Haemovigilance is now an internationally established part of the safe management of blood process for patients. However, the part played by the Transfusion Practitioner within haemovigilance is less well known. The aim of this article is to outline the pivotal role that the Transfusion Practitioner plays within the haemovigilance process in the hospital setting.
Haemovigilance is a tool to improve the quality of the blood transfusion chain, primarily focusing on safety and can be defined as a set of surveillance procedures covering the whole transfusion chain from the collection of blood and its components to the follow-up of its recipients, intended to collect and assess information on unexpected or undesirable effects resulting from the therapeutic use of labile blood products and to prevent their occurrence and recurrence.
Within the UK, the haemovigilance scheme known as Serious Hazards of Transfusion (SHOT) has been in place for 20 years and it is now an integral part of the transfusion landscape, both clinically and within the laboratory. SHOT reporting encompasses both transfusion reactions and adverse events, with the latter from both the clinical and laboratory areas.
There is a great deal of emphasis within haemovigilance on the errors that are preventable and identifying points within the transfusion process where mistakes might happen. SHOT have identified nine critical steps (see 2016 SHOT report www.shotuk.org/shot-reports) where errors may occur and these steps encompass all parts of the transfusion process within the hospital setting, and to manage them requires team effort. An essential member of that team is the Transfusion Practitioner who is involved in the pre and post laboratory steps, and understands the laboratory processes.
The Transfusion Practitioner
Transfusion Practitioner (TP) is an umbrella term used to encompass the many different roles that exist in transfusion medicine. These roles include but are not limited to Transfusion Nurses, Transfusion Safety Officers, Haemovigilance Officers or Patient Blood Management Coordinators, and it can be undertaken by a Registered Nurse, Registered Midwife, Healthcare Scientist, Medical Practitioner or Operating Department Practitioner. One of the key aspects of the TP role is bridging the clinical-laboratory gap. In the laboratory there are rules and regulations that must be followed; “transfusion” is the main job whether grouping, cross matching or issuing components. The laboratory staff are the scientific experts in transfusion. In the clinical area, transfusion is one part of the patient journey contributing to the bigger overall picture. The clinical experts are not necessarily transfusion experts but understand where transfusion fits in their plans for the patient. The TP role helps to bridge that gap.
One summary of the TP role was in the 2014 UK Patient Blood Management (PBM) launch document:
Transfusion nurse/practitioner
- Provide and/or facilitate transfusion-related education including for PBM throughout the hospital
- Ensure clinical transfusion incidents, transfusion reactions, specimen labelling errors are investigated
- Submit data to haemovigilance programmes
- Develop constructive working relationships with the many clinical users of blood products, and assist with the implementation of PBM programme
- Support local, regional and national transfusion audits by involving appropriate stakeholders to undertake data collection and implement quality improvements arising from audits.
So what role does the TP play in haemovigilance?
The TP involvement in haemovigilance includes the investigation and reporting of transfusion reactions/adverse events internally and externally to national haemovigilance schemes. By conducting process reviews and communicating directly with clinical/laboratory staff or patients, the TP can provide additional details that are needed to complete investigations. Often this extra information assists the determination of the type of transfusion reaction/adverse event and provide valuable input to future transfusion plans and management of the patient.
For adverse events, TPs are often the drivers of the root-cause analysis process, and in collaboration with others, work on corrective and preventative measures. Surveillance is often achieved through audits which help to identify current clinical practice, understanding of transfusion processes, and any gaps or potential risks that may be present. Part of this may include a review of staff knowledge to guide education requirements, which all contribute to quality improvement.
As previously mentioned, the TP acts as a liaison between the clinical and laboratory settings improving communication and understanding. They also liaise between the hospital, the blood supplier and the national haemovigilance agency. To this end, an essential part of the TP role is excellent communication and collaboration skills as they interact with staff on different levels, in multiple settings.
TPs promote safe transfusion practice by sharing their excellent knowledge in this field to support changes and quality improvement in transfusion policies, procedures, reference guides, digital systems, and educational resources. They also participate in the development and delivery of staff education, for instance pre-transfusion sample collection or the management of transfusion reactions. Staff education by a TP may be formal in the form of lectures, or informal when staff can discuss a case or seek advice and ask questions. By maintaining a visible presence in the clinical setting, the TP ensures that staff have access to information and so support improved transfusion outcomes.
TP’s participate in transfusion committees and other professional groups that strive to improve practice on regional and national levels. TPs also collaborate nationally and internationally to develop the role and learn from each other. In most countries this is the only way to share knowledge, best practice and enhance quality because no specialised training for TPs is available.
Do TPs make a difference?
Although there is much published on the role of haemovigilance in safe transfusion practice, there is considerably less on the role of the Transfusion Practitioner in haemovigilance. There are some papers on the role of the Transfusion Practitioner and within the ISBT Transfusion Today member’s publication, the TP role has been highlighted but more peer reviewed papers are required to demonstrate their impact. However, in practice, most clinical audits related to blood management/transfusion rely on the TP to collect and submit the data, many SHOT report vignettes highlight the TP as part of the corrective and preventative actions or give a lack of TP as contributing factor, and the TP can also be pivotal in implementing patient blood management (PBM) strategies and acting as a central point for the different elements of PBM being undertaken.
Conclusion
The TP is uniquely placed to work with all teams bridging the transfusion gap and ensuring the patient remains at the centre of the transfusion process. They are seen as an expert practitioner in transfusion field with knowledge including appropriate blood management, use administration, and a good understanding of laboratory practices. They ensure clinical staff have access to the most up to date transfusion training and policies, and as a result patients and families are given the right transfusion information.
The TP role, which unfortunately is not yet established in all countries, can help to enhance transfusion and patient safety. Unfortunately, in many jurisdictions, they have limited formal status. There is wide variation in working hours, allocated tasks, payment, and training. It is hoped that these issues are addressed over time. To promote this role internationally, International Society for Blood Transfusion (ISBT) recently established a TP forum. Part of this forum includes an online discussion forum for TPs or those interested in the role to have discussions, share ideas or pose questions. To further promote the role there have been designated TP sessions at the ISBT Congress since 2016, and TPs are able to become a member of ISBT at a reduced rate (www.isbtweb.org). All this will contribute to the TP role being more widely recognised internationally as an essential part of the haemovigilance system.
The author would like to thank the ISBT Transfusion Practitioner Forum Steering Group for their contribution to this work.
Linley Bielby, Blood Matters Program Manager, Australia
Rozemarijn Deelen, Haemovigilance Officer , Netherlands
Clare O' Reilly, Transfusion Safety Nurse, Canada
Aman Dhesi, Development Manager - Patient Blood Management Team, UK