Bloodlines - BBTS have raised the profile of Bloodlines amongst the members. They are now looking at...

BloodlinesIssue No.110 December 2013

and CPDnews

Blood on Board: Pages 34 & 35

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4 Society NewsEditorial

Council Meeting Report

Member News

7 Feature ReportsBBTS in Focus

Offshore Transfusion:60 Degrees North

National Practitioners Conference

Mollison Award 2013

15 CPD NewsShot or Not?

Grouping

Geoff Daniels - Question 6

17 Feature ReportsThe Warm Heart of Africa:Blood Transfusion in Malawi

Annual Conference

The Use of Fresh FrozenPlasma in Adults

Blood Bank Technology SIG

Microbiology SIG

Tranexamic Acid

UK Cell Salvage Action Group

Paediatric SIG

Components SIG

Blood on Board!

The deadline for copy to be submitted

for the next edition of the newsletter (111)

is Friday 31 January 2014.

con ten t s

After a blood transfusion career thatcommenced in 1971 as a Junior ‘A’ LaboratoryTechnician and ‘ended’ in 2012 as Director of Operations at the Scottish National BloodTransfusion Service (SNBTS), I am honouredto have the opportunity to extend myobsession with blood transfusion by takingover the Presidency of this very specialSociety. I am looking forward enormously to ensuring the British Blood TransfusionSociety is well placed to meet and overcomethe many and varied challenges that lie ahead.Undoubtedly, some of those challenges willalso represent opportunities and we will seekto fully exploit these to the benefit of BBTS,its members and the patients we serve.

Being a member of Council and the ExecutiveWorking Group for the past year has allowed me to become familiar with the Society’s currentand future plans. It also gave me the opportunity to work with Clare Milkins, your outgoing President,and I have been so impressed by her energy,commitment and willingness to go the extra mile.On your behalf, I’d like to say a sincere thank youto Clare for the considerable contribution she hasmade during her time as President and I lookforward to receiving her on-going support andcounsel.

Of course there are many people who give of their time and talent to help deliver the key aimsof BBTS and perhaps this is an opportune timeto remind our members just how big a number that is. It includes our Council Members, ourProfessional Affairs and Education Committee(PAEC), our Scientific Meetings AdministrationCommittee (SMAC), our CommunicationsCommittee, our Special Interest Group Chairs and Secretaries, our Editors and Sub Editors of Transfusion Medicine and Bloodlines, themembers who represent BBTS interests on a widerange of external bodies (such as the RCPath Blood Transfusion Subcommittee and the MHRA Blood Consultative Committee), our examiners

3

P R E S I D E N T ’ S C O L UMN

We would like to thank all the advertisers in thisedition of Bloodlines. If you are interested inadvertising in future editions, please contact the BBTS Office: Enterprise House, Manchester SciencePark, Lloyd Street North, Manchester M15 6SE.Tel: 0161 232 7999 or email: [email protected]

Disclaimer - The Publisher, British Blood TransfusionSociety, cannot be held responsible for errors or anyconsequences arising from the use of informationcontained in this journal. The views and opinionsexpressed do not necessarily reflect those of thePublisher or the Editor, neither does the publicationof advertisements constitute an endorsement of theproducts advertised.

Martin Bruce - BBTS President

and CPD advisors. Last but by no means least is our fantastic Office Team in Manchester.

To one and all I say a huge thank you. However, I would encourage the remainder of our membersto think about lending their skills and expertise andgetting more involved in the work of BBTS. Don’t leave it to someone else, be proactive andstep forward! Whether you wish to stand forelection to Council, serve on a Committee orcontribute as an examiner, if your offer can beaccommodated then you will undoubtedly gainsome valuable personal development which couldbenefit your career whilst at the same timecontributing to the delivery of the aims of BBTS.

This month saw our Annual Conference take place at the stunning Birmingham InternationalConference Centre. Whilst we await the resultsof our feedback questionnaires, the generalconsensus is that the conference was anunqualified success. The programme was extremelywell constructed and well received, and the venuewas ideal. The food was excellent as were the commercial exhibition and posters and thedelegates were enthusiastic throughout. Manythanks to all involved in the organisation anddelivery of this key annual event but especially so to Jane Keidan (who has now stepped down as Chair of SMAC) and BBTS Events Manager, Cath Riley – we applaud the scale and qualityof your commitment!

Our work to address the requirements ofModernising Scientific Careers continues and we hope to have seconded expert resource in placebefore Christmas where the first priority will be toupdate the current Specialist Certificate inTransfusion Science Practice learning materials.Council has also approved a major overhaul for this Specialist Certificate which will see a fargreater level of control and support from BBTSexperts. There will be two exams: one after around100 hours of study and, if successful in the first, afurther exam after around 300 hours of study.BBTS will supply a training logbook and during thesecond part of the course there will be twoassignments with BBTS expert feedback and an array of distance learning materials. We aim to have this accredited by the University ofManchester. More detail will be provided as thisexciting programme of work progresses.

Finally, a warm welcome to our new CouncilMembers Roy Kettle and Emma Clenshaw.Congratulations on your appointment to Council,I’m sure you will find it a fulfilling experience.

The swallows may have long since departed, theautumn leaves are falling fast but we have muchto look forward to!

Martin Bruce OBE, BBTS President

@BritishBloodTS ‘British Blood Transfusion Society’

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I hope all BBTS members and other readers

who attended the BBTS Annual Conference

in Birmingham have returned to work full

of enthusiasm and new ideas, and that

those of you who were unable to attend

are making plans to join us in Harrogate

next year, 24th – 26th September. This

edition of Bloodlines features reports of

many aspects of the Annual Conference

both academic and social, which we hope

reflect the ethos of the meeting.

The BBTS Annual General Meeting takes place

at the conference and is a time to welcome new

council members and to sadly say goodbye to

Editorial by Jennifer Duguid

others. Thanks and bouquets were presented to

those who were leaving council and we at

Bloodlines were particularly sad to witness the

end of Jane Murphy’s term of office. She has

been the excellent chair of the Communications

Committee for the 5 years I have been editor

and though she has agreed to continue to serve

on the committee we will miss her unique style

of chairmanship.

This edition of Bloodlines features a mix of

articles and news that should appeal to all.

We continue with our newly introduced

Members News section, which has been well

received. We also continue with other ongoing

series especially Offshore Transfusion, this time

from Shetland. The plasma series continues

with details of administration, an aspect of its

use which is unfortunately not always carried

out appropriately and may explain the high

incidence of reactions to plasma transfusion

reported to SHOT. BBTS in focus features

this time members of the Communications

Committee and will help you realise who is

responsible for producing Bloodlines.

S O C I E T Y N EW S

Jennifer Duguid

The recently undertaken survey of BBTS

members showed a high appreciation of

Bloodlines but some respondents suggested

that they would like more articles with a clinical

relevance. In answer to this suggestion we

include an article about the use of tranexamic

acid. The CPD section also includes information

and learning opportunities of clinical relevance.

Professor Roberts, the editor of Transfusion

Medicine, and I have recently discussed the

ability of Bloodlines to source some clinical

cases submitted to Transfusion Medicine in

order to increase the number of such cases that

we publish. Readers of Bloodlines, whether

BBTS members or not are always welcome

to submit clinical cases as well as other

topics of interest directly to Bloodlines to:

[email protected]

Details of acceptable formats for submission

can be found on the BBTS website.

I hope you enjoy this edition of Bloodlines and

please keep your suggestions, comments and

articles coming in.

5



Highlights from the BBTS Council Meeting

18th September 2013 | Birmingham

• The Society is reviewing how we ensure

our brand values and presence, accurately

reflect the strength and integrity of the

Society.

• We are developing information on R&D

being undertaken across the UK.

• We have reformed the Nursing Committee

chaired by Diane Creighton, SNBTS.

The group will discuss professional and

educational issues specific to nurses.

If you have any queries/issues you would

like to raise contact the BBTS Office on

0161 232 7999 or

email: [email protected]

• The CPD on-line tool was used by 53% of

members who submitted returns.

Council Meeting Report by Joan Jones

• 50 candidates registered for the November

BBTS Specialist Certificate in Transfusion

Science Practice and 10 for the Specialist

Certificate in Cell & Tissue Transplantation

Science.

• The 3 year business plan has many of the

items on it now completed. This will be

reviewed and revised this year to take is

into the next few years.

• Age demographics of the Society were

discussed and we were encouraged to note

that younger age groups are increasing.

• The proposed new UK TLC Standards

(not recommendations any more) were

reviewed. Changes are not many but

more clarification to certain points.

• The MSC project is moving forward and

we have recently advertised for a

secondment. Support for this programme

has been received from the UK Forum.

It is the end of an era for the Communications

Committee as Jane Murphy steps down as chair.

Jane has ably chaired the committee for

the last 6 years (with a short break) and in

that time working with Jenny Duguid the editor,

they have raised the profile of Bloodlines

amongst the members. They are now looking

at how social media can be used. The Council

Joan Jones - Honorary Secretary

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BBTS Member Age Demographics

thanked both Jane and Jenny for their excellent

work. The new Chair of the Committee will

be Marie McQuade who is looking forward to

this role.

Member News


6 www.bbts.org.uk

Geoff Poole RetiresGeoff Poole, Director of the Welsh Blood Service, retires after almost 40years working in the NHS. As a foundermember of BBTS, Geoff has beeninfluential in driving the society forwardfrom the beginning.

Born in Wales, Geoff obtained a degree inChemistry before embarking on a career withthe NHS. He then gained his doctorate atPortsmouth University.

Geoff has seen many changes throughout the years and worked with many leaders ofthe transfusion industry including MargaretKenwright, George Bird and Dame ProfMarcela Contreras. Post retirement Geoff islooking forward to spending more time withhis family, walking, honing his photographyskills and learning a new language. Geoff willremain on BBTS Council and the ProfessionalAffairs and Education Committee until 2014.We wish him well in his retirement.

NEW COUNCIL MEMBERS

BBTS has two new council members.Since the last issue of Bloodlines,BBTS has lost two excellent Councilmembers – Jane Keidan (who waschair of the SMAC Committee)

and our very own outgoingcommunications committee chair,

Jane Murphy. We would like to thank both Janes for theirsubstantial contribution to BBTS,

especially Jane Keidan’s dedicationand contribution to the BBTS Annual

Conference and Jane Murphy’scommitment to Bloodlines.

Also, a huge welcome to new councilmembers Roy Kettle and EmmaClenshaw, it is great to have you

both on board!

Survey Winner!The winner of the Membership Survey prizedraw has been selected. Congratulations toSue Andrews, the 7� Galaxy Tab is on its wayto you. Thank you to all members who tookpart in the survey. Your comments will help usto develop the membership experience andhave given us some great insight that wehope will help to expand our membershipbase. Don’t forget you can contact us at anytime with comments or questions by [email protected]

Committee NewsWe have two new committee chairs tointroduce you to. Marie McQuade willbe replacing Jane Murphy as chair ofthe Communications Committee.

Marie’s experience and contacts make her the natural successor to Jane and she is well placed to continueto guide the excellent work of theCommunications Committee. Hugethanks go to Jane for all the hard workshe has put in to making Bloodlineswhat it is today.

Kate Pendry will take over the reins as chair of the Scientific MeetingsAdministration Committee (SMAC).

Kate’s background as the abstract co-ordinator for SMAC has given hergreat insight into the requirements ofthe Annual Conference and it seemedlike a natural progression for her to take over from Jane Keidan to developthe scientific programme of the event. Jane will be greatly missed on thecommittee who wish her well in herretirement.

Marie McQuade Kate Pendry

Season’s Greetings from BBTSAs this is our last Bloodlines for 2013 we’d like to wish

all of our members a very happy festive period.

Thank you for supporting the Society throughout 2013 and

we look forward to seeing you all in 2014.

Best Wishes from the BBTS Office, Council and Committee

The Blood Bank Technology SIGseeks a new committee memberWe meet twice a year (plus one telephone conference).

The main business is to organise the SIG meeting for the BBTS AnnualConference and the joint meeting with UK NEQAS BTLP.

Members are sometimes asked to contribute to guideline writing groupsand sounding boards. Please submit expressions of interest to

Jayne Sharpe, BBTG Secretary on: [email protected] with a short resume.

Steve Tucker, BBTG SIG chair

Erratum The article entitled Collection and Manufacture

of Plasma in issue 109 contained an error.

The temperature at which whole blood is

centrifuged should say 22o not -22o.

Sorry for any confusion caused.

7

F E A T U R E R E P O R T S


BBTS in Focus: Communications Committee

Communications Committee

The BBTS Communications Committee (Comms) is responsible for developing

the profile of BBTS. Comms produces Bloodlines ensuring an informative

an educational content. However, their responsibilities stretch to all areas of

the society including management of the BBTS stand at the Annual Conference,

producing promotional materials and managing the development of the

BBTS website.

We’re currently looking for new members and contributors, if you have

a creative flair and would like to discuss any ideas for Bloodlines or the

committee please contact Marie Maguire, BBTS Marketing & Communications

Officer [email protected]

More about the members . . .

Marie McQuade – New Communications Committee Chair

Three things you could not live without

My friends, holidays in the sun, New Zealand Sauvignon Blanc

(or whatever wine is on offer at Tesco!)

One thing you would do anything to avoid

Public transport, especially buses

Your favourite place / holiday destination

Florida - but it’s really difficult to choose just one

If you could do any other job what would it be and why?

Blue Peter presenter - I can’t believe they get paid to do all those fun & unusual activities and I might

get a badge at last. I don’t think Helen Skelton would want to change with me though

How would those who know you best describe you in three words

Fun, caring, talkative

Jennifer Duguid – Bloodlines Editor


Family, friends and health


Football


A ski resort with snow and sunshine and good food and wine for apres-ski


Tour guide to exotic places


Mad, bad and dangerous

Karen Shreeve


My morning cup of tea, my family and a good nights sleep


Travel by sea! For me the words ‘pleasure’ and ‘cruise’ cannot appear in the same

sentence. Cruising is my worst nightmare – not just because of the (very small I’m told)

possibility of seasickness, but I couldn’t bear being ‘trapped’ on board and unable to walk out

whenever or wherever I choose.


Too many to name but there are some places that I like to revisit from time to time: The city

Palma in Mallorca, Nice in the South of France and Bardolino on Lake Garda. Closer to home there is

nowhere I like better than The Gower in South Wales.


Growing up I always wanted to be a midwife but during my latter years in school I thought about

teaching art (making my then hobby my work). I saw sense and Midwifery won! – but maybe I would

have been a good art teacher.


Enthusiastic, energetic and motivated

Michael Douglas


Family (OBVIOUSLY), music and ice hockey


Sitting in traffic – I’d rather spend longer driving round than sitting in stop-start traffic.


I loved NYC – but I think the Cumbrian hills in autumn are hard to beat; all that colour then almost

complete blackness in the evening.


I’d be a pilot. I’ve just always fancied that feeling of freedom to soar above the clouds.


I was apprehensive about this but “Loyal, determined and sociable” is pretty good I think!

Jane Murphy


Red wine, Music and Friends


Public Speaking


Somewhere hot and Sunny


A dance teacher - my hobby and a job all rolled into one!


Outgoing, reliable, organised

• Edmond Lee makes up the final member of the communications committee •

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Professional Affairsand Education

Committee (PAEC)

Special InterestGroups (SIGs)

Scientific MeetingsAdministration

Committee (SMAC)

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9



Offshore Transfusion: 60 Degrees North

One of the most difficult balances to get right is blood stock management.

Our current ‘ideal’ stock level is thirty group O units of red cells (including

four O Negative units which are allocated for emergency use). Twelve units

of fresh frozen plasma and two of cryoprecipitate are also stocked.

Platelets are not held by the laboratory and are ordered on a per patient

basis. The nearest Blood Transfusion Centre is 210 miles away in

Aberdeen. Routine deliveries are flown on one of the five flights scheduled

per day. Usually deliveries are ‘next day’. At very best urgent orders will

take a minimum of four hours to arrive; the request has to be processed

by SNBTS Aberdeen, then the blood taken to the airport at least one hour

before departure, the flight takes one hour and the hospital is 40 minutes

drive from the airport. Outside of scheduled flights delivery of urgent

supplies relies on an air ambulance being available.

As with all remote laboratories the maintenance of blood stocks can be

challenging. Weather in the form of summer fogs and winter storms often

disrupts travel. Fog is caused by warm air from mainland Scotland mixing

with colder air from the Arctic. During June and July 2013 there were

more than twenty consecutive days with fog occurring somewhere

in Shetland cancelling many scheduled flights. When the rest of the

U.K. is enjoying good summer weather Shetland becomes fog bound.

In the winter months both flights and ferries may be cancelled due to

severe storms.

A close relationship with our suppliers, the Scottish National Blood

Transfusion Service (SNBTS) regarding arranging blood deliveries is

essential. In the recent past there have been two occasions where flights

were suspended for a significant period. One due to the volcanic ash cloud

caused by the eruption of Eyjafjallajökull in Iceland 2010 and another

in 2012 due to fog. On both occasions, the SNBTS arranged for a

refrigerated van to travel from Edinburgh to Aberdeen, then on to Shetland

by ferry (a fourteen hour journey) in order to keep us supplied with blood.

In order to save space most maps of Britain show Shetland in

a box at the top right hand corner. The majority of people therefore,

do not have any concept as to how remote Shetland actually is.

The islands are closer to the Arctic Circle than they are to Manchester

and the same distance away from London as Milan. Our closest large city

is Bergen. The current population is around 23,000 but this can increase

considerably due to tourism (such as the ‘Up Helly Aa’ Viking festival and

the arrival of cruise liner passengers). There has also been a recent influx

of transient oil and gas workers developing the terminal at Sullom Voe.

The islands are served by the Gilbert Bain Hospital which has eighty beds.

It is situated on the largest island of one hundred (called Mainland), in the

capital, Lerwick. The hospital provides a consultant led service having

three wards; general medical, general surgical and care of the elderly.

There is an Accident and Emergency Department as well as a Maternity

unit which is GP/midwife led. Other specialities are provided by visiting

consultants from NHS Grampian (Aberdeen).

The laboratory issues about 500 units of red cells per year of which

300 units are transfused. Whilst most transfusions are for anaemia we

always have to be prepared for the unexpected. The islands have their

fair share of road traffic accidents and about 150 patients per year are

‘medevaced’ (medically evacuated) by coastguard helicopter from oil rigs

and fishing boats. The majority of elective surgery is routine in nature,

such as cholecystectomies, TURPs (Trans Urethral Resection of Prostate),

hernia repairs, etc. but some more major procedures including radial

nephrectomies are carried out. With 180 babies delivered per year there

is always the chance of a post partum haemorrhage.

Bressay Light from Gilbert Bain Hospital

1 0


The staff skill-mix dictates that training is of paramount importance and

BMS staff perform a minimum of two immunohaematology external quality

control exercises per year. In addition two mandatory training exercises are

performed and assessed using the laboratory computer’s training

environment. Training is also supplemented by formal presentations by

laboratory staff and outside speakers. Time spent in the department is

documented and if a BMS does not perform serological testing within two

months a full formal competency assessment is carried out.

As with any hospital laboratory in the UK, large or small, there are still the

same pressures placed on laboratory staff in order to meet the standards

for CPA and MHRA. However, working in a small well integrated team who

provide support and cover for each other makes working in Shetland an

extremely satisfying experience. An added bonus is that Gilbert Bain

Hospital has one of the best views of any hospital in Britain.

Peter Parker

Haematology and Blood Transfusion Manager

Any person working in transfusion medicine in a mainland hospital

would be surprised at a wastage rate of about 50%. Coming from a large

city hospital I was initially taken aback at this figure. However, events

such as the Super-Puma helicopter crash which occurred off Sumburgh

in August 2013 served as a tragic reminder as to how vulnerable our

stocks are when faced with mass casualties. In the past it was possible

to supplement blood supplies in the event of an emergency with so

called ‘walking donors’. This practice is no longer possible due to more

stringent regulations.

Shetlander islanders have a well developed sense of community and many

are very keen to donate blood. At present there are no donor sessions

held in Shetland. The primary reason for this is location and the logistics

of transporting donated blood from the island within the time constraints

required for processing.

Laboratory Services at Gilbert Bain Hospital is multidisciplinary with six

Biomedical Scientist (BMS) staff: an overall Laboratory Manager,

Quality Manager, Biochemistry Manager, Microbiology Manager, Reception

Lead and a Blood Transfusion Manager who also is responsible for

Haematology. These are supported by five Biomedical Support Workers

(3 WTE).

The workload for Blood Transfusion is 1000 group and screens and

500 units of red cells issued per year. The methods used are manual

blood grouping and antibody screening by DiaMed (BioRad) technique

and quick spin and LISS/Coombs crossmatch. However, it must be

remembered that the ‘core business’ for the laboratory is the provision of

Biochemistry, Haematology and Microbiology testing for the hospital and

the ten GP practices. Consequently the laboratory is extremely busy even

without the provision of a Transfusion Service.

www.bbts.org.uk

Gilbert Bain laboratory staff

Lerwick Harbour

1 1



BBTS National Transfusion Practitioners Conference 2013

During lunch there was opportunity to visit the trade stands and talk

to representatives from the companies which help to deliver safe

transfusion practice.

The afternoon session then began with Susan Cottrell reflecting on

a decade of ‘Better Blood Transfusion’ in the Scottish National Blood

Transfusion Service (SNBTS), with some fascinating insight into how it all

began, the progress and achievements made over the years through

established networks and the future for providing safe, efficient and

effective use of blood across NHS Scotland. Of particular interest was

their education and training programme which is managed centrally,

and strongly supported by the use of Learnbloodtransfusion e-learning.

Andrea Harris went on to give an inspirational presentation encouraging

us to step out of our comfort zone as TPs, and eschewing the benefits

of ‘Getting involved when you are busy’ with examples of upcoming

opportunities.

The final speaker of the day was Donna Knight who outlined the

algorithm and referral process to empower laboratory staff at Queen

Elizabeth Hospital in King’s Lynn to question requests for transfusion.

Effective communication between the laboratory staff and the clinicians

addresses the management of inappropriate transfusions and avoids the

risks of delay when treatment is required.

This meeting was very informative with enthusiastic speakers and

engaging presentations, providing useful information and plenty of

opportunity to ask questions, share good practice and discuss some

key topics.

The BBTS TP group committee is very grateful to all of the speakers who

kindly gave their time and effort to help make this day such a success.

Kathleen Wedgeworth

Clinical Nurse Specialist - Intravascular Fluid Management,

Northern Devon Healthcare Trust

A successful conference was held at the Crowne Plaza Hotel in

Birmingham on 15th May 2013 for Transfusion Practitioners (TP)

and other staff with an interest in transfusion practice. In all

56 delegates attended representing the nursing, laboratory and

medical disciplines.

The third annual national TP conference, organised by the ever efficient

BBTS Office, was held the day after the BBTS Hospital Transfusion Special

Interest Group as both events complemented each other perfectly.

In addition, there was also a ‘networking’ dinner on the 14th May, giving

delegates the opportunity to socialise, catch up with old acquaintances

and make new ones. The atmosphere was relaxed and friendly.

The conference day started with us wondering what to do with our

overnight bags, but help was at hand with the BBTS team directing us to

the cloakroom. So with a welcome hot coffee in hand we took our seats

in a comfortable, well lit room at the large round tables which set the tone

for the informality of the day.

Claire Atterbury, the chair of the TP group opened proceedings,

welcoming everyone and set the scene by outlining the theme of the day

– Transfusion Practitioners as ‘Champions’ of best practice.

Tony Davies generously stepped in at short notice (though this wasn’t

at all apparent), to give a presentation on incident reporting and Serious

Hazards of Transfusion (SHOT) which was very well received and lead

to a lively discussion.

The next speaker, Emily Okukenu, offered a stimulating overview of the

Francis Report. As part of her presentation we participated in a healthcare

themed game of consequences, which provided food for thought on

a novel approach when delivering a teaching session.

The final presentation of the morning session was given by Dr Dafydd

Thomas. It was interesting to find out how the UK compares with

haemovigilance and blood regulations throughout Europe.

CONFERENCE SPEAKERS

Claire Atterbury (Chair of BBTS TP Group)

Tony Davies (Patient Blood Management Practitioner [PBMP]: NHSBT; SHOT Team)

Emily Okukenu (TP: Barts. & The London NHS Trust)

Dr Dafydd Thomas (Consultant Intensivist: ABM University Health Board; Chair of SHOT Steering Group; President of NATA)

Susan Cottrell (TP: SNBTS)

Andrea Harris (PBMP: NHSBT)

Donna Knight (TP: QEH King’s Lynn NHS FT)

Presentations from the Transfusion Practitioners meeting are available on the BBTS website. Visit bbts.org.uk/events for more details.

The Mollison award is a new BBTS award given in recognition of

Professor Patrick Mollison’s outstanding contribution to clinical

transfusion medicine during his career. Award recipients will

similarly have made a significant contribution to the practice of

clinical transfusion medicine throughout their career. The inaugural

recipient is Mrs Alexandra (Sandra) Gray, Professional Lead and

Head Nurse for Nursing and Clinical Services at the Scottish

National Blood Transfusion Service (SNBTS).

I met with Sandra at this year’s BBTS Annual Conference to find out a bit

more about her career in transfusion to date. I’ve known Sandra since

2002 but felt there was a lot I didn’t know about this private but influential

nurse leader. Our discussion follows below.

KS: Thanks for agreeing to meet up Sandra. I’m interested to know

more about your early career, before you got involved in transfusion.

SG: It’s a pleasure Karen. When I qualified as a registered nurse in the

1970s, I worked in operating theatres at the Royal Infirmary, Edinburgh,

consolidating my learning, competence and experience in all aspects of

general, cardiac and vascular surgery. After completing a first line

management qualification that helped me get promotion to senior staff

nurse and then charge nurse, I enjoyed coaching and mentoring junior

colleagues, championing their CPD programme and supporting colleagues

develop their roles. I suppose the ‘education bug’ had got me even back

then so while working part time and bringing up my sons I took the

opportunity to complete an Open University Degree, a BA in Arts and

Literature. This sparked a further interest in research as I’d really enjoyed

that aspect of the degree.

KS: So how did this lead you to blood transfusion?

SG: Brian McClelland at the SNBTS was advertising for a Research Nurse

to support the SANGUIS study in Scotland. Because the audit of blood use

was in elective surgery it was the ideal opportunity to combine my theatre

knowledge and experience with my new found enthusiasm for research.

The study ran from 1991 to 1994 after which I joined my colleague Joyce

Palmer as a transfusion research nurse in SNBTS. Then in 1995 Brian

worked with the Optimal Use of Blood Group; the group recommended

setting up a clinical team to support the safe and effective use of blood.

SNBTS supported the recommendation by establishing the Effective Use

of Blood (EUB) group in 1998. We enhanced that aspect of the audit

and research work by following up on incidents and delivering education

to clinical staff. Back then, anyone with an interest in clinical blood

transfusion would have heard of the work in the Mayo Clinic in Rochester,

USA and the transfusion nurse role. I had discussed with Willy Murphy

how we could develop the transfusion nurse specialist role, he had worked

with haematology nurse specialists in Canada; I had recently completed

a higher degree and achieved a Masters in Education at Edinburgh

University in 1998, so with

SNBTS support I applied for

a Florence Nightingale Travel

Scholarship in the same year

and was fortunate enough to

achieve this.

KS: That is such an

achievement. How did you

use the scholarship funds?

SG: I used the award to

spend a month at the Mayo

Clinic in Rochester, working

with their transfusion nurses,

followed by 2 weeks at the

National Institute for Health

in Bethesda where they

had developed a Transfusion

Nurse Specialist role in

research. This was such

an amazing opportunity and

I came back full of

enthusiasm and new ideas.

I succeeded in addressing

these ideas with the support

of the wider team.


1 3@BritishBloodTS ‘British Blood Transfusion Society’

BBTS Mollison Award 2013 – Mrs Alexandra Gray, OBE

Mrs Alexandra Gray (centre) receiving theMollison Award at the BBTS Gala Dinner 2013

Alexandra Gray


1 4 www.bbts.org.uk

KS: When the EUB was set up you were a small team I believe.

Where did you start in terms of identifying and implementing your

priorities? You were after all very much ‘writing the script’.

SG: Yes, we were a small team, Joyce and I were involved from the start

and Liz Pirie joined us a little later. We all had experience in education,

and/or audit and research but we also each took responsibility for specific

areas. Professor Marc Turner was by then our Clinical Lead until around

a year after the team was established when I applied and was successful

in taking on the role of the EUB Project Manager with the key objective

of promoting the safe, efficient and effective use of blood. We coordinated

a programme of audit, research and education in blood transfusion, for

example, blood use audit and feedback for orthopaedic surgery, patient

information resources and developing educational resources for multi-

professional staff groups. Our function reflected our title – Effective Use

of Blood group. Then in 1998 following the UK Chief Medical Officer’s

‘Better Blood’ Transfusion Meeting and the publication of the Health

Services Circular ‘Better Blood Transfusion’, even though the Transfusion

Nurse Specialist role had been around since 1995, there was a growing

interest in developing the Transfusion Practitioner role. We then conducted

the 3-year Safe and Effective Study in Scotland, which showed the impact

the TP role could have as part of a hospital team. The Better Blood

Transfusion Programme (BBTP) was then funded by NHS Scotland using

the priorities set by the HSC. We launched the BBTP programme in 2003.

KS: From my own experience I know that you were instrumental in

championing the collaborative project to explore the feasibility of

nurses and midwives expanding their roles to ‘prescribe’ blood.

SG: Yes, that piece of work has resulted in nurses and midwives around

the UK taking on the extended role to make the clinical decision to

transfuse and to provide the written instruction. Liz Pirie led this piece of

practice development for Scotland working closely with Jan Green from

NHSBT to come up with the national framework and subsequent roll-out.

KS: You’ve achieved such a lot in your career.

Who was your greatest influence?

SG: Gosh that’s hard, I can’t name just one person but there are some

people who have supported not only me but the concept of Better Blood

Transfusion. Brian McClelland, Willy Murphy, Marc Turner, Audrey Todd

and Karen Bailie have all shared my vision and each in their own way

have helped shape my career and the outputs of the BBT programme

over the last 20 years. Liz Pirie has been with me for most of that journey

and I will miss her work ethic and her counsel as she retires later this

year. I must also pay tribute to my partner, Eddie; he has been there over

the years, taking care of the family and supporting me as my career

progressed.

KS: What of the challenges ahead. Are you optimistic for the future?

SG: It is difficult to predict but with an increasing, and ageing, patient

population and decreasing donor base we are going to have to continue

driving the BBT agenda whilst investing in new and innovative advances

in healthcare.

KS: Now of course you have a much wider role. Tell me a bit about it.

SG: Yes, since 2012, I have taken on the role of professional lead and

Head Nurse for Clinical Services in SNBTS. That gives me a wider remit

with strategic and operational responsibilities for nursing within the BBT,

Tissues and Cells, Therapeutic Apheresis and Home Immunoglobulin

Therapy teams.

KS: Sandra, I can’t let this conversation end without a brief mention

of your trip to Buckingham Palace this month to collect your OBE.

SG: I was really proud to receive the OBE in the Queen’s Birthday Honours

List this year for services to blood transfusion; it is testimony to all the hard

work by the team over the last two decades.

KS: I sense though that you are incredibly fulfilled in your career.

What else is there to achieve?

SG: I am fortunate to have a job that I love and I am enjoying the new

challenges that the role of Head Nurse brings. There will always be plenty

to do and more to achieve, we just have to watch for the opportunities.

However, my priorities are changing a bit now. My family remains vitally

important to me and as you know I’m now a ‘granny’. I’ve picked up my

knitting needles again, it goes with the territory of being a ‘granny’ you

know, although I believe that knitting is trendy again. I also get great

pleasure from singing in the UK Rock Choir. There is something

therapeutic about singing in unison with others.

KS: It seems to me Sandra that your singing in unison is an extension of

working in unison, which is something you’ve achieved so ably in your

career. You are a role model and an inspiration, not only to nurses, but

to all involved in transfusion. Thank you for your time and Congratulations

on receiving the Mollison award.

Karen Shreeve,

Manager Better Blood Transfusion Team, Wales.

Karen and Sandra.

CPDnewsIssue No. 46 December 2013

Continuing Professional Development

Sorry this is so brief this time, but time pressures and a spot of annual leave have caught up with me!

This issue we have another SHOT conundrum from Tony Davies, a picture of some green plasma from

Rob Lees and answers to previous items. We also have an email from Dr Geoff Daniels regarding an answer given

to a question from Bloodlines 108.

As ever, I am always looking for topics to cover in future CPD News sections. If you have any items, images or like Geoff, you would

like to query an answer please email [email protected] John Eggington

CPD News – Issue 46

SHOT or not?A middle-aged woman with known alcoholic liver disease presented withhaematemesis with a Hb of 11.3 g/dL. The patient ws transfused 7 unitsof blood consecutively without assessment or monitoring of the Hb.Her post-transfusion Hb was 16.4 g/dL, requiring venesection of 2 units

and admission to HDU for ventilation because of pulmonaryoedema. She later died of multi-organ failure, and it was felt thatdeath was related to the transfusion.

Who is this reportable to – SHOT, MHRA or both?

What should it be reported as?

Geoff Daniels - Question 6Following publication (last issue) of the ‘answers’ to some multi-choice questions, Dr Geoff Daniels submitted some welcomecomments on the answer to question 6 (question and answerreprinted below);

6). Which of the following should be given Rh Negative blood?a). DVIb). Weak Dc). DVIId). Rore). DvaNote; Firstly ‘Rh negative’; should we say ‘D negative’, ‘Negative for D, Cand E antigens’, something else, or is everyone comfortable with ‘Rhnegative’? Secondly; Ror was originally given as a ‘should be given Rhnegative blood’ but I have changed it to ‘no’, any thoughts? Finally; although DVII is given as ‘should be given’, it is almost certain that (unless anti-D appeared to be present) DVII would be grouped as‘D positive’, and be treated/transfused as such.

Dr Daniels states;

‘I have been looking at the MCQs and answers in CPD News, and I thinkthat the situation relating to question 6 is more complex than that.

Firstly, the new BSH Guidelines distinguish between 1) females withchildbearing potential and transfusion-dependent patients and 2) otherpatients whose red cells give equivocal results in D testing. Taking theseguidelines together with recommendations from NHSBT, patients in group 1would receive D-neg red cells unless they are shown to have weak D types1, 2, or 3, whereas those in group 2 would receive D-pos red cells.

Of course that would not apply to DVI because that would not be detectedby the reagents used and so would be treated as D-neg.Another issue from this is what is the definition of weak D (and partial D forthat matter)? I have yet to find a publication that provides a meaningfuldefinition of these terms.

‘Sorry to complicate matters.’

Algorithms have been published, for serologic D testing, that intend to helpaddress the issue Dr Daniels raises (1, 2, 3), but as he implies, just howshould we define weak D and partial D? I’d welcome your comments.

1. Willey A. Flegel, et al. (2007) On the complexity of D antigen typing:a handy decision tree in the age of molecular blood groupdiagnostics. Journal of Obstetrics and Gynaecology Canada, 29, 746-752.

2. BCSH (2013) Guidelines for pre-transfusion compatibility proceduresin blood transfusion laboratories. Transfusion Medicine, 23, 3-35.

3. Geoff Daniels (2013) Variants of RhD – current testing and clinical consequences. British journal of Haematology, 161, 461-470.

2

CON T I N U I NG P RO F E S S I O N A L D E V E LO PMEN T

www.bbts.org.uk

Answers (CPD issue 45)

SHOT or not? AnswerTransfusion laboratory staff noticed at routine analysermaintenance that the screening cells in use had expired two daysago, and that in the meantime 120 group & screen results hadbeen validated and issued to the clinical area.

Is this reportable to SHOT, MHRA or both ?

If so, what as ?

Reportable to the MHRA as a SAE, failure of the laboratoryquality management system. Not reportable to SHOT as it isa generic quality error, and there has been no adverseoutcome reported for a specific patient.

This image was taken within 24 hours of the samples being taken.

The information you get is;They are ‘pre-op’ samples, from a 64 year oldwoman, who is not receiving any ‘treatment’.

What has caused this?

The sample was from ahistorically D positivepatient, who had been transfused 2 units of Dnegative red cells 24 hoursbefore this sample wastaken. The last transfusion,prior to this, was given 9 years previously. On

further testing it could be shown that the automated results couldbe duplicated, by manual technique, if the red cells were sampled

from the ‘bottom’ of the red cell layer (in the sample tube). The ‘manual’ groupingresults could be duplicated,by repeat manual testing,when the red cells weresampled from the ‘top’ ofthe red cell layer (in the

sample tube). All of the tests were performed on samples that hadundergone the local process of centrifugation, prior to testing.

Automated grouping result from patient X

‘Manual’ grouping result from patient X



The Warm Heart of Africa: Blood Transfusion in Malawi

discharged. To optimise the supply of blood, many whole blood donations

are split into three for paediatric use.

Hospital blood banks have seen their role change. No longer are they

primarily responsible for collecting donor blood as they can now call on

MBTS, so they are now responsible for handling, storing and cross-

matching blood. To facilitate this change, with funding from the USA,

I helped MBTS set-up and run courses for hospital blood bank staff.

The inclusion of an Indirect Antiglobulin Test (IAT) in compatibility testing

was a major goal as it was rarely performed when blood from FRDs was

used; often only the groups of donor and recipient were checked. A study

of 1,000 patients1 showed that some 10% had been previously

transfused, contrary to the widely held view that in Africa very few patients

receive blood more than once. Furthermore 1% had atypical antibodies

detectable by an IAT.

The central African country of Malawi is one of the world’s poorest

nations with a largely rural population. As with many resource

poor countries, blood was collected from family replacement

donors (FRD) rather than voluntary, non-remunerated blood donors

(VNRBD) as recommended in the World Health Assembly (WHO)

resolution WHA 28.72, which Malawi had signed.

The Ministry of Health had produced guidelines for the practice of blood

transfusion in 1997 but it was not until 2003 that the Malawi Blood

Transfusion Service (MBTS) was formally established to ‘provide safe and

adequate blood and blood products and to spearhead improvement of

blood transfusion systems within hospital blood banks’.

With funding from the European Union (EU) a national system based on

VNRBDs was set up, and three new centres built: one in the capital,

Lilongwe; one in the north, Mzuzu; and the third in the country’s largest

town and business centre, Blantyre. Blood is collected by teams based

at all three centres and blood components made in each, but all

samples are sent to the Headquarters Centre in Blantyre for testing.

All donations are fully tested for microbiological markers using current

generation test kits and automation, and for ABO and RhD using a manual

microplate technique. D onations are also screened for malaria parasites

using a thick, stained blood film; those found positive are labelled

and used.

The initial EU funding included four Technical Assistants (TA) to help

with Donor Recruitment, Quality, Transfusion Transmitted Infection (TTI)

testing and Immunohaematology. TAs for the first donor recruitment and

quality were South Africans and for TTI testing and immunohaematology

were from the UK. It was as the immunohaematology TA that I went to

Malawi first in 2005 and on several subsequent occasions to advise and

do some training on grouping, component preparation and quality control

(QC), laboratory management, and the planning and commissioning of

the new centres.

Prior to the establishment of MBTS, blood was collected from FRDs as

and when it was needed with very little kept in stock; blood components

were not produced. Once MBTS was up and running blood components

were made and the supply of blood improved. In 2005 18,939 units of

blood were collected and this has now risen to about 50,000 a year but

there are still annual shortages especially over the Christmas holiday

period which is the height of the rainy – malaria – season and students,

who form the bulk of the regular donors, are away from college.

About half of transfusions are for young children with acute anaemia

associated with malaria. Haemoglobin’s of 2 g/dL are not uncommon

by the time a child has arrived at a hospital. A simple transfusion of

100 - 150mL of blood, together with anti-malarial drugs, is often enough

to treat these cases and within a couple of the days the child can be

Malawi

1 8


www.bbts.org.uk

The BBTS’s Princess of Wales Award, which funds overseas workers to

attend the Annual Conference and spend some time looking at our

practices in the UK has been awarded several times to deserving

individuals from African Blood Services, including the now Medical Director

of the Malawi Service. This year the awardee is a biomedical scientist

working for the Ghanaian BTS.

BBTS makes its members only areas of the website available to members

of the African Society for Blood Transfusion and with its many links to

guidelines, standards and other organisations it is another tool for those

seeking to improve blood safety in often difficult circumstances.

Robin Knight

Transfusion Science Consultant, ex NHSBT

1M’baya B, Mfune T, Mogombo E, Mphalalo A, Ndhlovu D, Knight RC

The prevalence of red cell antigens and antibodies in Malawi.

Transfusion Medicine 2010; 20 (3): 196-199.

As part of the on-going training MBTS set up an external quality

assessment scheme for grouping and crossmatching in hospital blood

banks. Having had a member of staff attending one of the courses their

hospital blood bank was invited to participate in the scheme. There are

now 70 participants and results show a slow but steady improvement in

performance.

MBTS also runs courses for other hospital staff involved in the transfusion

chain to increase awareness of the national guidelines and good practice,

as well as teaching students at Technical and Medical Colleges. Recently

MBTS requested BBTS send 15 copies of their ‘An Introduction to Blood

Transfusion Science and Blood Bank Practice’ text book, for their own and

college libraries. These were supplied without charge as part of the

Society’s international commitment.

In 2007 BBTS made a project grant to Dr Baljit Cheema to evaluate a

new paediatric transfusion protocol being used at the Queen Elizabeth

Central Hospital in Blantyre where some 200-300 children are transfused

each month during the malaria season. A brief report from Dr Cheema

was published in Bloodlines in 2008 showing that the protocol was

suitable in resource poor settings.

Traditional Malawi Village

ANNUAL CONFERENCE 2013

Poster Winners

Junior Bursaries

Princess of Wales Award Winner

CommunicationsReport

2 0

A N N U A L C O N F E R E N C E

Poster Winners

Clinical Transfusion

Winner

Labelling of Transfusion Samples from Unknown Patients in

Emergency Situations

J. White, C. Milkins, M. Rowley

Commended

Should anti-D prophylaxis be given to RhD negative solid organ

transplant recipients of childbearing potential?

S.Dukka, A.Naeem, S. Murtaugh, R. Haggas, S.Davison, P.McClean,

M. Rowley, M. Karakantza

Immunohaematology

Winner

Anti-D in Pregnancy with the Novel RHD*IVS6+1G>T DEL Phenotype

J. Eggington, S. Grimsley, A. Nawrocki, L. Tilley,

N. Thornton, G. Daniels

Commended

Transfusion of K+ units to K- Antenatal Patients -

The Welsh Experience 2008-2013

H. Davies, C. Davis

Three novel RHD alleles resulting in D variant phenotypes

L. Tilley, S. Grimsley, A. McNeill, M. Cahill, H. Reid, E. Reardon, N.

Moore, N. Thornton, G. Daniels

Clinical Audit/IT & QA

Winner

A retrospective uni-centre audit to assess the appropriateness

of Red Cell Transfusions in a Tertiary Trauma and Orthopaedic Centre

J. Davids, A. Rafique, W. Tice, D. Agacy

Commended

Auditing and improving the transfusion pathway

M. Hitchinson, M. Budd, L. Rogers, H.Doughty

Miscellaneous (non-clinical)

Factors Affecting Residual Haemoglobin Content in Supernatant

of Deglycerolised Frozen Red Cells for Therapeutic Use

G. MacLaren, D. Healy, F. Sweeney M. King, S. Procter,

G. Nicholson M. Nightingale

Commended

Enhancing blood supplies - additional testing by NHS Blood

and Transplant

L Cieply, M Vasconcelos, CA Reynolds

T lymphocytes from cord blood have better proliverative potential than

lymphocytes from adult peripheral blood after TCR gene transduction

and in vitro expans

F. Guido, Y. Zheng, G. Aubert, M. Raeiszadeh, P. Lansdorp,

P. Moss, S. Lee, F. Chen

www.bbts.org.uk

The 2013 BBTS Annual Conference took place 16th -18th October

at the ICC in Birmingham. This year’s feedback has been very

encouraging with over 96% of delegates rating the programme

either good or excellent with many stating that the scientific/

clinical balance was good providing something for everyone.

All authorised speaker presentations are now available to view

online at www.bbts.org.uk/annualconference

Almost 500 delegates attended making the most of the excellent

sessions available and utilising down time to network with

colleagues and suppliers whilst also taking in the work of fellow

professionals by browsing the posters displayed in the exhibition

hall. We had a record number of submitted abstracts this year

with a hope to build on this in 2014 now that we are officially

affiliated with NATA via Transfusion Medicine. 18 of the 132

abstracts submitted were chosen for oral presentations, these 18

abstracts were of an exceptional standard. If you have an original

body of work that you would like to submit for the 2014

conference, entries open 3rd March. Remember, if your abstract

is accepted not only will it look great on your CV and add to your

CPD portfolio, it could also improve your chances of obtaining

funding for the conference.

Thank you to all the delegates who attended this year’s

conference. We look forward to seeing you in Harrogate next

year 24th – 26th September!

Race and Sanger Award Applications Open Now | Close 31st January 2014

Mollison Award Applications Open Now | Close 31st January 2014

Abstract Submissions Open 3rd March | Close 2nd June 2014

Princess of Wales Submissions Open 3rd March | Close 2nd June 2014

Junior Bursary Applications Open 3rd March | Close 2nd June 2014

To receive a reminder when

applications open email:

[email protected]

with the name of the award

in the subject header.

Datesfor yourDiary

2 1



The BBTS Junior Bursary scheme supports talented and ambitious

undergraduates and junior staff enabling a select few to experience

our Annual Conference completely free of charge. Our scheme gives

winners access to fantastic educational and networking opportunities

which they otherwise would not experience until much later in their

careers. But don’t let us tell you how great it is, here are a few

comments from the 2013 BBTS Junior Bursary Awardees:

Lectures were fascinating and many covered topics to use at your

workplace. I would definitely recommend this to any junior member

of staff.

Kirat Bansal, Junior Bursary

The lectures were fascinating and it was a great experience seeing

the work being done now and the developments for the future

of blood transfusion. I definitely want to be a part of this when

I graduate.

Helen Owens, Junior Bursary

It was great meeting the other junior bursary winners and we ended

up being our own little family, even when we went to different

lectures/workshops we all met up and discussed what we had been to.

Loraine Holland, Junior Bursary

The variety of presentations, posters and trade stands gave

a fascinating insight into current practices, new developments and

future possibilities.

Kathryn Lee, Junior Bursary

I thoroughly enjoyed my experience at the BBTS and would recommend

the conference to anyone involved in Blood Transfusion or Transfusion

Science.

Ewan McCourt, Junior Bursary

Applications for the 2014 Junior Bursary awards will open early next

year. If you would like to be informed when applications open, or

know someone who would, please email [email protected]

and you will be added to the mailing list. Full details can be found at

www.bbs.org.uk/bursaries

Junior Bursary Scheme

It has been a great experience. I met many intelligent, experienced

colleagues, specialists in various transfusion and transplantation

science.

Sade Olorode, Junior Bursary

The conference was a great opportunity for my continuous professional

development. It allowed me to meet other professionals and attend

several interesting educational and social sessions, which gave me

in-depth view of transfusion related issues.

Lukasz Cieply, Junior Bursary

A large enthusiastic trade show, 39 stands in total

joined us this year, many of whom were exhibitors who

continue to loyally support the BBTS conference

and our one day meetings. We were delighted to

welcome new trade support who we hope will decide

to join us again in Harrogate next year.

If you would like information regarding

the trade exhibition please contact Cath Riley by emailing

[email protected]

2 2


www.bbts.org.uk

My Experience – Princess of Wales Award Winner

As a sole beneficiary of the BBTS Princess of Wales Award, I was

deeply honoured to be taken through an extensive training

programme at the Welsh Blood Service (WBS), the SHOT office and to

attend the BBTS Annual Conference in Birmingham.

My experience at the WBS was more of an eye opener into discoveries

of new technologies and recent advances in Transfusion Medicine.

The knowledge on Intraoperative Cell Salvage brings to light the

resolution of the risk of allogeneic blood and avoidance of

inappropriate and unnecessary blood transfusions. I strongly believe

its usage will completely allay fears of blood shortages.

My session with Quality Assurance made me understand how its

integration in management is essential for effective patient health care

delivery. Furthermore, competence and training which are valuable

components in the Quality Manual are rigorously monitored.

The donor care nurses during the mobile session used uniformly

stringent procedure of disinfecting donor’s arm and I learnt

occasionally, this practice is individually examined for compliance by

the QA Laboratory. There was also consideration of the diversion

pouch in which the first 30 mls of donor blood assumed to contain

skin flora flows. Ultimately, all processed platelets concentrates are

sampled and cultured for bacteria contamination. These sessions were

of great importance to me since bacterial contamination of blood

components is a problem at the National Blood Transfusion Service

(NBTS), Ghana and there is an urgency of putting measures in place

to address it.

My session with the patient Diagnostic Services also brought to the

limelight how in-house panel of cells can be prepared and laboratory

assessment of feto-maternal haemorrhage by the kleihauer test and

the flow cytometry method. I will advocate for a routine screening of

pregnant mothers with such conditions so that the logistics as well as

training of staff for especially carrying out the manual method are

provided.

I learnt a lot from my visit to the SHOT office in Manchester including

highlights of 2012 report of SHOT, lessons for transfusion laboratory

staff, update on UK Transfusion Laboratory Collaborative and data

analysis from SHOT Database.

Finally, the BBTS Annual Conference of which I was an attendee

provided a solid platform to new technologies and recent advances in

the field of transfusion medicine. It was indeed a stupendous mass of

invaluable insights in the world of transfusion science. The conference

was well organised and commendable. The trade exhibition was a

fun-loving piece of the conference where state-of-the-art equipment

and reagents were displayed and marketed.

In conclusion, the conference was worthwhile and I thank the BBTS for

this opportunity. It has been a delightful experience and cherished the

wealth of knowledge I have acquired, not forgetting the heart-

warming assistance I received and the beautiful scenery of the places

I visited.

My utmost desire is to see an improvement in the quality delivery of

health care in the area of Transfusion Medicine in my country. I will

advocate for effective surveillance of blood and its components and

initiate reporting of transfusion incidents and laboratory errors.

I therefore intend to share my experience with my colleagues at the

National Blood Transfusion Service through series of workshops and

seminars. I strongly believe with a robust team work, my action plan

will be effectively implemented.

Miss Adelaide Allotey,

Princess of Wales Award Winner 2013

Adel with Clare Milkins, Outgoing BBTS President

The Princess of Wales award is an excellent opportunity

for overseas transfusion professionals to visit the UK and train

with a British institution. Using funding provided by BBTS,

the awardee can arrange a training /work placement in the UK

which will help them learn, network and develop new

skills which can be utilised on their return. Complimentary

registration and accommodation at the BBTS Annual Conference

in Harrogate, 24th – 26th September 2014 is offered

to the successful applicant to coincide with their organised

placement training.

Applications for the Princess of Wales Award

will go live in the New Year. If you would like to be alerted

when applications open, or you have someone in

mind for the award please email [email protected]


Communications Report

So my bags were packed and train ticket booked, hoping not to have

to contend with the floods from last year on the way to Harrogate, off

I set with some excitement but also a twinge of sadness.

The first council challenge was to get from our hotel to the hotel where

the junior bursary winners were staying, after a scenic tour of

Birmingham and the help of the App on Joan Jones’ phone, we all

finally made it and spent a pleasant time chatting to the junior bursary

award winners. This is a perfect opportunity for the bursary winners to

meet each other, especially if they are on their own. It is always great

to see them all chatting to each other by the end of the evening and to

recognise them throughout the conference and to be able to chat to

them and see how they were getting on.

The first day of the Annual Conference started with the Special interest

Groups and some interactive sessions. Once the key pads and

countdown to vote were mastered these went very well. There was

plenty of choice for all, in fact almost too much! I really must master

the act of being in two places at once. This was followed by the first

plenary session in the superb auditorium.

The official trade opening and informal evening followed giving

delegates a chance to catch up with old friends and network. The

exhibition hall was very spacious and allowed delegates to easily visit

the exhibition stands – I must congratulate the Scientific Meetings

Administration Committee (SMAC) on the ‘collecting stickers’ idea - a

great way for the shyer delegates to have a reason to visit the stands.

As usual the standard of lectures and diversity of subjects were

excellent as I have come to expect, well done to SMAC under the

‘chairship’ of Jane Keidan for pulling together a brilliant programme,

she has certainly set a high standard for Kate Pendry to follow.

The Gala Dinner was held in the conference centre, very convenient I

have to say for me as I only had to wander across the link bridge from

my hotel. The room was beautifully decorated and the meal superb…

especially the trio of puddings. I was amazed and delighted to be

presented with a wonderful bouquet of flowers, not so delighted to be

also handed the microphone - anyone who knows me knows my fear

of public speaking!

This year there were several very worthy award winners but a special

mention must go to the Percy Oliver Award winners Beverley DeGale

and Orin Lewis for their work recruiting bone marrow donors. I have

to say there were very few dry eyes around the room during their

acceptance speech and I am sure the catering company are

wondering why the serviettes are all mascara stained.

Soon it was time to pack our bags and check out of hotels before a

final day of sessions. This was rounded off by cupcakes… well they

were there and it would have been very rude not to eat one!

This is to be my last Annual Conference report as Chair of the

Communications Committee as I have come to the end of my

(extended) term of office on BBTS council. Watch this space for the

new Communications chair Marie McQuade and her report on

Harrogate next year.

Jane Murphy

Outgoing Communications Committee Chair

BBTS Annual Conference 2014

We’ll save you a seat...BBTS Annual Conference 2014 | 24th - 26th September | Harrogate International Centre

www.bbts.org.uk/annual confernece


2 4 www.bbts.org.uk


The Use of Fresh Frozen Plasma in Adults

FFP should NOT be used for reversal of warfarin. For immediate reversal

of warfarin effect in the presence of life-threatening bleeding prothrombin

complex concentrate is the treatment of choice. FFP only has a partial

effect and is not the optimal treatment (NBTC 2013).

DosageIt is important that the correct dose of FFP is given. The patient must

receive sufficient to be clinically effective, but not too much as over-

transfusing increases the risk of transfusion associated circulatory

overload. Using more of donor units than required would increase the risk

of transfusion related acute lung injury, acute transfusion reaction,

incorrect blood component transfused, and transfusion transmitted

infection (all recognised Serious Hazards of Transfusion3).

The NBTC (2013) recommends a therapeutic dose of 15mL/kg in adults,

which is equivalent to 4 units of FFP in an ‘average’ adult. In 2009 a

National Comparative Audit looking at FFP transfusion reported that in

40% of all adult cases, the administered dose was below 10mL/kg4.

FFP Dosage PosterTo support administration of a therapeutic dose, a table to aid the

prescription of FFP has been developed.

Fresh-frozen plasma (FFP) is a blood component usually transfused

to patients to replenish coagulation factors. It may also be used to

exchange plasma in some patients with particular conditions such

as thrombotic thrombocytopenic purpura (TTP). FFP should never

be given simply to replace circulating volume in patients1.

IndicationsCircumstances where it is appropriate to use FFP are documented in the

National Blood Transfusion Committee (NBTC) 2013 Indication Codes for

Transfusion2.

These are –

• replacement of single coagulation factor deficiencies where

no concentrate is available

• the treatment of acute disseminated intravascular coagulation (DIC)

with associated bleeding and abnormal coagulation results

• as therapy for TTP, usually in conjunction with plasma exchange

• in the management of massive haemorrhage

There is no evidence for use in non-bleeding patients with liver disease,

regardless of the Prothrombin Time ratio.

Calculations for One Adult Therapeutic Dose FFP

Patient Weight (kg)

15mL/kg Units FFP

50 kg 750 mL

55 kg 825 mL

60 kg 900 mL

65 kg 975 mL

70 kg 1050 mL

75 kg 1125 mL

80 kg 1200 mL

85 kg 1275 mL

90 kg 1350 mL

95 kg 1425 mL

100 kg 1500 mL

FFP doseVolume / Units

3

4

5

References

1 British Committee for Standards in Haematology, Blood Transfusion Task Force (2004).

Guidelines for the use of fresh-frozen plasma, cryoprecipitate, and cryosupernatant. British

Journal of Haematology 126: 11-28. Accessed 01/05/12 online at:

http://www.bcshguidelines.com/documents/FFP_28020604.pdf

2 National Blood Transfusion Committee (April 2013). Indication Codes for Transfusion –

an audit tool. Accessed 01/08/13 online at:

http://www.transfusionguidelines.org.uk/docs/pdfs/nbtc_2014_04_recs_indication_co

des_2013.pdf

3 Bolton-Maggs, P.H.B. (ed), Poles, D., Watt, A., Thomas, D. and Cohen, H. on behalf of

the Serious Hazards of Transfusion (SHOT) Steering Group (2013). The 2012 Annual

SHOT Report. Accessed 01/08/13 online at:

http://www.shotuk.org/wp-content/uploads/2013/08/SHOT-Annual-Report-2012.pdf

4 NHS Blood and Transplant (February 2009). National Comparative Audit of the Use of

Fresh Frozen Plasma: Full Report. Accessed 01/05/12 online at:

http://hospital.blood.co.uk/library/pdf/Audit_of_FFP_Elsewheres2009.pdf

5 NHS Blood and Transplant (October 2012). Portfolio of Components and Guidance for

their Clinical Use. Accessed 01/08/13 online at:

http://hospital.blood.co.uk/library/pdf/components/SPN223_5_4.pdf

Alister Jones

Patient Blood Management Team, NHS Blood and Transplant

[email protected]

This is intended as a reference to the correct adult dose of FFP, and should

not be used in place of clinical assessment. Prescribing should always

be guided by the clinical situation and coagulation results. It should also

be noted that there are specific protocols for the use of FFP in the

management of massive haemorrhage.

UK sourced FFP is predominantly from processed whole blood donations,

and a consequence of this is that the volume in a unit varies; the NHSBT

portfolio of components5 notes the mean unit volume of FFP produced by

NHSBT as 273 mL.

FFP volume required at each of the weights indicated is calculated at

15mL/kg, and the corresponding number of units of FFP being either

rounded up or rounded down from 0.5.

The patient weight range has been capped at 100kg to avoid advocating

volumes of FFP that may be disproportionate to circulating blood volume

in overweight patients (which may lead to a risk of fluid overload).

Indeed, this caveat applies to all patients deemed overweight.

Clinical staff can seek advice from Hospital Transfusion Laboratory staff

who are well placed to support the appropriate use of FFP.

SummaryFFP should only be given when clearly indicated, and it is important

that the correct therapeutic volume is prescribed. A table to aid dosing

has been developed to make decisions easier, and aims to ensure all

patients receive sufficient units of FFP required to achieve a clinically

effective dose.

The FFP dosage poster can be accessed on the NHSBT Hospitals and

Science website at:

http://hospital.blood.co.uk/safe_use/general_educational_resources/

index.asp

SCOTBLOOD 2014ANNUAL CONFERENCE

SCOTBLOOD 2014ANNUAL CONFERENCE



BBTS Hospital TransfusionSpecial Interest GroupSpring Meeting 2014Tuesday May 13th 2014

Austin Court,Birmingham city centre

Check the websitemid January 2014 for registrationdetails and programme content

www.bbts.org.uk/events

Thursday 12th and Friday 13th JuneUniversity of Stirling

Scotblood 2014 has an excellent programme of national

and international speakers who will be discussing the current

issues and future developments affecting the fields of

transfusion medicine, cellular therapy, and transplantation.

From mid January 2014 you can check the website

www.scotblood.co.uk/event/annual-conference-2014.aspx

for registration details.

Alternatively you can contact us at the email address below if you

require more information.

email: [email protected]

2 6 www.bbts.org.uk

Blood Bank Technology Special Interest Group - Meeting Report

Katherine Philpott, Chief Biomedical Scientist - Blood Transfusion,

Cambridge University Hospital gave a review of ‘antibody titration’. This

included the clinical value of the test in predicting HDBN, the likely

success of ABO incompatible solid organ transplants and severity of

Cold Haemagglutinins Disease. She pointed out the inherent variation

demonstrated by NEQAS in current UK practice and the effect this can

have on clinical outcomes depending on by who and where the test was

performed. She highlighted that automation offered a possible solution to

standardisation problems and improving outcomes.

Sharon Gale, Senior Biomedical Scientist- Blood Transfusion, Poole

Hospital NHS Foundation Trust, talked about the introduction of a system

of ‘supply on demand’ for red cells using electronic issue rather than pre-

crossmatch for elective surgery. Also the introduction of measures to

ensure appropriate transfusion by the use of Hb triggers and alternatives

to transfusion such as IV iron being given to pre-op patients with anaemia.

These measures have reduced red cell use by approximately 40% over a

5 year period within her hospital.

Any suggestions for topics of relevance to the SIG for future discussions

are always welcome.

Steve Tucker BBT SIG Chair

Once again we received excellent support for our meeting at the

BBTS Annual Conference. Thank you to all who were able to attend

and to our colleagues who gave a series of presentations of great

interest. These were either interactive or prompted some good

debate and questions.

Joan Jones, Head of Quality Assurance & Regulatory Compliance – Welsh

Blood Service, led an interactive session on Incident Reporting and

Corrective Actions, mainly relating to problems seen with red cell storage

and gave the audience various choices of actions to take in each

circumstance. The responses were varied, but most responders were

in-line with Joan’s recommendation. Which I’m sure she found quite re-

assuring! Richard Haggas, Transfusion Quality Manager - Leeds and

Bradford Teaching Hospitals, gave a presentation on “Maintaining

Analysers in a Validated State”. This is a confusing requirement which

Richard did much to clarify and re-assure; that most of us were doing this

already within our routine processes. It is mainly a question of ensuring

we state how validation is maintained within our Risk Assessments (for

example the delta checking of historical groups on Laboratory Information

Management Systems (LIMS) etc.)

Heather Aplin, Lead Customer Service Manager, Projects – NHSBT,

gave an update of progress with the SpICE reporting system used

by NHSBT Red Cell Immunohaematology (RCI) and Histocompatibility

& Immunogenetics (H&I). The vast majority of NHS Trusts are now signed

up and when users are satisfied and willing, the plan would be to go

paperless. Topics such as using the system to request tests and to track

samples were also discussed as possible future developments. Alison Watt

(SHOT) strongly recommended users agree to share report as this would

improve patient safety.

Steve Tucker - Blood Bank Technology SIG Chair

Joan Jones presenting at the Blood Bank Technology SIG

S I G R E P O R T


S I G R E P O R T

Microbiology Special Interest Group - Meeting Report

immunocompromised recipients presented with a prolonged viraemia.

The impact of HEV in the blood supply is hard to determine but if

intervention is needed, selective screening for ‘at risk’ recipients may be

a way forward.

Dr Tyrone Pitt gave a presentation on ‘The Threat of Pseudomonads in

the Water Supply’. Contaminated water sources may transmit bacteria to

hands of personnel and the wider environment and increase the risk of

product contamination. Following a brief review of the problem organisms

and their ubiquity in water he illustrated the development of biofilms of

bacterial communities in storage tanks, temperature control valves and

individual tap components leading to contaminated water at sink outlets.

He discussed the timing of sampling and microbiological testing and

the interpretation of these tests and suggested various solutions that have

been implemented to reduce and possibly eliminate pseudomonas

contamination of outlets including chlorination, tap design, and point-of

use filters. He also highlighted recent recommendations by the

Department of Health and the value to NHSBT of reviewing sink outlets

and associated water sources in terms of supply, usage and design, and

concluded on the value of regular bacteriological monitoring to mitigate

and reduce risk of personnel and product contamination.

The final presentation was given by Ms Helen Munro from SNBTS in

Glasgow. Her presentation was on ‘Lyme borreliosis, an Emerging

Infection’. Ms Munro talked about the cause of Lyme borreliosis, the

symptoms of this disease and also the possibility of transmission through

transfusion. She also presented a seroprevelence study of this disease in

Scottish blood donors. Donors were selected at random, grouped based

on gender, age range and postcode. The samples were renumbered,

anonymised then screened for antibodies to Borrelia burgdorferi which is

the bacteria causing Lyme borreliosis. According to this study, males aged

≥ 46 years of age living in rural areas were at the highest risk ofcontracting this disease although female donors ≤ 25 years living in ruralareas also demonstrated exposure to this infection.

Stanislava Mravcova

Microbiology Special Interest Group Meeting Secretary

The Microbiology Special Interest Group (SIG) meeting was chaired

by Dr. Carl McDonald (NHSBT), who introduced the first speaker,

Dr Su Brailsford. In her presentation entitled ‘Post Transfusion

Infections - Is it really the blood?’

Dr Brailsford talked about transfusion infections caused by viruses.

Usually about 20-25 reports of possible post-transfusion viral infections

are reported annually to NHSBT. It is possible for viral infections to go

undetected for years with no apparent symptoms. Of those viruses in the

routine screen Hepatitis B Virus (HBV) is the virus that causes most

concern, due to its long window period of approximately 38 days.

Dr Brailsford presented a case study of a male blood recipient with

suspected acute HBV. The possible risks were:

• transfused blood during surgery for Myocardial Infarction

• root canal treatment

The patient received sixteen donations from different donors. Fifteen

donors were cleared of infection. The sixteenth donor of FFP was positive

for HBV DNA but this result could not be confirmed. The associated

red cell unit from this donation was also transfused into an

immunosuppressed patient, this recipient developed chronic hepatitis B

infection. The donor did not develop any symptoms and was compliant

with the donor selection criteria.

The next speaker was Dr. Alan Kitchen who presented interim data,

to the end of August 2013, from a joint NHSBT/PHE study on ‘Hepatitis

E Virus (HEV) in Blood Donors’. The HEV was first recognised as a human

disease in the 1980s. This study is being undertaken initially to

determine the incidence of HEV in blood donors, and also to look at the

outcome in recipients of HEV viraemic donations. At the end of

August 197,712 individual donations, in pools of 24, had been tested.

Of those, 63 were repeatedly positive for HEV RNA (1:3100 donations).

All donors were asymptomatic at the time of donation. The limited

outcomes of the study at this time suggest that where transmission has

occurred immunocompetent recipients remained asymptomatic, whilst

2 8

F E A T U R E R E P O R T

www.bbts.org.uk

Tranexamic Acid – What it is and its effect on Blood Transfusion

Fibrinolysis is a process of clot breakdown where fibrin is degraded by

plasmin. This process is part of haemostasis, designed to prevent vessel

occlusion and to manage clot size as the vessel wall heals. Unwanted

fibrinolysis can have the effect of prolonging bleeding episodes; inhibition

of fibrinolysis can attenuate bleeding. TXA is a lysine analogue molecule

which interacts at the lysine binding site of plasminogen and the heavy

chain of plasmin; subsequently inhibiting fibrin degradation (see Figure 1

below) (Dunn, Goa 1999).

Tranexamic acid is a hot topic in transfusion – but there are still

some people unaware of how it works, why it is used and its

potential impact on transfusion.

Tranexamic acid (TXA) is a popular agent used by clinicians to minimise

bleeding in patients undergoing surgery or with increased bleeding due to

medical conditions. It was first described in 1964 during a search for

agents that inhibit fibrinolysis.

Figure 1 - Antifibrinolytic action of TXA - Plasminogen normally binds

to fibrin at a lysine binding site (left) resulting in the breakdown into

fibrin degradation products. Tranexamic acid (right) blocks the lysine

binding site, preventing binding of fibrin (Dunn, Goa 1999)

Since TXA was first developed as an anti-fibrinolytic drug in the 1960s

(Okamoto, Sato et al. 1964) its effect has been extensively studied in a

variety of surgical and medical conditions.

Significant blood loss is a problematic side effect of major surgical

procedures. Both cardiac and orthopaedic surgical procedures can be

associated with increased fibrinolysis; which can be a factor in episodes

of major bleeding. TXA has been shown to exert an anti-fibrinolytic effect

resulting in the reduction of blood lost, and the number of patients

requiring transfusion. This reduction has been observed even when using

modern surgical techniques known to minimise blood loss during surgery,

further emphasising the effect of TXA.

Some oral and maxillofacial surgical procedures can be associated with

relatively large amounts of blood loss in patients with haemophilia or

taking oral anticoagulants. Blood loss can obscure the surgical field,

hampering the completed surgical procedure. When using TXA, these

patients had less blood loss leading to an improved surgical procedure.

Due to the mode of action of TXA, patients taking oral anticoagulants were

able to continue their treatment – there were no observed problems of

increased thrombosis.

2 9



References

AK, K., ISBIR, C.S., TETIK, S., ATALAN, N., TEKELI, A., ALJODI, M., CIVELEK, A. and

ARSAN, S., 2009. Thromboelastography-based transfusion algorithm reduces blood

product use after elective CABG: a prospective randomized study. Journal of cardiac

surgery, 24(4), pp. 404-410.

DUNN, C.J. and GOA, K.L., 1999. Tranexamic Acid: A Review of its Use in Surgery

and Other Indications. Drugs, 57(6), pp. 1005-1032.

KAWASAKI, J., TANAKA, K.A., SATO, N., SAITOH, T., SHIMIZU, M. and KAWAZOE, T.,

2002. Blood component therapy guided by celite-activated thromboelastography for

perioperative coagulopathy. Journal of Anesthesia, 16(1), pp. 79-83.

OKAMOTO, S., SATO, S., TAKADA, Y. and OKAMOTO, U., 1964. AN ACTIVE STEREO-

ISOMER (TRANS-FORM) OF AMCHA AND ITS ANTIFIBRINOLYTIC (ANTIPLASMINIC)

ACTION IN VITRO AND IN VIVO. The Keio journal of medicine, 13, pp. 177.

ROYSTON, D. and VON KIER, S., 2001. Reduced haemostatic factor transfusion

using heparinase-modified thrombelastography during cardiopulmonary bypass.

British journal of anaesthesia; Br.J.Anaesth., 86(4), pp. 575-578.

SPERZEL, M. and HUETTER, J., 2007. Evaluation of aprotinin and tranexamic acid

in different in vitro and in vivo models of fibrinolysis, coagulation and thrombus

formation. Journal of Thrombosis & Haemostasis, 5(10), pp. 2113-2118.

WILLIAMSON, L.M. and DEVINE, D.V., 2013. Challenges in the management of the

blood supply. The Lancet, 381(9880), pp. 1866-1875.

Away from the surgical scenario, TXA has also been shown to be effective

at minimising blood loss during instances of significant haemorrhage

whether due to trauma, or a medical onset such as gastrointestinal

bleeding. Post-partum haemorrhage is a major cause of early maternal

death but its onset is poorly predictable (Sperzel, Huetter 2007).

Early studies have shown that bleeding volume has been reduced in PPH

with the use of TXA.

The structural formula for Tranexamic Acid

Transfusion Impact

Transfusion services are facing increased demand for blood components

from various sources – more complex surgery in ageing populations,

increased success of chemotherapy and an ‘unavoidable increase in

violent trauma’ (Williamson, Devine 2013). One method of decreasing

demand is to minimise bleeding in major surgery or trauma through the

use of TXA. Current literature shows that TXA has a positive effect on

reduction of blood loss, however many studies still fail to show a reduction

in transfusion requirement.

The variety of different transfusion strategies may account for this; also the

use of techniques such as autologous cell salvage may not be reported

together resulting in an apparent lesser effect of TXA. Although the

majority of studies do show that there is a reduction in bleeding

associated with TXA, which should be associated with less transfusion

requirement if transfusion strategy does not alter.

The introduction of TXA has led to increased interest in using

thromboelastography (TEG) as a method of assessing a patient’s

haemostasis. Several studies have investigated using TEG-based

transfusion algorithms (Royston, von Kier 2001, Kawasaki, Tanaka et al.

2002, Ak, Isbir et al. 2009) with one of these has reporting reduced

transfusion requirements in patients (Ak, Isbir et al. 2009). Although still

in its infancy this has the potential to cause a reduction in the demand

for blood products if incorporated on a wider scale.

Michael Douglas, Biomedical Scientist, Royal Derby Hospital

3 0


www.bbts.org.uk

assurance (QA) ensures the maintenance of a desired level of quality in

the service/product. QA not only involves the quality of the end product,

but also incorporates staff training and maintenance of equipment.

To ensure this could be met, Royal Cornwall Hospitals NHS trust set

the objective that QA should provide a rational and practical framework

on which to maximise patient safety during ICS by introducing a QA

The UK Cell Salvage Action Group session on Friday morning at the

BBTS Annual Conference was chaired by Rebecca Gerrard, joint

chair of the UK Cell Salvage Action Group.

The session began with an introduction to the UK Cell Salvage Action

Group (UKCSAG) from Hannah Grainger, Cell Salvage Co-ordinator

at the Welsh Blood Service. The UKCSAG was formed following

a consultation in 2005 undertaken amid concerns that intraoperative

cell salvage (ICS) in the UK was failing to progress. Regional reports

about the use of ICS and barriers to its implementation were gathered

and following the consultation, at the direction of the Department of

Health’s Appropriate Use of Blood Group, the UKCSAG was formed.

The remit of the group is to address the issues preventing the

development of cell salvage (both intraoperative and postoperative)

and to facilitate a UK approach to its use.

The UKCSAG consists of multidisciplinary experts in cell salvage from

around the UK. Following its formation, work plans were developed to

address the barriers identified and, in the past 7 years, many resources

have been published. These include education resources, framework and

policy resources and patient information. All outputs form the UK Cell

Salvage Action Group can be downloaded from the Better Blood

Transfusion Toolkit: www.transfusionguidelines.org.uk

Next Dr Craig Carroll, Consultant Anaesthetist at Salford Royal NHS FT,

shared his experiences of “Implementing a Cell Salvage Service”.

Following several cases where fat contamination was seen in the ICS

disposable, concerns regarding how ICS was being managed were raised

and the service was suspended to allow a full review of service delivery

to be undertaken. The hospital decided to go back to basics, reviewing

all of the current guidance (NICE, AAGBI Safety Guidelines etc) and

developing the service from scratch.

A policy was developed and an anaesthetic driven service with an

operational lead was implemented. This has allowed the organisation to

address areas of concern such as training, service delivery and cost

effectiveness.

ICS has now become part of the Trust’s NHS Quality Improvement Plan

and has become standard practice through linking with the WHO Surgical

Safety Checklist and the Major Haemorrhage Protocol. Using this

co-ordinated approach, the Trust now delivers the same level of service

for ICS as for allogeneic blood.

Following on, John Faulds, Blood Conservation Co-ordinator at Royal

Cornwall Hospitals NHS Trust, presented on “Quality Assurance, Data

Collecting and What’s New in ICS?”. ICS is a process and quality

UK Cell Salvage Action Group - Cell Salvage: Back to Basics is the way to go!

programme for all staff who participate in ICS. A new policy was

introduced in 2013 which included a partnership with the laboratory staff.

The policy was ratified by the Trust and implement by the Patient Blood

Management Team. The QA policy incorporated all aspects of QA including

staff training and competency, sampling, consistency of end product,

record keeping and machine maintenance.

The session concluded with “Clinical Cell Salvage” from Malcolm

Chambers, Transfusion Practitioner at the University of Leicester NHS

Trust. This final presentation was interactive and the audience were asked

for their views on some key topics and clinical case scenarios.

Look out for some of the results of this final presentation in

upcoming issues of Bloodlines.

The session concluded with a reminder that all information and

publications from the UK Cell Salvage Action Group can be downloaded

from the Better Blood Transfusion Toolkit at:

www.transfusionguidelines.org.uk

Hannah Grainger

Cell Salvage Co-ordinator, Welsh Blood Service


S I G R E P O R T

Paediatric Special Interest Group - Meeting Report

haemoglobin thresholds that will be recommended for this patient group.

Both SHOT and National Comparative Audits have highlighted areas of

poor prescribing practice for paediatric transfusion, including volumes

prescribed and the use of neonatal Fresh Frozen Plasma, and these will

be emphasised. The recent changes to paediatric components including

the introduction of methylene blue treated cryoprecipitate and the impact

of the SaBTO guidance on the use of CMV seronegative components will

be incorporated and clarified. Tony’s overall emphasis was that the new

guidelines will provide pragmatic guidance in areas where there is little

evidence and allow for a balance between recommendations and clinical

judgement, while at the same time encouraging best practice by clarifying

situations where transfusion is not considered appropriate.

Finally, Philip Arnold, Consultant Paediatric Anaesthetist at Alder Hey

Hospital, Liverpool gave delegates a detailed insight into the

complexities of transfusion decisions in paediatric cardiac surgery and the

difficulties from translating from

adult to neonatal practice, again

emphasising a balance between

guidelines and clinical judgement.

He presented a local audit of

perioperative transfusions over ten

years from 2012 and showed a

significant decrease in the use of red

cells over time, with the greatest

impact following introduction of

cell salvage.

In addition, a more recent policy of

using neonatal red cell split units

where possible has been associated

with a decrease in red cell donor

exposure. Conversely, there has been

a marked increase in the use of

cryoprecipitate over recent years,

which may be associated with

increased neonatal high risk surgery. This finding highlights the need for

continued detailed local audits to monitor and try to understand changes

in practice. There is a need for better understanding of the appropriate use

of blood components in paediatric cardiac surgery and in paediatrics as

a whole.

Overall, the Paediatric SIG session explored both areas of accepted good

practice and those where there is much uncertainty, and it provided

a thought-provoking start to the conference for many.

Helen New

Paediatric SIG Chair

The Paediatric Special Interest Group (SIG) meeting constituted

a series of thought-provoking talks. One of the recurring themes

was the balance between guidelines and clinical judgment.

The session had strong input from clinicians involved with

transfusing neonates and children day to day in different specialist

settings, including the expert Guest Chair, Georgina Hall, consultant

paediatric haematologist from Oxford, and was very well attended

by delegates.

Vidheya Venkatesh, consultant neonatologist at Addenbrookes in

Cambridge, gave a thoughtful presentation of a recent study of adverse

outcomes of neonatal transfusion (ANT) conducted at Addenbrookes

in partnership with SHOT and NHSBT. As background he reviewed the

recent literature, including the suggestions that some cases of necrotising

enterocolitis or intraventricular haemorrhage could be associated with

blood transfusion, and he raised the issue that transfusion reactions

in neonates may not be appropriately

defined or recognised. The ANT study

collected detailed clinical data

during, and for the first 24 hours

following, 100 neonatal transfusions,

primarily measuring cardiorespiratory

parameters. The data was compared

with baseline pre-transfusion and

analysed to look for evidence of

transfusion reactions according to

definitions modified for neonates

for the purpose of the study.

While there were no cases that fitted

definitions of transfusion related

acute lung injury (TRALI) and

transfusion associated circulatory

overload (TACO), a number

had sustained changes in

cardiorespiratory parameters during

the monitoring period. This was an

intriguing finding and may provide the basis of a future multicentre study

incorporating a control group for comparison.

Tony Davies, Patient Blood Management Practitioner with NHSBT and

SHOT, Manchester, presented highlights of the new BCSH guidelines for

transfusion of neonates and children, now in their final stages of

preparation. The guidelines will aim to provide more clarity for both clinical

and laboratory staff as to the rationale for recommendations, and will

include practical tools in the appendices that can be adapted for local

use, such as an algorithm for allocation of neonatal red cell split packs.

Since the previous guidelines in 2004 there have been a number of

paediatric transfusion studies, and Tony described how the data on

neonatal red cell transfusion thresholds in particular have influenced the

3 2

S I G R E P O R T

www.bbts.org.uk

Components SIG – BBTS Conference 2013

as a response to growing demands for cost reductions and pressures from

global suppliers, with the aim of yielding significant financial and non-

financial benefits. A set of standard blood pack specifications and

validation protocols had been produced and used by blood services for the

procurement of Top and Top bags and Bottom and Top bags. Sharing the

burden of evaluation, validation and audit had reduced timescales and

costs, and benefits will continue to be seen as services using the same

packs can pool their defect data and detect problems before they become

a significant issue.

This was followed by a presentation from Colonel Heidi Doughty on the use

of blood components in military settings which outlined the levels of

military medical installations and the protocols and procedures for blood

use in these settings. It gave a sobering insight into just how many blood

components are sometimes transfused into individuals who have suffered

major trauma on the battlefield and need to be stabilised for a series of

procedures and for transport back to England. How these components

are provided to the military was discussed and led into the next talk,

presented by Athina Meli, entitled “From Parachutes to Petri Dishes -

evaluating the equality of red cells”. NHSBT’s Component Development

Laboratory had conducted some work for the Ministry of Defence to

assess the ability of some delivery systems to preserve the quality of red

cells. Red cell units had been packed into Golden Hour temperature

control boxes and then into waterproof containers with flotation devices.

These containers were then dropped from height onto dry land, to model

their delivery by helicopters into the sea for collection by boat. Data were

presented on red cells dropped in one of two alternative containers, and

showed that there was no difference between the two containers and that

the red cell quality was not significantly different from the control units that

had not been subjected to the impact.

In the second part of Dr Meli’s talk she presented some data on the use

of small storage bags and small volumes of red cell concentrate. These

validation studies were a prelude for a storage study of cultured red cells

that are being developed in NHSBTs R&D laboratories, with the aim

of conducting a first in man volunteer recovery study within two years.

The data showed that the haematocrit of the red cells, the surface area

to volume ratio of the bag to the cell suspension, and the bag material

itself all have an impact on haemolysis.

In closing the session, the Chair thanked the audience for attending

and participating in the discussions, and thanked the speakers for

their excellent talks. The appeal for new committee members

was repeated and interested parties invited to contact either

[email protected] or [email protected]

Dr Stephen Thomas

Chair, Components SIG

The Chair opened the session with an update on the committee,

beginning with the sad news that Dr Phil Cookson who had worked

in the Component Development Laboratory of NHSBT since 2003

had died earlier this year from a long illness; he was thanked for

all of his contributions to the work of the SIG.

Tony Docherty of Scottish National Blood Transfusion Service (SNBTS) has

taken on the role of Head of Quality Assurance and Regulatory Affairs at

SNBTS, unfortunately this is occupying all of his time therefore he has

had to step down from the committee. As a result there was an appeal for

new committee members – there is currently representation from all UK

Blood Services but it is very development-focussed, and representation

from non blood service parties would also be welcomed.

In a change to the advertised running order the session began with Mike

Wiltshire standing in for Alex Morrison who was unable to attend but had

prepared a talk on Overnight Hold Implementation in the SNBTS. The

study had looked at two overnight ambient hold conditions, short hold

(mean ~13 hours) and long hold (mean ~21 hours). Both ‘Top and

Bottom’ and ‘Top and Top’ production methods were studied, as was the

influence of irradiation. Units in all parts of the study complied with UK

specifications for haemolysis, and the expected levels of supernatant

potassium and cellular ATP were seen. The aim is to have overnight hold

fully implemented in Scotland by 2017.

The second talk was by Harry Croxon of the Irish Blood Transfusion Service

(IBTS) who summarised the Eurobloodpack initiative. This was a

collaborative effort by members of the European Blood Alliance, initiated

3 4


www.bbts.org.uk

Blood On Board!

controlled by invasive techniques such as surgery or interventionalradiology. On scene blood transfusion provided a ‘bridge’ allowing them toreach hospital.

For medical teams like those provided by LAA, which undertake openchest surgery, the ability to deliver pre-hospital transfusion will potentiallyincrease the survival rate from this procedure. LAA have already seenpatients resuscitated successfully using this technique2. The team believethat these patients would not have survived without blood at the scene.

Summary of patients receiving on-scene blood transfusion 6th March2012 to 31st August 2013

On 6 March 2012 London’s Air Ambulance (LAA) became the firstUK air ambulance service to start flying with blood on board (BoB).The LAA physician – paramedic team responds to severely injuredpatients within the Greater London area using an aircraft and rapidresponse vehicles. The impetus was that of the 2000 patientsattended to each year approximately 200 were suffering fromserious blood loss, some dying before reaching hospital. It tookover three years to come up with a solution that was user friendlyand met legislative requirements.

In these serious cases it is unlikely that crystalloid transfusion will resultin a return of spontaneous circulation. Traumatic cardiac arrest due tohypovolaemia has a dismal outcome in the absence of blood transfusionand damage control techniques2. Journey times can compound thesituation when patients may not reach hospital in time to receive atransfusion.

Following extensive research, testing and validation a decision was madeto use the Golden Hour box from SCA Cool Logistics. Each box containsfour units of O RhD negative red cells and the relevant documentation. A data logger is kept in the box to monitor the temperature so that unusedunits can be returned to stock.

Standard Operating Procedures for Pre-hospital Blood Transfusion ensurethat all personnel (clinical and laboratory) understand the requirementsand responsibilities. No major drawbacks have been encountered and theprocess is now routine practice. The team have a traceability record of100% (possibly our only area that consistently achieves this with noprompting!). All of the LAA team know that wasted blood componentsmust be avoided at all costs as O RhD negative blood is a preciousresource. So far only one unit of blood has been wasted.

Clinical outcomes

LAA have now delivered over 140 pre-hospital transfusions. Some patientswere suffering from non-compressible haemorrhage, which can only be

PH Transfusions – Pre Hospital TransfusionsHEMS Helicopter Emergency Medical Service(previous name for London’s Air Ambulance)PLE – Pronounced Life ExtinctROSC – Return of Spontaneous CirculationED – Emergency DepartmentTCA –Traumatic Cardiac Arre

3 5



• 63 patients were in traumatic cardiac arrest and 51% had their

heartbeat restarted, which most definitely would not have happened

without blood

• Commonest mechanisms of injury were road traffic collisions

(40%) and penetrating trauma (35%)

• Average on-scene time with blood transfusion patients was

38 minutes

The British Military Medical Emergency Response Team in Afghanistan(MERT) carries 2 units of thawed plasma, so that has given the teamideas!

For medical teams and Air Ambulance services that do not attend thesame volume of severely injured patients there is still a potential benefit– even if a small number of patients survive to hospital as a result of pre-hospital transfusion it is definitely worthwhile.1

Emily OkukenuLead Nurse TransfusionBarts Health NHS TrustEmail: [email protected]

Anne WeaverConsultant in Emergency Medicine and Pre-hospital CareRoyal London Hospital, Barts Health NHS TrustLead Clinician London’s Air AmbulanceEmail: [email protected]

Acknowledgements:

The transfusion team at The Royal London Hospital; Chris Smith, Sarah Eshelby and Jess Norton for data analysis.

References:

1. Lockey DJ, Weaver AE, Davies GE (2013) Practical translation of hemorrhage

control techniques to the civilian trauma scene Transfusion 53 17-22

2. Davies GE, Lockey DJ (2011) Thirteen survivors of prehospital thoracotomy for

penetrating trauma: a prehospital physician-performed resuscitation procedure

that can yield good results.

Journal of Trauma 70 78-78

Blood on Board Helicopter at dusk - Lee Parker

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