Proposal for Continued Funding of the Transfusion Nurse Role

Proposal for Continued Funding of the Transfusion Nurse Role at St.Elsewhere’s Hospital.

Recommendation

The recommendation of this proposal is that one operational Transfusion Nurse position be funded by St. Elsewhere’s from 1st July 2004. Review of practice at St. Elsewhere’s has exposed risks to patients and the organisation that are avoidable or able to be minimised. The transfusion nurse position would enable the continuation of necessary improvements for better, safer transfusion care at St. Elsewhere’s.

Background

Whilst in the last 30 years there has been impressive improvements in the safety of donated blood products, it is now apparent that the majority of residual risks to patients are related to errors in hospital transfusion practice[1].

Data collected at St. Elsewhere’s Hospital confirms three significant local problem areas:

1. The decision to transfuse (little or no formal training is received at medical school in clinical indications for blood transfusion therapies). At St. Elsewhere’s , up to ….[Insert own data here]. percent of audited fresh product transfusions are inappropriate when compared with national transfusion guidelines. Also, documentation of the indication for transfusion is ……[insert audit data here].

1. Patient sample collection. Over the last two years at St. Elsewhere’s , …… insert audit data here ….. crossmatch specimens received at St. Elsewhere’s Blood Bank contained one or more labelling errors and … insert audit data here ……… transfusion request forms received contained labelling errors. Conservative figures show that ‘Wrong Blood In Tube’ occurs at a rate of 1 per …[ insert audit data here]… samples. Thus the risk of a catastrophe relating to clerical error resulting in an ABO haemolytic transfusion reaction remains worryingly high.

1. Bedside administration of blood. A spot audit showed there was … [insert audit data here]…. compliance with existing policy and procedures for documentation of critical patient observations at the time of giving blood products.

The unsafe practices in transfusion at St. Elsewhere’s expose patients to avoidable risks and expose the organisation to:

• Unnecessary risks of error at a time when the community and statutory authorities are taking an increased interest in quality and safety in public hospitals
• Preventable waste in time and money as resources are used inappropriately

Purpose of the Transfusion Nurse Role

In hospitals, transfusion activities outside those of the laboratory have not been significantly controlled or monitored. The transfusion nurse role provides the necessary resource for this to now occur.

At the St. Elsewhere’s Hospital a specialist transfusion nurse change management role has been created (Jan 2003) and tested as part of the DHS Blood Matters project, to take transfusion safety into pilot clinical areas.

Similar to the Infection Control Nurse model, the transfusion nurse (TN) functions include:

-education of staff regarding best practice (eg medical, nursing, scientific, other)

-auditing St. Elsewhere’s transfusion activities to ensure KPI’s are well defined, achievable and monitored

-conduct research/project manage/coordinate improvement initiatives across all domains of transfusion practice

-ensure patient and carer information is current and readily available

(also see Appendix One for current TN position description).

Key Results Achieved (and expected to be achieved)

The Transfusion Nurse as a resource has been used to achieve the following practice and financial benefits at St. Elsewhere’s :

Improved Clinician Decision Making for transfusion to reduce patient risks through inappropriate transfusion

As part of the Blood Matters project, the national guidelines for use of blood components have been implemented in the project areas of the hospital. Significant improvements have resulted within 8 months:

• Increased Staff Awareness of the Guidelines from …. to …..%
• Increased Staff knowledge of the Guidelines from …. to …..%
• Increased Alignment of practice against Guidelines from …. to …..%

.

The evidence based NH&MRC/ANZSBT Transfusion Clinical Practice Guidelines are now implemented in …………..areas of the hospital. The TN role has been key to this success and is essential for the ongoing maintenance of best practice in this area.

Equipment Savings and Implementation of Best Practice:

A review of transfusion protocols at St. Elsewhere’s highlighted the clinically unnecessary and widespread use of ………… across the organisation. The ….. is no longer a stock item for ordering and …….. are no longer available in ward stores.

Cost ………….. $.

Number of ….. ordered in 2003…… Units

Saving in un-used …….. $.

The potential for further savings via large volume purchases is made possible by the implementation of consistent practice across the whole of St. Elsewhere’s. For example, the Transfusion Nurse is currently involved in reviewing the use of …………

Productivity Benefits due to Appropriate Use of Blood Products

We know that the total cost of giving a unit of red cells to one patient is relatively high at $xxx per patient (see Appendix Two for a breakdown of costs). At St. Elsewhere’s Hospital ……. units of blood are used annually. Even a modest target of a three percent reduction in red cell use across St Elsewhere’s could deliver overall significant productivity gains for those areas that transfuse patients.

Total Cost of a Red Cell Unit$xxx (Cost to Red Cross- $xxx. Cost to St. Elsewhere’s- $xxx)

Total number of units transfused/year [insert figure]

Total Cost to St. Elsewhere’s/annum[insert figure]

St. Elsewhere’s Productivity savings due to 3% reduction

in Red Cell use$[insert figure] per annum

($[insert figure] at five years)

Improved Administration Procedures for transfusion enables organisational consistency

• Blood Matters and the TN have developed and trialed a new documentation system relating specifically to Blood Products.
• The new system now enables documentation of key steps that were previously often undocumented. For example:
• clinical indications for transfusion (…[insert audit data here ]….. completed documentation)
• checking procedures undergone prior to transfusion commencement …[ insert audit data here]..%)
• critical patient observations during transfusion (…[insert audit data here] …%)

• The new system brings key procedural information to the bedside where it is needed. The system incorporates international best practices for transfusion.
• The sustained focus in this area by the TN is beginning to overcome any inertia to change and reduces medico-legal risk from incomplete documentation.

Improved Error reporting rates to increase patient safety

• An increase from … insert audit data here.. percent of requests up to .. insert audit data here ……percent on individual wards, over a twelve month period, has been achieved with the implementation of new systems and education.
• .St. Elsewhere’s current risk reporting system, [Insert name of system] has been expanded to include several different types of transfusion incident. This is highlighting transfusion as an issue and making reporting easier.
• The increased error rate reflects greater awareness about good, safe transfusion practice which reduces the likelihood of other significant errors occuring.

Organisational Transfusion Risks and Benefits of the Transfusion Nurse role

Risks of NOT having a TN at St. Elsewhere

/

Benefit of TN role at St. Elsewhere’s

Unsafe transfusion practices may lead to errors, patient morbidity and mortality, and potentially litigation in the areas of wrong blood to wrong patient and failure to seek informed consent. / Preventative education, audit, review of international best practice and system redesign has reduced unsafe practices already. These would continue in order to ensure St. Elsewhere’s at international standard for transfusion especially for key problem areas (sample collection, clinician decision making and bedside administration).
Uncertainty about where to seek guidance may result in poor performance and poor decision making skills by staff involved in transfusion. / The TN is a role model to peers and health professionals. Other specialists can access the specialist knowledge of a TN in a timely and supportive way. These skills are especially important since St. Elsewhere’s has high volume transfusion needs given it is has….List here speciality areas that use large volumes of blood products.
Equipment costs are higher when there is no monitoring of accessory items related to transfusion and less standardisation of protocols. / Equipment for transfusion practice is constantly evolving and a confusing plethora of products existed on site atSt.Elsewhere’s. The TN coordinates the regular review of stock items.
St. Elsewhere’s has already made significant investment in the TN role and development of improved transfusion systems since it commenced in Jan 2003. This knowledge/investment will be lost if the role is not operationalised. Further, without the resource to maintain the system, the gains to date will be lost. / The difficult and time consuming task of establishing the role has occurred already. This effort and resource is now required at only a maintenance level that is achievable with a TN and via the existing HTC [Hospital Transfusion Committee] and transfusion specialist staff at St. Elsewhere’s. The existing TN has already completed a Certificate in Transfusion Practice course run by Melbourne University.
Inability to supply accurate data to National Blood Authority, DHS and/or their delegates may impact negatively on the supply of products to St Elsewhere’s for patient care / The TN is a resource to collate and/or coordinate data collection to meet reporting obligations

Other National and International Factors bringing Transfusion to the forefront of the Quality and Safe Practice Agenda

Transfusion Nurse Role

The transfusion specialist role already exists internationally. For example, the United Kingdom employs at least 50 practitioners and Canada has a regional system involving approximately 45 transfusion safety officers.

The specialist role provides the content knowledge required to negotiate change. To affect change across an organisation, effective relationships need to be built and sustained with numerous stakeholders in transfusion. This activity is time consuming and requires a full-time focused and knowledgeable effort that cannot be effectively provided by any other than a specialist practitioner.

The transfusion nurse is more effective than sole delegation of such responsibilities to a transfusion committee where members take on committee responsibilities in addition to existing operational roles. The transfusion nurse is the main resource for the committee to action operational goals.

External Drivers for Change in the Use of Blood Products

Blood products are the result of donations ‘gifted’ by the general community. Recent changes in donation procedures has led to this precious resource being increasingly harder to obtain. For example, the recent introduction of higher haemoglobin thresholds before donors are able to donate (Jan 2004) will mean an estimated 36,000 less donations (4% of current whole blood donors) over the next 12 months. This is in addition to the estimated national loss of more than 50,000 donations annually due to the donor deferral policy in 2000 arising from potential vCJD risks. As a result, the focus has shifted from mainly interest in the management of the supply, to now include review and management of demand ie improving hospital use.

The National Blood Authority (NBA) has been formed to provide national management and oversight of Australia’s blood supply. The NBA will seek reports both at a Victorian and National level about how products are used. There is an expectation that accurate reports be provided by individual hospitals on what products have been issued. From these figures, the NBA will liaise with stakeholders to ensure supply meets demand. Analysis of usage by Diagnostic Related Group is also likely to be needed.

Annual Cost and Resources Required

One Grade 4B Clinical Nurse Consultant position at:

Yearly award salary $xx,xxx

Oncosts 15% (workcover, supperannuation, leave) $x,xxx

TOTAL Annual Salary Cost of CNC

Computer (updated every three years): $x,xxx

Administrative support: $x,xxx

TOTAL ANNUAL Cost of TN position$xx,xxx

Proposed Line Management and Reporting

Reporting to

Nursing mgt Transfusion Mgt

Transfusion Nurse

Working

Relationships

Time scales for agreement and recruitment

2004

Mar / Apr / May / Jun / July
Submission of Proposal to St. Elsewhere’s Executive
Executive Decision to fund Position
Review of Position Description by key stakeholders
Recruitment of TN
Funding for Collaborative TN role ceases
Commencement of Operational TN at St. Elsewhere’s

Proposal Summary

Worldwide awareness of the hospital risks of transfusion has increased in the last four years as error and incident reporting has exposed the very large number of errors made throughout the transfusion process. Also, recent changes to management of the blood supply in Australia has put a spotlight on hospital use of blood. Audit data derived from the Blood Matters project at St. Elsewhere’s has shown St. Elsewhere’s harbours significant risk management issues in particular for specimen collection and bedside administration and clinician decision making.

In the last eighteen months as part of the Blood Matters project, significant investment has gone into laying the foundations for and achieving improved transfusion practice at St. Elsewhere’s . The following five elements have been found to be critical to the ongoing management of transfusion risks:

A transfusion nurse specialist

Transfusion Medicine Specialist Senior Medical and Scientific staff

An effective hospital transfusion committee

An organisational risk management structure

Executive support for safety in Transfusion

The transfusion nurse role has already been used effectively to achieve system and service improvement at St. Elsewhere’s . Removal of this resource, would significantly reduce the focus on transfusion atSt. Elsewhere’s , lose the momentum already gained for service quality improvement and leave the organisation and it’s patients exposed to unsafe transfusion practices and the consequences of incidents that may arise.

This proposal recommends that the transfusion nurse specialist position be made an operational position at St. Elsewhere’s , effective from 1st July 2004 when the Blood Matters Breakthrough Collaborative project ends. A strategic three year plan would be used as the focus to enable organisation wide transfusion management.

 ANZSBT = Australian and New Zealand Society for Blood Transfusion

REFERENCES

[1] Serious Hazards of Transfusion (UK) Annual Report 2001-2002. Available at