It confirms that the BMC ‘should have authority within the hospital structure to determine hospital policy in relation to transfusion and resolve any problems that have been identified.’

BMCs can be pivotal in ensuring appropriate blood utilization and that best practice standards are followed. Where the primary goal for BMCs are to improve patient safety there is a number of roles they may have (5, 6, 7, 8).

Develop systems for the implementation of national guidelines within the hospital.
Develop and regularly review policies, procedures and guidelines covering PBM and transfusion practice to ensure alignment with national guidelines and standards.
Monitor the implementation of national guidelines within the organisation and take appropriate action to overcome any factors that may be hindering their effective implementation.
Monitor to see that blood components are used appropriately and administered safely in accordance with national guidelines, standards and institutional policies. Where appropriate compare data on appropriate use of blood components within the hospital and external to the organisation.
Monitor and review blood component wastage and develop strategies for reduction and improvement.
Monitor, report, investigate transfusion adverse events and near misses and develop strategies for reduction and improvement. Utilize these examples as educational case studies.
Ensure a cycle of clinical audits to check PBM/transfusion practice are compliant to national requirements. Set appropriate benchmarks.
Liaise with blood transfusion services to ensure adequate supply of blood components and undertake strategic planning exercises (i.e shortages, disaster impact, pandemics etc).
Liaise between the organization and the regulatory authority/(ies) – be the link with regulatory authorities and agree any submissions and inspection outcomes.
Ensure adequate training and assessment of all staff involved in the blood transfusion/management process.
Ensure appropriate education and safety and quality improvement programs are available
Disseminate transfusion related information, e.g. changes to national guidelines, audit results and examples of good practice.
Ensure PBM initiatives including transfusion alternatives or minimization techniques (for example minimal blood sampling or intraoperative cell salvage) are used appropriately and in accordance with relevant guidelines – reviewing transfusion alternatives and making recommendations of their use.
Oversee and review component recalls.
Include processes to actively involve patients/consumers in their care when providing safe blood management.

Some BMC functions and requirements are written into local country legislation and law and compliance attracts a financial premium.

BMCs should ensure that transfusion practice related risks are added to Hospital Risk Register (or equivalent system) and an annual report is submitted to relevant committees/managers. A work plan of activity might support the BMC to ensure their work is focused towards the agreed Terms of Reference. Many sites will have a Hospital Blood Management/Transfusion Team (BM/HTT) or steering team that will ensure work carries on in-between meetings. The BM/HTT is usually made up of the Blood Transfusion Laboratory Manager, Consultant Haematologist in charge of blood transfusion, Transfusion Practitioner and Quality Manager for transfusion.

Effectiveness of BMCs

BMCs are essential to transfusion safety, and appropriate use of blood components. Liumbruno and Rafanelli (5) indicate that according to Italian legislation, a functional BMC should have a major impact on local rates of inappropriate transfusion, as well as on clinical governance, haemovigilance and safety of the transfusion medicine process. Blood Management/Hospital Transfusion Committees and Transfusion Teams, if properly constituted and adequately resourced, can be a powerful force for improving transfusion safety (6). The success of the BMC in improving blood management and reducing inappropriate use of blood have been reported (8), for example by developing local transfusion policies that was followed by a reduction in red cell transfusions after they were introduced (1).

Not only can a functional BMC have a major impact on local rates of inappropriate transfusion (9) they can also be seen as the hub of PBM activity. PBM will require engagement with end-users, managers and other key stakeholders all of whom should be represented at BMCs. To implement PBM initiatives the first point of presentation may be at a BMC meeting for engagement and approval as well as building partnerships for implementation. The BMC is also an ideal forum to present progress and final results (10, 11). In some countries, for large projects approval is sought of the hospital medical board (representatives of all medical staff). In England, following the NHS England endorsed PBM recommendations, 94 per cent of Trusts have PBM initiatives included on the standard BMC agenda whilst six per cent have a separate working group or PBM agenda (12).

The BMC is considered the expert group for transfusion in hospital.

In recent years BMC’s are have become more active in some countries and are taking charge of transfusion matters, even in situations where there is a lack of support from management bodies. However; without adequate support, resources and real authority the BMC will not be fully functional nor have a strong enough impact on transfusion practice (5).

Challenges for the BMC

Executive/hospital board endorsement is crucial for the success of a BMC; some sites may even mandate BMC activities to further support success.

Some journal papers (5, 7) highlight the fact that in practice few fully functioning BMCs exist. This is due to the numerous challenges that BMC must overcome to meet their terms of reference and mandates. Some challenges common to BMCs are as below but these vary from country to country:

1) Attendance (7) – ensuring adequate and consistent attendance is a struggle that most BMCs experience. This may be due to a number of factors including voluntary attendance, timings of meetings, clinical commitments, other meetings and commitments, etc.
2) No central guidance or education for these committees and their chair (7) – the chair may not be the transfusion expert and so relies on the transfusion team to provide context and expert information.
3) Ongoing professional education of health care professionals involved in transfusion. (5) This may be due to high staff turnover or lack of investment time from the trainer.
These challenges can be overcome with resources that are now available (see resources below) and also
1) Increase attendance - senior manager support could be used to highlight the importance of BMC work, secretarial support to find appropriate venues and times.
2) Develop Key Performance Indicators (reports should be in a user-friendly format) - to ensure hospital and BMC meet requirements.

3) Resources and education - to support members in the requirements of their role and improved understanding of transfusion practice.
4) Celebrate success and use as a driver for continued improvement.
5) Link in with regional/associated BMCs or other hospitals to share practice.
6) Survey committee members on what they would like to include in meetings /add to the agenda.

These challenges can be overcome with resources that are now available (see resources below) and also

1) Increase attendance - senior manager support could be used to highlight the importance of HTC work, secretarial support to find appropriate venues and times.

2) Develop Key Performance Indicators - to ensure hospital and HTC meet requirements. Report regularly in an easy user-friendly manner.

3) Resources and bespoke education - to support the new HTC chair and the other HTC members in their requirements of the role and improved understanding of blood transfusion.

4) Completion of audits to establish progress and use results as momentum for improvement and as comparative to benchmark against others. However, it should be noted that audits have their own challenges.

5) Link in with regional/associated HTCs or other hospitals to share practice.

Resources to Support the Role of BMCs

BMCs need to remain flexible and continue to influence practice in clinical areas. As new evidence becomes available, they should advise clinician’s on the best practice for the use of blood and blood components to improve outcomes and save patient lives. Below are some resources, which will support BMCs.

If you have others please contact the ISBT office to get these uploaded.