3.4 Blood counts
The core objective of the Blood Counts Program is to work with jurisdictional health professionals and other stakeholders to improve the appropriate use of blood and blood-related products.
The Clinical Advisory Council identified priority actions in this area and structured the actions around four streams.
Stream 1—Development, implementation and promotion of best practice guidelines and standards
Criteria for the Clinical Use of Intravenous Immunoglobulin in Australia
The National Blood Authority provided secretariat and coordination support to the Jurisdictional Blood Committee working party on the development of draft Criteria for the Clinical Use of Intravenous Immunoglobulin in Australia. The Criteria will provide Australian clinicians with information that:
- identifies the conditions recommended for IVIg therapy
- categorises those conditions against available evidence
- describes diagnostic, qualifying, exclusion and review criteria for the use of IVIg in those instances
- provides an overview of the manufacture, supply and safety aspects of IVIg.
The demand for IVIg has increased significantly worldwide and corresponds with a rise in the number of conditions which appear to respond to the use of IVIg or immuno-replacement therapy. The growth in demand for IVIg, its relatively high cost, and the potential for supply shortages have prompted action by Australian governments to ensure that its use remains consistent with an evidence-based approach and to ensure it is reserved for those with the greatest need.
Review of National Health and Medical Research Council/Australian and New Zealand Society of Blood Transfusion Clinical practice guidelines on the use of blood components
The National Data Workshop, held in September 2006, confirmed the need for the alignment of the use of products with agreed guidelines and acknowledged the coverage gap in the current guidelines, which were developed in 2001. In conjunction with the Australian and New Zealand Society of Blood Transfusion and the wider clinical community, an assessment of the guidelines identified limited or no advice on:
- paediatric practice
- critical bleeding scenarios
- unstable patients
- chronic transfusion recipients.
A joint proposal was submitted to the National Health and Medical Research Council to request that the review of these guidelines specifically address these gaps. This has been agreed and the project will commence in 2007–08.
Stream 2—Facilitation of education, information sharing and practice improvement initiatives
National Transfusion Practice Improvement Network
In November 2006, the National Blood Authority sponsored a workshop with senior clinical, nursing, transfusion scientist, government and private representation from states and territories across Australia. The aim was to facilitate the sharing and exchanging of transfusion practice improvement tools, methodology and ideas aimed at promoting and implementing standardised, safe and appropriate transfusion practices in Australia.
The Australian and New Zealand Society of Blood Transfusion has established the Clinical Practice Improvement Committee to further the achievement of these goals. The group's development of a first national audit tool has commenced.
Australian Commission on Safety and Quality in Health Care accreditation standards reform
The National Blood Authority obtained the agreement of the Australian Commission on Safety and Quality in Health Care to hold a 'blood-specific' consultation session on the proposed reforms to national safety and quality accreditation standards. The National Blood Authority subsequently provided a submission to the Australian Commission on Safety and Quality in Health Care, on behalf of the blood sector, which emphasised:
- gaps in standards across the transfusion chain
- the less than optimal alignment of clinical practice with best blood use practice
- the complexities associated with transfusion medicine, as it involves multiple professional groups and accreditation bodies covering various aspects of the transfusion chain
- the lack of nationally standardised oversight of transfusion-related activities outside the pathology laboratory.
The submission encouraged the use of tracer methodology covering the entire vein-to-vein process, with recognition of the boundaries of responsibilities between different accreditation bodies. It also highlighted the need for a strong nexus between the level of safety risk and the rigour of measures imposed to encourage compliance.
Stream 3—Improvements to systems
National haemovigilance reporting
In 2006 the Jurisdictional Blood Committee agreed to establish a national database and reporting framework to capture transfusion-related adverse events to deliver improvements in quality and safety. The Haemovigilance Project is an example of how the National Blood Authority has worked to create a solution that uses existing systems and national capability, without imposing additional reporting burdens on health-care professionals. The National Haemovigilance Project Working Group met three times. It identified and agreed that adverse events should be captured in the national system. The working group established and documented the reporting framework, and considered ongoing governance arrangements.
The group recommended a national minimum dataset of reportable adverse events, which was agreed by the Jurisdictional Blood Committee.
The collation and analysis of this data at a national level has commenced and is expected to allow for the provision of the first national report on haemovigilance data in early 2008.
As part of preparatory work for the national program, the National Blood Authority cooperated with the South Australian Government to jointly fund an investigation into the potential of the existing state-based incident management system to capture and report adverse events. A similar investigation was conducted in New South Wales. These investigations clearly identified that blood-related adverse events information was available in the existing systems.
Stream 4—Research, data and benchmarking to understand the use of red cells and to target inappropriate practice
National Data Workshop
The National Blood Agreement requires that the National Blood Authority:
- undertake or facilitate national information management, benchmarking and cost and performance evaluation for the national blood supply
- facilitate the development of national information systems for safety
- consider quality issues in relation to the Australian blood sector.
To ensure appropriate sector input into these priorities, the National Blood Authority held a National Data Workshop in September 2006. Its purpose was to define key questions and understand their relevance to improving sector performance, explore the value of existing datasets, define additional data that would contribute to answering these questions and establish priorities.
The workshop was conducted over two days with a series of presentations on developments, resources and research relevant to the blood sector. The presentations were designed to prompt discussion on the most important questions for the blood sector and to identify the data needed to answer those questions.
Through discussion and voting, participants refined the questions they considered important for the blood sector, prioritised them and identified data requirements. The key questions for which data was agreed to be a priority were:
- What are the national priorities for improving and maintaining best transfusion practice?
- How can the provision and use of blood products with optimum contribution to patient care be more cost-effectively managed?
It was agreed that, following the workshop, the activities with the best chance of success were those likely to take advantage of existing systems and allow jurisdictional participation. The primary opportunities to progress were agreed as:
- Guidelines—Review/revise the transfusion guidelines, aiming to make them more operational and cover more than the 'stable, non-pregnant, adult' situation.
- National prescribing document—Develop a national prescribing document for transfusions. It would encompass the guidelines in a convenient format in order to facilitate better practice and provide auditable data.
- Audit tool—Provide a means for more widely disseminating an audit mechanism which would assist hospitals to improve their use of blood in patient treatment.
- National haemovigilance—Establish a group to determine whether a national haemovigilance system is in fact practical, given existing initiatives at state level. If not, determine the most appropriate system at a national level.
- Data strategy refinement—Establish a process to refine data-relevant matters raised at the workshop and build a sound strategic framework for future data activities.
These priorities have been incorporated into the work of the Blood Counts team and strong progress has been made.
Refining the National Blood Authority data strategy
Consistent with the findings from the National Data Workshop, the National Blood Authority obtained the Jurisdictional Blood Committee's agreement to a set of principles to guide activities in the data field. These principles cover requirements in relation to:
- compatibility
- access
- efficiency of collection
- collection development frameworks
- use and interpretation.
Awareness of guidelines and influencing factors on the prioritising of blood
In March 2007, the National Blood Authority and the Clinical Excellence Commission in New South Wales jointly commissioned research to establish the influencing behaviours that will identify the clinical and non-clinical factors that affect red cell transfusion decision making.
This research will provide insight into decisions and recommend strategies applicable at the state and national levels to enhance the appropriate prescribing of blood components.