Making blood safer
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7361.400 (Published 24 August 2002) Cite this as: BMJ 2002;325:400
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Response to:
Making blood safer: Stricter vigilance and fewer transfusions are the
way forward.Philip J Mortimer BMJ 24 August 2002
Dr Philip Mortimer’s excellent editorial1 is welcome when once again
the safety of the UK’s blood supply has been forced into public focus by
the recent announcement that the supply of fresh frozen plasma for
neonates and children born after 1 January 1996 will be imported from
sources known to be free of bovine spongiform encephalopathy (BSE).2 The
action is a precautionary measure taken in the response to the unknown
risk that variant Creutzfeldt-Jakob disease (vCJD) may be transmissible in
the blood supply. This group of patients has been chosen because they are
deemed not to have been placed at risk of developing vCJD from ingestion
of beef contaminated by BSE.
Dr Mortimer points out the dilemma facing the UK blood services in
developing strategies to mitigate the potential threat of vCJD, whilst at
the same time dealing with public expectation of a safe blood supply. This
expectation was recently reinforced by the judgement of Mr Justice Burton
in relation to transfusion-transmitted hepatitis C infection.3 We agree
with Dr.Mortimer that the indication for every transfusion should be
carefully considered before it is given, and the search for alternatives
to donor blood intensified. We wish to enlarge on the steps, which are
being taken to promote the appropriate use of blood.
Dr.Mortimer uses the term ‘haemovigilance’ to include efforts to
encourage appropriate use of blood, and suggests that a haemovigilance
programme is long overdue in the UK. The term is generally used to define
a system for collecting hazard data and epidemiological information on
donors and recipients. The UK has had a haemovigilance scheme, Serious
Hazards of Transfusion (SHOT), since 1996. Its main remit has been to
collect data and report annually on adverse events arising from
transfusion of blood and blood components. Cumulative data over 5 years
have shown that the majority of reports were errors resulting in the wrong
blood being transfused to patients, accounting for 61% (699/1148) of
cases. Transfusion-transmitted infections comprised 2.8% of reports, of
which the largest proportion (20/32 cases) were bacterial contamination.4
SHOT has made firm recommendations to improve transfusion safety including
pressing for greater emphasis on transfusion practice and education in
hospitals. Haemovigilance systems worldwide have not so far tackled the
question of appropriate blood usage, although SHOT has consistently
recommended that a parallel initiative be taken to address this important
aspect of blood safety.
As Dr.Mortimer indicates, this recommendation has been taken up in a
recent initiative by the UK Chief Medical Officers, who have held seminars
on better transfusion practice involving health service managers, blood
services, clinicians and patients in 1998 and 2002. The output of these
seminars has been two Health Services Circulars, the most recent titled
‘Better Blood Transfusion - Appropriate Use Of Blood’.5 This sets out a
comprehensive programme of action for the NHS. One of the main aims of
this initiative is to avoid the unnecessary use of blood in clinical
practice; there is known to be considerable variation in the use of blood
despite the existence of national guidelines. Better Blood Transfusion
emphasises the essential role of the Hospital Transfusion Committee (HTC)
in providing a lead for promoting better transfusion practice as part of
each Trust’s clinical governance framework. It recommends that each Trust
establishes a Hospital Transfusion Team (HTT) to ensure that the work of
the HTC is progressed between meetings. The HTT will be led by the
haematologist in charge of transfusion in each Trust, and additional
sessions will be required from haematologists to fulfil this role. New
resources will also be needed for the education and training of staff who
prescribe and administer blood, to carry out audits of practice, and for
investment in information technology for data retrieval and new electronic
systems for improving the safety of the transfusion process. About 50
Trusts have appointed Transfusion Nurses or Specialist Practitioners of
Transfusion (SPOTs) to promote safe and effective transfusion. SPOTs may
be from a medical, biomedical scientist or nursing background, and there
are advantages and disadvantages to each. Large Trusts and Trusts with
multiple sites may need several SPOTs to ensure good practice is
implemented in all clinical areas. As Dr.Mortimer suggests, resources for
new initiatives for better transfusion practice could be identified
through savings in the use of blood. The cost of blood has escalated in
recent years because of the introduction of new safety measures, and each
unit of red cells now costs £99.99.
Other important measures that are being taken on a national level are
the establishment of national schemes for the audit of the safety and
effectiveness of transfusion in collaboration with the Royal College of
Physicians Clinical Effectiveness and Evaluation Unit, and for the
management of blood stocks and reduced wastage of blood through the Blood
Stocks Management Scheme.The newly established Chief Medical Officer’s
National Blood Transfusion Committee (Chairman: Professor E.Gordon-Smith)
will play an important role in supporting the Better Blood Transfusion
initiative. Its membership includes representatives from the Regional
Transfusion Committees, Royal Colleges, SHOT, blood services, patients,
and the Department of Health (further details can be found on
www.doh.gov.uk/blood).
The UK blood services have the difficult task of balancing threats to
safety posed by known and unknown risks against the sufficiency of the
blood supply. To provide a focus for these difficult issues, the most
prominent of which is vCJD, the National Blood Service in England has
formed a Blood and Tissues Safety Assurance Group, chaired by the Chief
Executive. Its aim is to ensure that it develops strategies for dealing
with different levels of risk to the blood supply and recipient safety
which are cohesive, based on the best available expert advice and subject
to rigorous risk assessment. Appropriate blood use is one of the main
thrusts of these measures.
The UK blood services must keep additional measures under review,
including even more stringent donor selection criteria, and novel ways to
maximise available donations. At the same time, they must prepare for the
possibility that a screening test for vCJD will become available in the
foreseeable future, and that it could have a devastating effect on blood
availability should large numbers of donors decide that they no longer
wish to come forward for testing. We therefore entirely agree with Dr
Mortimer’s call to bring blood usage under firm control. This will require
a major collaborative effort involving health service managers, blood
services, clinicians and patients.
Elizabeth M Love, Michael Murphy, Lorna Williamson and Angela
Robinson on behalf of the National Blood Service Blood & Tissues
Safety Assurance Group
References
1 Mortimer PJ. Making blood safer. British Medical Journal 2002; 325:
400-401.
2 British blood too risky for our children, Daily Mail, 16 August
2002.
3 Liability for defective blood product, The Times, 4 April 2001.
4 Serious Hazards of Transfusion Annual Report 2000-2001, 9 April
2002, ISBN 0 9532 789 4 8 (http//www.shot.demon.co.uk).
5 Health Services Circular, Better Blood Transfusion – Appropriate
Use of Blood, HSC 2002/009, 4 July 2002 (http//www.doh.gov.uk/bbt2).
Competing interests: No competing interests
Dear Editor,
In response to the article, "Making blood safer", I would like to
congratulate Philip P Mortimer for a very timely and well written piece of
work. I whole-heartedly agree with some of his comments.
It has been a source of concern to me for some time that the
legislation pertaining to the most fundamental piece of equipment
routinely used by health care workers and especially surgeons has not been
subjected to a lot more scrutiny. Glove integrity should be a major
concern to all of us. This could also have an impact on the sex industry
since the same manufacturing material is also used in condoms.
The sequencing of the European directives are such that they
facilitate the manufacturers and do not pay adequate attention to the
health and safety or human rights legislation also imposed under European
law. It may interest your readers to know that the Personnel Protective
Equipment Directive came out in 1989 and the Medical Devices Directive
came out in1993 and the Carcinogenic and Mutagenic lists came out in 1999
and the Biological lists came out in 2000 and the Council Conclusions on
nvCJD came out in June 2001. Consequently the specifications are already
out of date. It is also most important that the standard setters, health
and safety authorities and the various departments in Europe and in the UK
keep up to date with the European lists of biological hazards and have
their lists all synchronized.
Given that the government has ordered blood from America for
children, it is maybe time they took a much more serious look at the glove
integrity problem. If they say that gloves are safe I would like to ask
why it is that surgeons who have certain titre levels of Hepatitis or HIV
infection in their blood are not allowed to do exposure prone procedures.
Could it be that the authorities realize the situation, but do not wish to
advertise this, as they are already suffering a staff problem.
It is time for the authorities to ensure that the glove manufacturers
are aware of their legislative responsibilities. The manufacturers have to
give very specific details about viral penetration loads, and to state if
they have tested the gloves against routinely used potions and lotions
mentioned in COSHH and also if they have done tests during surgery and
after surgery. Testing pre-surgery is not adequate and the Americans
realize that it is a good idea to electronically monitor glove integrity
during surgery, to avoid onward transmission of infection. It might be a
good idea to check that the testing of gloves is done in Europe and that
it can come under the legislative requirements of the European Union.
If there is an intractable problem on glove integrity it may well be
one that is easily dealt with. It may be a better way forward if the glove
manufacturers guarantee to subscribe to a greater provision of health care
costs for staff and most importantly to continue the research and
development needed to ensure the standards are maintained, for an
increased use of their product.
With increasing sexual infection rates and pep-resistant HIV, and
prion protein carried in blood, there is a need to be ever more vigilant.
The standards that govern the safety and well being of patients and
surgical staff and all other health care workers should be under close
scrutiny as it impacts upon the whole of society.
It may well be that the biomaterials market has already addressed
this situation and has new glove manufacturing material in the pipeline
and that I am not aware of this. I do know from documents received from
the British Library that the Americans have already found an alternative
to natural rubber latex but in 1999 it had only been discovered and had
not been put into production, the situation may have changed in the
interim. It is imperative that more professionals take an interest in the
standards that govern the production of routinely used safety equipment
and medical devices in their working environment. It is also necessary to
ask how many will take this problem up with their European Members of
Parliament to ensure that the sequencing of directives is such as to put
the safety of patients and staff first.
Competing interests: No competing interests
Salvage autotransfusion needs to be promoted in gynaecology
Dear Editor,
Philip Mortimer raised very important issues in his editorial (1).
However, his summary line should have been ‘Strict vigilance, fewer
allogenic transfusions are the way forward’. It is important to separate
allogenic blood transfusion from autologous blood transfusion since the
risks that were discussed relate mostly to the former. The risks of blood
mismatch and the transmission of blood borne infections are virtually
eliminated by salvage autotransfusion.
In the UK, autologous blood transfusion is underutilized (2). In
gynaecology for instance, ruptured ectopic pregnancy with significant
haemoperitoneum is one clinical situation where salvage autotransfusion
eliminates the need for allogenic transfusion (3,4). Salvage
autotransfusion has also been successfully employed in abdominal
hysterectomy and abdominal uterine myomectomy (5,6).
Therefore, in addition to reducing the number of allogenic
transfusions, one certain way forward in the march towards making blood
safer is to actively promote salvage autotransfusion – at least in the
management of ruptured ectopic pregnancy.
References.
1. Mortimer PP. Making blood safer. Strict vigilance and fewer
transfusions are the way forward. BMJ 2002; 325:400-401.
2. Torella F, Haynes SL, Lardi A, O’Dwyer ST, McCullum CN. Unchanging
attitudes to autologous transfusion in the UK. Transfus Med 2001; 11:15-19
3. Selo-Ojeme D O, Onwudiegwu U, Durosinmi O, Owolabi AT. Emergency
autologous blood transfusion in the management of ruptured ectopic
pregnancy. J Obstet Gynecol 1997; 17:353-355
4. Yamada T, Kasamatsu H. Laparoscopic surgery with intraoperative
autologous blood transfusion in patients with heavy haemoperitoneum due to
ectopic pregnancy. J Am Assoc Gynecol Laparosc Surg 2000; 7(2): 255-256
5. Yamada T, Ikeda A, Okamoto Y, Kanda T, Ueki M. Intraoperative
blood salvage in abdominal simple total hysterectomy for uterine myoma.
Int J Gynecol Obstet 1997; 59:233-236.
6. Yamada T, Yamashita Y, Terai Y, Ueki M. Intraoperative blood
salvage in abdominal uterine myomectomy. Int J Gynecol Obstet 1997; 56:141
-145
Competing interests: No competing interests