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Western Australian Success Story of Patient Blood Management

Optimising Donor Health and the Blood Supply: Update on the Interval Study

S. Towler

D. J. Roberts1,4 & on behalf of the INTERVAL study group1,2,3,4

Royal Perth Hospital, Perth, Australia Leading Australian transfusion haematologist, Professor James Isbister, coined the expression Patient Blood Management. Professor Isbister had as early as 1988 promoted the need for a major change in the care of patients with anaemia or coagulation disorders promoting a greater patient-focussed, rather than product-focussed, approach to their management. Professor Isbister’s views were reinforced by research conducted by Professor George Rubin in New South Wales during the late 1990’s which identified as many as 20–40% of allogeneic red cell transfusions administered in Sydney hospitals may be inappropriate. Following the Stephen’s Report into the Australian Blood Sector in 2001, and the establishment of the National Blood Authority (NBA), Australia has taken a lead in implementing Patient Blood Management (PBM). PBM emphasises good clinical care including careful clinical assessment of patients and the application of a range of treatments aimed at improving patient outcomes whilst reducing the dependence upon allogeneic blood products. These principles have now been included in the evidence-based, NHMRC-endorsed Patient Blood Management Guidelines sponsored by the NBA. In 2008, the Western Australian (WA) Department of Health introduced a structured 5-year Patient Blood Management Program. Although WA started with a demonstrably lower utilisation rate for fresh blood products when compared with other Australian and overseas health regions, published work from a leading tertiary hospital in WA demonstrated that there was still a significant variation in transfusion practice and room to improve. Furthermore, a program established at the Kaleeya Hospital in Western Australia had demonstrated significant reductions in red cell transfusions especially for patients undergoing major joint replacement. The presentation will detail the WA Patient Blood Management Program, outline the evidence for reduced patient complications, describe the changed utilisation of fresh blood products and provide an estimate of the economic benefits of the Program.

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society


Nuffield Department of Clinical Laboratory Sciences, John Radcliffe Hospital, 2Department of Public Health and Primary Care, University of Cambridge, 3Department of Haematology, University of Cambridge, and 4NHS Blood and Transplant

Introduction: One approach to increase and stabilise the blood supply is to collect blood more frequently from existing donors. Currently, NHS Blood and Transplant recommend donation every 12 weeks (men) and 16 weeks (women) but European standards can be as frequent as every 8 weeks. The primary aim of INTERVAL is to determine whether donation intervals can be reduced whilst maintaining the health of the donor. Design and Methods: 50,000 male and female donors were recruited at donation centres in England between June 2012 and May 2014. Donors were randomised to one of three gender-specific donation frequencies for 2 years. The primary outcome is the number of donations per year and the main secondary outcome is quality of life (using Short Form Health Survey SF36v2). Further secondary outcomes are number of deferrals of donors due to low haemoglobin and other factors, iron status, cognitive function, physical activity and donor attitudes to giving blood and participating in research. Data have been collected via online questionnaires and research blood samples collected at the time of routine blood donation. Physical activity will be measured in a subset of 6000 donors using wristworn accelerometers after their 2 year-involvement. Results: The study has achieved considerable successes including: integration of research protocols in routine donation practice; good questionnaire response (~80%) and sample retrieval (~97%) and good adherence by participants to allocated donation frequencies. Conclusions: INTERVAL will generate scientific evidence on which to base future blood collection policies in England, and potentially elsewhere. It will yield, currently lacking, reliable data on the effect of donation frequency on blood supply and donors’ physical and mental well-being. We plan to investigate tailoring donation intervals according susceptiblity to iron deficiency. A full list and contributions of the study group members can be found at

doi: 10.1111/tme.12138

2 XXXII Annual Scientific Meeting of the British Blood Transfusion Society PL03 Trauma Patients: Give Tranexamic acid but Randomise to Blood Transfusion I. Roberts London School of Hygiene & Tropical Medicine, London, UK We now have an effective drug treatment for trauma patients which is affordable and widely practicable. The CRASH-2 trial showed that tranexamic acid safely reduces mortality in bleeding trauma patients. Given within 3 h of injury, tranexamic acid reduces the risk of bleeding to death by a third, and at less than US$10 per treatment is a fraction of the cost of a pint of blood. It is one of the most costeffective ways to save a life that exists and could prevent over 100,000 premature deaths each year. We have the evidence. We must now use it in the service of humanity. Sadly, it can take over a decade for the results of medical research to become standard practice. This is too long.

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Unlike tranexamic acid, there is little reliable evidence on the safety and effectiveness of blood transfusion in trauma patients. It seems reasonable to assume that some trauma patients will benefit from transfusion but we cannot be sure that the benefits of current transfusion strategies exceed the harms. Nevertheless, blood is administered to trauma patients across a wide range of injury severities. This is potentially dangerous. When haematologists and transfusion physicians say that blood is safe, they mean that there are few or no impurities or pathogens in the bag. It does not mean that the benefits of giving a blood transfusion exceed the harms. This important question needs to be answered in high quality randomised controlled trials. Remarkably, very few such trials have been conducted. Until they are, there should be a change in emphasis in trauma care. We should ensure that every bleeding trauma patient arriving in hospital within three hours of their injury receives tranexamic acid but they should be enrolled into a randomised controlled trial of blood transfusion.

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

XXXII Annual Scientific Meeting of the British Blood Transfusion Society



SI01 Analysis of Outcomes to Anticipated Regulation M. Sayers Carter BloodCare, Bedford, Texas and University of Texas Southwestern, Dallas, Texas, USA

Introduction: Updates to blood banking regulation often follow conclusions from donor studies and clinical trials. Research in these categories, which could have profound implications for donor recruitment, includes the effect of donation on nutritional iron balance and identification of circumstances that would justify transfusion of ‘fresh’ blood. Against this background, we decided to analyze the effects that two possible regulatory changes would have on current practice: lengthening the interdonation interval (IDI) and decreasing the shelf life of red blood cells (RBCs). Method: We reviewed experience at our blood program in North Central Texas. The population in the service area is 8.5 million. Annual donations are 350,000. To predict the effect of longer IDIs, we analyzed the contributions to our annual inventory of RBCs by donors according to their ABO and Rh types and by their frequency of donation. To predict the effect of changes in shelf life, we reviewed the age of RBCs, again by ABO and Rh types, at distribution to the area’s 200 hospitals. Results: With regard to the IDI, doubling of the current interval, from 56 to 112 days would have significantly different effects on the more persistently recruited donor groups. For example, while the loss to the annual group A Rh positive inventory would be 5.5%, the loss to the group O Rh negative inventory would be twice that. With regard to shorter shelf life, an analysis of the annual distribution of 250,000 RBCs, of all ABO and Rh types, showed that 5% were older than 28 days. When group O Rh negative units were reviewed separately, however, more than 20% were older than 28 days. Conclusions: The impact of regulations, especially those with bearing on recruitment, such as changes to the IDI or the shelf life of RBCs, can be underestimated, unless donors’ blood types are analyzed separately.

SI02 A Year in Social Media G. Morrison & J Wilson SNBTS, UK In line with other UK services, the Scottish National Blood Transfusion Service (SNBTS) have an active Social Media presence SNBTS use social media to assist with Awareness, Recruitment and Retention. It is also increasingly used to manage Public Relations

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

issues and to support blood stock inventory challenges. Both PR issues and blood stock inventory challenges may be specific to Scotland, so this presentation will outline methodology used by social media teams within the UK to manage specific messaging within each territory in the global digital landscape. This presentation will cover the following areas: 1. Clutha Helicopter Crash. 2. Neknomination. 3. Blood stocks shortage September 2013. 4. Patients Ambassadors and Donor Selfies. 5. Conclusions: Lessons learned and effective integration.

SI03 What Do We Know about UK Blood Donors? Going in Search of the Bigger Picture K. Davison, C Reynolds, M Vasconcelos & S Brailsford NHSBT T/Public Health England Epidemiology Unit, London, UK Since 1995, national surveillance has captured data about blood donors routinely tested, and found positive for markers of HBV, HCV, HIV, HTLV and syphilis. The annual number of prevalent infections detected has fallen since surveillance began, however, still of concern is the small number of newly acquired infections detected in repeat donors. These may result from ‘high-risk’ behaviours in donors which were not disclosed at session. Any very recently acquired infection will be at increased risk of not being detected on testing due to the infection being in the window period. Donor Selection Guidelines (DSG) are fundamental to blood safety, and along with testing and processing ensure a safe supply. However, it is important that donors fully understand the importance of the questions asked during the donor health check and that they feel they can disclose any relevant information including ‘high-risk’ behaviours i.e. comply with the DSG. In 2011, SaBTO recommended that the UK lifetime MSM deferral should be changed to a deferral of 12 months since last sexual contact. The advice that led to the change acknowledged that compliance was important for all donors and an assessment should be made as to the extent of this. In November 2013, Public Health England launched the UK Blood Donor Survey. Over 12 months using an anonymous online questionnaire all eligible new donors and a sample of repeat donors are being asked about their responses to the Donor Health Check to find out if they understood the questions and correctly applied it to themselves at their last donation; donors who appear non-compliant are asked about their reasons for not disclosing information. By the end of the 6th month of the survey almost half (48.5%) of the target 50,000 donors had responded; some reporting additional information they had not declared at session.

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4 XXXII Annual Scientific Meeting of the British Blood Transfusion Society


SI04 Next Generation Sequencing (NGS) For Immunogenetics C. Gabriel Red Cross Transfusion Service for Upper Austria, Linz, Austria

Introduction: The combination of semiconductor technologies, bioinformatics, high resolution optical systems and a broad range of new DNA-techniques like emulsion PCR, barcoding of amplicons and long range sequencing are technical assets of next generation sequencing systems perfectly fitting in to immunogenetics with its highly polymorphic and polygenic regions. Solving the problem of ambiguous genotyping in Sanger sequencing remained a big challenge. In many laboratories the crucial argument to use NGS is to replace Sanger sequencing by much cheaper mass-screening methods. The selection of NGS systems is usually more or less driven by economic variables, as sequencing itself is expensive. This can be achieved by the attractive technology to use the long sequence reads covering one or two exons for clonal sequencing. Another possibility is c-DNA typing of transcripts of the HLA-genes. Methods: Clonal sequencing is possible for a selection of 17 exons enabling a very high resolution typing result (exons 2,3,4 of HLA-A; HLA-B: exons 1,2,3,4; HLA-C: exons 1,2,3,4,6,7; HLA-DP: exon 2; HLA-DQ: exons 2,3; HLA-DR: exons 2,3). Ambiguities are nearly non-existent with a maximum of 0.9% of all sequence runs in a 454 system. Clonal sequencing offers the possibility to sequence heterozygous regions and intronic regions, which also enables the determination of null-alleles. Although long range sequencing is not very common, the second method is c-DNA sequencing in which the total transcript of a HLA gene is sequenced. This is often done by a shotgun approach, which might be problematic in cases where alleles are closely related. New sequencing methods offer a thorough long range sequencing approach and the ability to discriminate between the two alleles. Anyhow, even with the most sophisticated and adapted method for immunogenetics, trimming the ends by bioinformatic tools is important to improve the quantity of reads useful for assignment. Nearly 50% of errors remain outside of a homopolymer region and nearly 12% are attributable to PCR artifacts. Published error data are conflicting, substitutions and insertions are the most common errors in second place. In average about 65–70% of reads are free of errors. The majority of the erroneous reads may occur at same positions even after resequencing. One may speculate, that certain nucleotide combinations or tertiary structures are error prone. About 10% of the reads cannot be aligned to known HLA reference sequences and approximately additional 10% are lost to trimming of primers and short read lengths, which exclude total exon information. Conclusion: NGS technology is complex and may demand in some systems expensive reagents. This is a disadvantage if a low- or medium- resolution typing for registry typing is considered. The main area of its use is in the field of high resolution testing for stem cell transplantation.

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SI05 NGS to Better Characterise Viral Infections: Hepatitis as an Example F. Rodriguez-Frias Hospital Universitario Vall Hebron, Barcelona, Spain More than 500 million people worldwide are currently affected by viral hepatitis, caused by five different viruses, four of which (B, C, D, E) can be transmitted parenterally, the main ones being B and C (HBV, HCV). Viral infections are caused by heterogeneous populations of viral particles known as quasispecies. This heterogeneity has clinical consequences, including the response to antiviral treatments. The most significant case is HCV, in which the various genotypes (G1–G7) show differing sustained virological response rates (SVR) to the standard antiviral therapy, pegylated-interferon+ribavirin (PEGIFN/ribavirin). Last-generation therapies with oral antivirals (DAA), which are added to PEG-IFN/ribavirin, even show differing SVR rates according to the viral subgenotype (eg, higher SVR in subgenotype G1b than G1a). These new treatments have significantly improved SVRs and raise the possibility of eradicating HCV infection. However, certain mutations in the therapeutic target regions (HCV proteins NS3, NS5A, or NS5B) are associated with treatment failure. The same may be true in other viral infections. One could argue that the best weapon to attack these infections would be detailed knowledge of viral variability (viral genotype and resistant variants). Classical methods (direct sequencing, molecular cloning, reverse hybridization, real-time PCR), have major limitations for this purpose. Given this reality, massive sequencing techniques, generically known as next-generation sequencing (NGS), particularly ultradeep pyrosequencing (UDPS), may be a suitable alternatives to resolve this problem, allowing correct phylogenetic classification of the components of the viral population and sensitive detection or quantitative measurement of viral variants potentially resistant to treatment. To illustrate the utility of this technology, this talk will discuss UDPS techniques that are being developed and applied to the study of HCV infection, and some applications for HBV, HDV, and HEV.

SI06 MALDI-TOF in Transfusion and Transplantation Medicine J. Allen National Bacteriology Laboratory, NHSBT Colindale, London, UK

Introduction: Matrix-assisted laser desorption/ionisation time-offlight mass spectrometry (MALDI-TOF-MS) is a soft ionisation technique that produces species-specific spectra in the mass range covering the microbial ribosomal proteins. Although studies have demonstrated the efficiency of the technique in the clinical setting, species isolated by the National Bacteriology Laboratory (NBL)

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

XXXII Annual Scientific Meeting of the British Blood Transfusion Society have a trend towards environmental and natural human flora and so performance may not be comparable. The aim of this study was to independently assess and compare two major commercial systems, Biomerieux Vitek MS and Bruker Biotyper, using isolates from the NBL, to determine their suitability for use within the laboratory. Methods: 164 bacterial isolates of blood and tissue origin were chosen (NBL cryobank, 80 °C) and grown on Columbia blood agar at 35  2 °C until suitable growth was obtained (≤72 h). These were analysed as per the manufacturing procedures supplied by each company, with quality control and calibration carried out as necessary, and compared with the original phenotypic identification result (ID) reported by NBL. Any isolates that failed to give a consistent ID were re-analysed and confirmed by 16S rRNA sequencing.

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society


Results: Of the 164 isolates tested, overall consistency to species level was 152/164 (92.7%) and 155/164 (94.5%) for the Vitek MS and Biotyper systems, respectively. Problems were encountered differentiating members of the Streptococcus mitis group (17/164 of the panel), as well as coagulase-negative Staphylococci (23/164), possibly due to greater homology within these groups. Each system failed to identify 2/164 isolates, possibly due to limitations in the databases. 16S sequencing was able to confirm the MALDI results for 78.7 and 79.5% of repeated analyses, highlighting additional limitations in the current NBL systems. Conclusion: Overall performance of both systems was comparable and clearly showed the benefits of MALDI analysis, each providing an inexpensive, rapid and more accurate analysis compared with the current phenotypic systems used.

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James Blundell Award Lecture–The Discovery and Significance of Selected Blood Groups

Race & Sanger Award Lecture–Cation Permeability of the Red Cell Membrane in Health and Disease

M. Reid

J. Flatt

New York Blood Center New York USA

Bristol Institute for Transfusion Sciences, NHSBT Filton, Bristol, U.K.

In 1825, after a long series of experiments with animal and unsuccessful human to human blood transfusions, James Blundell eventually successfully transfused a woman with severe postpartum bleeding. Blundell connected a donor’s artery directly to the patient’s vein, using a cannula of his own design. He pioneered the transfer of blood from donor to patient using a syringe, thereby showing that blood could be held briefly outside the body. He devised a ‘gravitator’, making the mechanics of direct transfusion more practical. While such technology and techniques were important in the advancement of direct transfusions they did not ensure a predictable safe outcome. At that time, it was thought that blood from healthy people was all the same; however, in 1900, using hemagglutination, Landsteiner demonstrated this was erroneous. It took over two decades before the importance of ABO blood groups in transfusion was realized and pre-transfusion testing became commonplace. Hemagglutination has been used to discover the several hundred blood group antigens now known and named and, with a variety of modifications, remains the gold standard method to detect incompatibility between donor and patient and to predict the potential clinical significance of antibodies to the various blood group antigens. Many components in the red cell membrane that carry blood group antigens were identified by sodium dodecyl sulphate (SDS)-polyacrylamide gel electrophoresis (PAGE) and immunoblotting. Various methods have been used to clone and sequence the genes that encode membrane proteins and transferases that attach carbohydrates to oligosaccharides. While hemagglutination was commonly used to predict the genotype of a person, the reverse is now true and DNA testing is used to predict the phenotype of a person. Selected blood groups will be discussed to illustrate how these techniques have led to the discovery and understanding of their antigens and antibodies.

The red blood cell membrane is composed of tightly-packed lipids and proteins, effectively forming a barrier between the internal cytoplasm and the external plasma. This barrier slows down the movement of positively-charged ions (cations) across the membrane, and certain proteins actively pump ions into and out of the cell, which is important for volume control and maintaining the cell’s classic biconcave discoid shape. The deregulation of ion distributions across the membrane can be caused by environmental factors, or can be genetically inherited. In a group of conditions known as Hereditary Stomatocytosis the permeability of the red cell membrane is pathologically increased. These conditions show a wide range in the severity of their cation leak, and may be accompanied by symptoms in other tissues. Over the last 10 years, the molecular bases of these conditions have been discovered. It has emerged that mutations in large multi-spanning membrane proteins such as Band 3, RhAG and the red cell glucose transporter result in altered protein structure that provokes leakage of cations across the membrane. Individuals with these conditions exhibit varying degrees of haemolytic anaemia and reticulocytosis. In the mildest and most common forms of Hereditary Stomatocytosis there are no symptoms at all, because the leak is close to normal at body temperature. This has implications for blood services, as these individuals may become blood donors. The cation permeability of the red cell membrane is significantly increased at refrigerated temperatures in certain types of mild Hereditary Stomatocytosis, resulting in greatly accelerated leakage of potassium from the cells into the blood bag media during routine storage. The consequence of a high potassium transfusion can be serious, including cardiac arrest, and is most relevant in large volume neonatal transfusions. Work is underway to further characterise the implications of this discovery for red cell transfusion practice.

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© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

XXXII Annual Scientific Meeting of the British Blood Transfusion Society





A Patient Blood Management (PBM) Service at Royal Cornwall Hospitals Trust (RCHT) Reduces Transfusion Rates for Combined Revision Total Hip Replacement Surgery

Predicting Blood Loss in Caesarean Section: Anticipating the Need for Intraoperative Cell Salvage

A. Ratcliffe, C. Ralph & J. Fauld,s

Introduction: Our institution routinely utilises intraoperative cell salvage (ICS) in cases of caesarean section (CS) associated with placental implantation syndromes. There may be, however, a further subset of patients who would benefit from ICS through the avoidance of allogeneic blood products and improved symptomatology as a consequence of improved postoperative haemoglobin. We performed a retrospective review of patients who had undergone a CS seeking to identify predictors of significant blood loss (SBL): >500 mL, in order to better highlight patients who might benefit from ICS. Methods: All patients undergoing CS between August 2012 and July 2013 were identified. Data was collated from hospital electronic systems and theatre logs relating to: patient demographics and clinical coding; estimated blood loss (EBL); pre & post-operative haemoglobin. Predictors of SBL (> 500mL) were identified using multiple logistic regression analysis (IBM SPSS). Results: 1126 patients were identified, of which 1080 had a recorded EBL. Of these, 462 (42.8%) had EBL>500 mL. Multiple logistic regression analyses identified various independent predictors of SBL [odds ratio (95% CI), P value]: Twins [3.58 (1.55, 8.26), P = 0.003]; Prolonged 2nd stage [2.47 (1.18, 5.19), P = 0.017]; Pre-op Hb 30 = 2; Preoperative Hb500 mL. This model had 54% sensitivity, 62% specificity and a positive predictive value of 52% when patients scored 4 or more. Discussion: This is a positive first step in identifying patients within our community that may be at risk of significant blood loss during CS. Further work will be focussed on refining the model and undertaking cost effectiveness studies to ascertain the impact of providing cell salvage for this expanded patient group. The dataset has been analysed and presented in two separate abstracts, this oral and Poster 91 under Patient Blood Management & Transfusion alternatives

Royal Cornwall Hospital, Truro, Cornwall, UK

Introduction: Revision total hip replacement (THR) surgery is associated with significant blood loss and allogeneic transfusion rates of 50–77%1. At RCHT our PBM service provides preoperative optimisation (intravenous iron +/ erythropoietin), and routine use of perioperative cell salvage (PCS). A retrospective audit of all patients who had a combined revision THR in 1 year (April 2013–14) was conducted to identify our local rate of transfusion, preoptimisation, and length of stay (LOS). Results: 84 patients were included for analysis. Mean age 66 years, 30% ASA 3. The mean operating time was 170 minutes and mean estimated blood loss 666mls. PCS was used in 95% of cases; of whom >46% were re-infused, average volume 264 mL autologous blood. Mean next-day Hb was 107 g L 1. 7 cases were pre-optimised to correct anaemia with a mean Hb gain of 13 g L 1.(range 12– 19 g L 1). 8% received allogeneic blood transfusion (ABT), total of 11 units (£1,375) mean 1.6 units (range 1–2 units). Of the 7 patients that had ABT 57% were ASA 3, mean age 79, mean pre-op Hb 114 g L 1. Operating times were not prolonged. 70% (5 patients) had PCS average volume 260 mL and 14% (one patient) received pre-op optimisation. Post-operative stay for patients that had ABT was 13 days in comparison with 7 days without ABT. Conclusion: We report a vastly reduced rate of transfusion of 8% following revision THR surgery, which we attribute to our PBM service. We believe ABT to be an independent risk factor for increased LOS (13 vs. 7 days) which is supported by our previous work2; reducing blood consumption through effective PBM reduces morbidity and saves money by reducing cost of blood = £8075 pa (50% transfusion rate of 1.8 units = £9450 vs. £1375). References 1. Walsh TS et al. (2012) Multicentre cohort study of red blood cell use for revision hip arthroplasty and factors associated with greater risk of allogeneic blood transfusion BJA 108(1):63-71. 2. E Nworah, CJ Ralph, L Jakt, (2012) Using PCS for revision hip surgery reduces risk of allogeneic blood transfusion. Transfusion Medicine 22(Supl 1): PO31

I. Okonkwo, C. Wai, S. Haynes & S. Smith University Hospital of South Manchester, UK

SI09 Significant Improvement in the Management of Major Obstetric Haemorrhage with a ROTEM Guided Algorithm Using Fibrinogen Concentrate S. Mallaiah, P. Barclay, C. Chevannes, A. Bhalla & I. Harrod Royal Liverpool Women’s NHS Foundation Trust

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

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8 XXXII Annual Scientific Meeting of the British Blood Transfusion Society Background: Massive Obstetric Haemorrhage (MOH) is often associated with coagulopathy of dramatic onset. Fibrinogen depletion in early post-partum haemorrhage (PPH) remains the single variable independently associated with progression to a severe PPH. Rotational Thrombelastometry (ROTEM) is a reliable near patient test for coagulation defects that allows rapid identification. Fibrinogen Concentrate is a pasteurized, freeze-dried product quickly accessible for treatment without the need for thawing or cross-match. Using this combination allows prompt correction of fibrinogen deficiency and may result in safer and more cost-effective management of major PPH. Patients and Methods: This is an audit of two algorithms for fibrinogen replacement in MOH that have been used at Liverpool Women’s Hospital. The first, a formulaic replacement using shock packs in all women who bled >1500 mL and had a FibTEM A5 6 units of RBCs Total RBC units transfused (units)

familiarisation with both the machinery, the disposable items required and the process. It is recognised that video technologies such as YouTube can facilitate deep learning (Clifton & Mann, 2011). I set about producing a video teaching package to that could be used by practitioners to improve their learning. Methodology: I contacted the Audio-visual department in NHS Tayside and confirmed a timetable for the filming, editing and production of the video. I wrote the script and checked that it would cover all the aspects of the process and content I had set myself. We filmed the pictures over a 6 h period, and then edited it with a commentary to create the instructional video. This was then piloted to both experienced and inexperienced practitioners and their comments were used to further modify the production to include their suggestions. Results: The pilot group enthusiastically viewed the video presentation and they universally expressed it a major advantage to their learning of the skills required. (See table below) They liked the format, were impressed by the clarity of the video and the quality of the commentary. However, they expressed reservations regarding the access to the video material. In taking the advice of my pilot group, I have set about putting the videos onto a dedicated downloadable App, which can be accessed through any smart phone or tablet. Conclusion: In order for practitioners of a skill to become competent, teaching and practice is best served in the environment in which they work at a time that suits them. This video production has been developed to support these aims. 1. Levett-Jones.T., Fahy, K., Parsons, K., Mitchell, A., (2006). Enhancing nursing students’ clinical placement experiences: a quality improvement project, Contemporary Nurse. 23 (1), 58–71. 2. Clifton, A., Mann, C., (2011). Can You Tube enhance student nurse learning, Nurse Education Today. 31, 311–313.

Shock pack (n = 42)

Fibrinogen concentrate (n = 51)

6 4

3 0

NS P = 0.037




161 70 2 193

50 0 65 90

P < 0.0001 P < 0.0001


P = 0.0003

Targeting the ‘Agents of Change’ to Influence Optimum Patient Blood Management G. Bass West Suffolk Hospital, UK



P = 0.044





Patient Blood Management advocates correcting the underlying cause of anaemia before transfusion is considered. To influence change in clinical practice it is important to identify a ‘need’ for the change. To evidence this, the Hospital Transfusion Team utilized hospital episode statistics (HES) to identify patients admitted with a primary diagnosis of iron deficiency anaemia and the associated number of in-patient bed days utilized. HES data was obtained from the clinical coding department to identify all such elective and non-elective admissions within a 12 month period. The records of those patients admitted for a short stay (0– 2 days) were further analysed using patient administration and laboratory information systems. Analysis of the data identified 77 admissions of which 37 were short stay. 25/37 admissions resulted in transfusion and 7/37 resulted in repeat admission with the same problem. Of the 25 patients that received transfusion: 1. 3/25 also received IV iron. 2. 18/25 also received oral iron. 3. 4/25 received no supplementary iron therapy.

Aim: Whilst there is a well-formulated on-line knowledge package to cover much of the theory of the techniques of Intraoperative Cell Salvage, the practical skills involved in assembling and using the equipment requires instruction on a series of mechanical steps and

By categorizing the admissions according to the Presenting Symptoms 2 main groups of patients were identified: 1. Women with menorrhagia 2. Medical patients with acute on long standing symptoms

Conclusions: Defibrination during PPH is common. A ROTEM guided Fibrinogen Concentrate algorithm, systematically applied can reduce the total number of blood products used, number of massive transfusions, ITU admissions and possibly hysterectomies. Limitations of this study are that it is an audit of events over two separate time periods and the small numbers.

SI10 The Development of an Online Instructional Video to Aid Skills Teaching of Intra Operative Cell Salvage Set-Up S. Baxter1 & C. Pirie2 NHS Tayside, UK, and 2University of Dundee, Scotland, UK

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© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

XXXII Annual Scientific Meeting of the British Blood Transfusion Society Supplementary clinical audit data of pre-operative anaemia identified a third group of patients who were iron deficient but often received transfusions rather than timely iron therapy: 1. Pre- operative patients awaiting surgery The data informed focused discussions with the gynaecology, preoperative assessment and medical teams to agree a generic patient pathway to identify and treat iron deficient patients in a timely manner. The paper will discuss the deficits of the patient management; potential bed days, and associated costs, which could be saved; the implementation of the patient pathway for identification and management of iron deficiency anaemia; and the potential for further improving primary care.

SI12 A National Survey of Red Cell Use in England and North Wales: Use of the Data to Promote Patient Blood Management Initiatives H. Tinegate,1 P. Babra,2 J. Grant-Casey,2 C. Hopkinson,2 J. Hyare,3 M. Murphy,2 K. Pendry,2 M. Rowley,2 F. Seeney,2 J. Wallis4 & D. Watson2 NHSBT Newcastle Upon Tyne, 2NHSBT, 3University Hospitals, Leicester, and 4Newcastle Teaching Hospitals, UK 1

Introduction: NHS Blood and Transplant (NHSBT), with support from the National Comparative Audit of Blood Transfusion (NCABT), has carried out a national survey of red cell use in England and North Wales in 2014. The primary aim was to provide a baseline prior to implementation of a Patient Blood Management

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society


(PBM) programme. In addition, this study provides data which indicate where to target educational initiatives in PBM Study Design: All NHS and private hospitals that use blood supplied by NHSBT were invited to collect data on the clinical indication for transfusion, gender and age of recipients for every unit issued and transfused, for two separate weeks in February and May 2014. Clinical indications were based on those used in studies of blood use in the North of England. Data were either recorded via the NCABT portal, or via spreadsheets or paper records sent to the NCABT. Results: For cycle 1, data were collected on over 21,390 red cell units, estimated to be 73% of all red cell issues for that week. The mean age of recipients was 63 years and the male: female ratio was 1.06 : 1. Red cell transfusion rates have fallen across all specialties, with a transfusion rate of 31.5/1000 inhabitants. Sixty-six percent of red cells were transfused for medical indications, the commonest category being haematology (26% of all usage). Twenty-eight percent were transfused to surgical patients, the highest-using specialty being cardiothoracic surgery (6% of all usage). Six percent of red cells were transfused for obstetric/gynaecological indications, the commonest category being obstetric haemorrhage. Neonates received 284 units, 1.3% of the total. Conclusions: Surgical use has reduced most rapidly, reflecting advances in surgical and anaesthetic techniques, as well as initiatives towards appropriate transfusion. However, a recent PBM survey has shown there is still scope for optimising use. The majority of red cell use is now for patients in medical specialties. National Comparative Audits have shown inappropriate use in medical patients, although transfusion triggers are less easily defined than in surgical patients. It is in this group of patients that PBM initiatives should be directed. Use within haematology may be considered more appropriate, but further study of the demographics of this patient group is necessary, to assist in future planning of PBM initiatives.

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XXXII Annual Scientific Meeting of the British Blood Transfusion Society


SI13 Change Stories: Staff Experiences of Change K. Shreeve Welsh Blood Service, UK Change is a powerful thing that can be simultaneously unsettling, frightening, exciting and empowering. This presentation uses staff stories to illustrate the effects of change within an organisation. Staff might see themselves as victims of a change that is being forced upon them, but if the change is handled well they can become willing change agents.

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© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

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SI14 Gaining UKAS ISO15189 Accreditation- A Hospital Blood Transfusion Laboratory Perspective D. Smith & K. Dowling University Hospital Southampton NHS Foundation Trust, Southampton, UK In 2009, CPA became a wholly owned subsidiary of UKAS and is currently managing the transition of all CPA accredited laboratories to ISO 15189 accreditation. Significant differences exist between CPA and ISO 15189 standards and laboratories are expected to need to change practices to ensure compliance. The Blood Transfusion and Haematology laboratories at Southampton General Hospital were inspected against these new standards in January 2014. The inspection was prepared for by establishing working groups and performing gap analysis. A number of new procedures were implemented such as determining the acceptability of referral laboratories and the requirement for all staff to have an UKAS compliant training record. The laboratory was inspected against both CPA and ISO 15189

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

standards. 27 non-compliances were identified; a mixture of failings against CPA, ISO and both sets of standards. Prior to the inspection it was felt that the Blood Transfusion laboratory already had many of the procedures in place to meet the UKAS standards after a number of years meeting MHRA and BSQR requirements. This was proved correct with only one failing found specifically in Blood Transfusion. The Blood Transfusion laboratory, like many around the country, already had in place procedures surrounding competency assessment, validation, calibration, reagent batch acceptance and analyser return to service; all requirements of ISO 15189. The failings with the most significant impact included a lack of meteorological traceability of calibration equipment, no procedure for trending QC and the absence of a procedure for dealing with uncertainty of measurement. The laboratory was able to clear all of the findings, by providing evidence of the implementation of new procedures and policies. CPA accreditation has been awarded and it is expected that ISO 15189 accreditation will be granted to make the laboratory the first or one of the first transfusion laboratories to achieve this status.

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AW 03 Kenneth Goldsmith Award Lecture - Playing with Fire J. Wallis Freeman Hospital, Newcastle upon Tyne, UK Oxygen has been instrumental in the geological and biological development of the earth over more than 4 billion years. A source of energy but also highly toxic, our physiology is almost literally playing with fire in utilizing oxygen as a component of life. Red cells carry oxygen from the lungs to the tissues but have a second important role in preventing excessive oxygen toxicity. Microcirculatory vascular control is sensitive to red cell oxygenation levels. Both release of nitric oxide and of red cell ATP have been suggested as mechanisms for this local control of oxygen supply. Most tissues have blood supply and potential oxygen delivery well above their likely oxygen requirements. Microcirculatory control mediated in part by red cells is key to maintaining a safe level of tissue oxygenation. The coronary circulation has the highest demand of any tissue

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for oxygen removing 60% or more of that bound to the delivered arterial Haemoglobin. Coronary blood supply increases in direct proportion to the cardiac work and output, partly in response to signals from red cell de-oxygenation. Professional cyclists have shown how important Haemoglobin oxygen delivery is to maximize energy output. At rest we tolerate low Haemoglobin well, but anaemia limits cardiac output under stress. We have investigated the effects of anaemia and transfusion on the anaerobic threshold and found a clear relationship with Hb level. (Wright et al., Br J Anaesth. In press) This relationship mimics the effects seen in studies of erythropoietin on exercise capacity. A better understanding of the effect of anaemia and transfusion on exercise physiology will help guide transfusion triggers in different circumstances. Summary: Oxygen delivery depends on red cell physiology as well as haemoglobin levels and the effect of storage changes in transfused blood may affect these more subtle functions. Triggers for transfusion should take into account likely demands on individual physiology and the effect on quality of life.

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SI15 An Overview of MAHSE, and Its Work with BBTS P. Padfield Manchester Academy for Healthcare Scientist Education, Manchester, UK The Manchester Academy for Healthcare Scientist Education (MAHSE) is a unique community of education consisting of university based educators and researchers and leading healthcare professionals. The Academy supports Modernising Scientific Careers (MSC) by promoting the development and facilitating the delivery of the educational programmes (undergraduate and postgraduate) that form the academic components of the MSC practitioner and scientist training programmes (PTP and STP). Since its foundation in January 2012, MAHSE has nearly tripled in size. It currently oversees the delivery of three undergraduate (PTP) programmes (life sciences; neurosensory sciences and physiological sciences) and seven masters (STP) programmes (blood sciences; cardiac, critical care, vascular, respiratory and sleep sciences; cellular sciences; clinical bioinformatics; clinical pharmaceutical sciences; neurosensory sciences and reconstructive sciences). These programmes are delivered via a multi-institutional and multi-professional network comprising academics from five universities (University of Manchester, Manchester Metropolitan University, University of Salford, University of Liverpool and King’s College London) and healthcare scientists from over 35 NHS trusts spread across England and Wales. MAHSE is therefore one of the largest educational networks in the UK, and is the largest single educator of healthcare scientists in Europe. MAHSE’s underpinning philosophy is to combine the scientific knowledge and educational experience of university academics with the clinical and professional expertise of the wider healthcare science community to deliver the highest quality education and training for the NHS healthcare science workforce. MAHSE has established a working relationship with the BBTS with the aim of supporting the Society develop its education and training provision. This will include formal validation of the Society’s specialist certificates by MAHSE’s partner Universities.

economic recession; an ageing population requiring more access to healthcare; new treatments requiring new products and tests; significant advances in technology with more automation and fewer, less skilled staff; consolidation of service delivery and the Modernising Scientific Careers (MSC) initiative). Responses to the challenges faced include the introduction of microarray and related technologies and the use of these technological developments to drive consolidation and deliver a multi-skilled (but less specialised) workforce (eg the hub, spoke and satellite approach). This aligns very neatly with the principles of Modernising Scientific Careers (MSC) which promotes a new approach to delivering pathology services via a number of themed groups. Blood Transfusion sits in the Blood Sciences group along with Haematology; H&I; Clinical Biochemistry and Clinical Immunology. New training programmes are being developed to support MSC which is designed to improve and standardise career structures for scientists working in the NHS. A major strand of the BBTS Mission is to play a leading role in the delivery of safe and effective transfusion practice by providing high quality education and training programmes. Consequently, given the prevailing circumstances, BBTS has reviewed its provision of training and concluded that priority should be given to the significant upgrading of its Specialist Certificate in Transfusion Practice, such that it will align with the principles of MSC; achieve University accreditation to masters level (with CAT points available); ensure there is a greater level of BBTS expert input and support for the student’s learning process thereby contributing to the delivery of better informed practitioners of transfusion which will in turn improve outcomes for patients. BBTS Council has committed significant funding in support of this key development and our Chief Examiner, ably supported by our Office Team, has made a huge amount of progress to date. Enrolment for the examination under the old system has now closed and enrolment for phase 1 of the accredited Certificate closes in November 2014 with the examination 1 year later. Exciting times indeed!

SI17 I Want to be a Clinical Scientist M. Scott1

SI16 Aligning Training Delivery with Changing Service Needs -Upgrading the BBTS Specialist Certificate in Transfusion Practice M. Bruce OBE, Edinburgh, UK Pathology services in the UK are once again on the brink of radical change. A perfect storm of powerful drivers is creating an environment which I believe is gathering a momentum that will make that change a reality (the drivers are virtually irresistible and include the

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society


NHSBT Filton, Bristol, UK

The Health and Care Professions Council Recognises Three pathways to Clinical Scientist Registration: 1. The ACS (Association of Clinical Scientists) Certificate of Attainment, a. Route 1–for applicants who have completed a pre-Modernising Scientific Careers approved training programme, b. Route 2–for applicants with 6 years relevant experience, three of which must have been in a supervised clinical scientist role.

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2. The AHCS (Academy of Healthcare Science) Certificate of Attainment for applicants who have completed a course from the Scientist Training Programme of Modernising Scientific Careers (STP). 3. The AHCS Certificate of Equivalence, for applicants who can demonstrate that they have the skills and knowledge equivalent to those who have completed an STP course. The ACS and AHCS have come together to set up an Integrated Assessment Unit. This provides a single entrance portal for individuals seeking to be registered as Clinical Scientists. Applicants who have not completed approved courses of training may opt to apply via ACS Route 2 or the AHCS Certificate of Equivalence. The ACS Route 2 requires applicants to have 6 years relevant post-graduate experience, three of which must have been obtained in a supervised clinical science role, supervised by a Senior Clinical Scientist (Band 8 or above) or a consultant medical practitioner. The AHCS Certificate of Equivalence has no formal requirement for length of experience, but does require the applicants to demonstrate achievement of the outcomes listed in the AHCS Good Scientific Practice document, interpreted in the context of a current STP curriculum. Applicants who lack the breadth of experience inherent in the MSC curricula may therefore favour ACS Route 2, whereas applicants who have the necessary skills and experience in clinical science, but cannot meet the precise requirements for ACS Route 2 may favour AHCS Equivalence.

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SI18 Modernised Scientific Careers: Who’s Paying for All This! D. Smith John Radcliffe Hospital, Oxford, UK The Healthcare Science workforce in England (and the neighbouring countries) is a significant and diverse workforce with multiple specialities and sub-specialities. However it can be grouped into 3 broad Divisions of Life Science, Physiological Science and Physical Sciences and Engineering. The Life Science workforce is by far the biggest with; in head count terms approximately 32,000 staff, to 9000 in Physiological Science and 6000 in Physical Sciences. Within the Life Science workforce Haematology and Transfusion is a significant part of the workforce with more qualified staff than any other single category and approximately a third of the total workforce. In 2011 a new Training programme was introduced led by the School of Healthcare Science. The Scientist Training Programme (STP) was a 3 year Masters level blended academic and vocational programme. It saw 5 places recruited in 2011 in Haematology and Transfusion Science and will see 3 recruited in 2014. In 2014 a new Higher Specialist Scientific Training programme will be introduced led by the School of Healthcare Science. There are zero direct entry places in Haematology and Transfusion in the first year. With the changes in Training programmes introduced by Modernising Scientific Careers in 2009 and the abolition of Strategic Health Authority funding routes for training and replacement by NHS England and Local Education and Training Boards, are Haematology and Transfusion staff making best use of what training and development resources are available?

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

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SIMULTANEOUS SESSION NON CLINICAL SHORT PAPER ORALS YS01 Generation of a Novel ENU-Induced Murine Pedigree Lacking Erythroid Lineage Marker TER119/Ly76 K. Kildey,1 R. Flower,2 J. Harris,3 R. Tunningley4 & M. M. Dean2 1

Australian Red Cross Blood Service, 2Australian Red Cross Blood Service, Queensland University of Technology, 3Queensland University of Technology, and 4Australian Phenomics Facility, Australian National University

Introduction: Murine models with a modified phenotype as a result of N-ethyl-N-nitrosourea (ENU) mutagenesis have been widely used to provide insight into red blood cell (RBC) development and biology. Methods: ENU-mutagenesis and a three generation recessive breeding strategy were employed to produce 50 pedigrees and evidence of a changed blood picture, including an automated differential count, were assessed using an automated haematology analyser (ADVIA). Changes in TER119 (lymphocyte antigen 76; ly76), complement receptor 1/2 and binding of peanut agglutinin were assessed by flow cytometry. RBC structural integrity was characterised via osmotic fragility and binding of eosin-5-malemide. Mann-Whitney analysis was used to identify pedigrees of interest (95% CI). Exome sequencing was used to identify homozygous mutations in pedigrees of interest and causative mutations confirmed by PCR. Results: Using a homozygous recessive breeding strategy, a novel pedigree lacking in erythroid lineage marker TER119 was generated. Absence of TER119 was confirmed by both flow cytometry and immunoblot. The TER119neg pedigree demonstrated no significant change in haematological parameters, differential cell count or RBC integrity, although reduced fertility and lifespan were evident. Exome sequencing and genotyping with sequence-specific primers determined that the phenotype resulted from a mutation in a gene annotated as a carbohydrate-modifying enzyme. This TER119neg phenotype was evident only with homozygous carriage of the mutation. This carbohydratemodifying enzyme was also detected in bone marrow erythroblasts (basophilic, polychromatic, orthochromatic) and reticulocytes. Conclusion: TER119 is an extensively utilised marker of RBC differentiation, yet the molecular basis of the TER119 epitope remains unclear. In this study, ENU-directed mutagenesis, recessive breeding and massive parallel sequencing were used to generate a novel murine pedigree lacking TER119 and provided unexpected evidence that widely used erythroid lineage marker TER119 is an epitope that results from modification of a RBC surface carbohydrate.

since been shown to have a vast array of applications in disease modeling and drug screening. Here, we describe the potential use of donor specific hiPSCs for the development of novel red cell diagnostics in transfusion medicine, such as antibody testing panels used for blood matching prior to transfusion. First, however, we need to understand and improve erythropoiesis from hiPSCs sources, to permit cost-effective scale-up and manufacture of these novel reagents. Methodology: We have generated over 10 hiPSCs lines from fibroblasts, umbilical cord and adult blood, using retrovirus and plasmid based approaches. We have used OP9 stroma and directed approaches to induce hematopoietic differentiation, and promote erythropoiesis. Derived erythroid cells arising were characterised by transcriptome array profiling, microRNA expression, surface antigen expression profiling, globin expression analysis and histo-chemical assessment. Results: Irrespective of reprogramming strategy or source of tissue, hiPSCs lines differentiate on OP9 stroma to yield hematopoietic progenitors that have full multi-lineage hematopoietic potential and undergo efficient erythropoiesis. We show at a single cell level that erythroblasts arising express common blood group antigens and can co-express HbF and HbA, which suggests adult erythropoiesis. However, hiPSC derived erythroblasts do not undergo extensive proliferation nor complete enucleation. Transcriptome and microRNA analysis reveals differences from cord and adult counterparts that might help explain aberrant differentiation. Conclusions: We have demonstrated the formation of hematopoietic progenitors from various hiPSCs sources that are able to differentiate efficiently into adult erythroblasts but do not undergo extensive proliferation nor efficient terminal differentiation. This may be overcome by identifying and addressing differences from cord and adult erythroblasts, as revealed by transcriptome and microRNA data, to permit cost effective scale-up and manufacture of novel hiPSC derived diagnostics for transfusion medicine. Funding: National Health Service Blood and Transplant, Medical Research Council, Oxford Stem Cell Institute, National Institute of Health UK (RP-PG-0310-1004).

SI20 The Impact of Maternal, Neonatal and Collections Factors on the TNC Count of an Umbilical Cord Blood Donation A. Jama, Y. Caffrey, A. Meally, S. Jeyabalan, A. Hussain & L. McKenna


NHS Cord Blood Bank, NHS Blood and Transplant, London UK

Use of Human Induced Pluripotent Stem Cells for Novel Diagnostics in Transfusion Medicine

The purpose of this study was to investigate the factors that contribute to obtaining a high quality umbilical cord blood (UCB) donation that is suitable for stem cell transplantation. One of the greatest factors in providing a UCB donation for clinical use is the total nucleated cell (TNC) count. At the NHS Cord Blood Bank (NHS CBB) we routinely bank all donations with a TNC count of >140 9 107 cells per unit, therefore, for the pupose of this study this is our definition of a high quality donation.

D. J. Roberts,1 L. Carpenter,1 A. Tippin,2 A. Merryweather-Clarke,2 A. Lamikanra2 & M. Abdul Razaq2 1

NHSBT, John Radcliffe Hospital, Oxford, UK, and 2Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, UK

Rationale: Human induced pluripotent stem cells (hiPSCs) were first described by Shinya Yamanaka and colleagues in 2007 and have

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This study evaluated whether a number of maternal, neonatal or collection factors of the UCB unit have any influence on the quality of the donation. We analysed 1513 UCB units collected from January to March 2014 from the 6 collection sites of the NHS CBB. The UCB donations were analysed according to: 1. Hospital site 2. Ethnic origin of the donor mother 3. Type of delivery 4. Time elapsed from delivery to collection 5. Midwife 6. NHS CBB collection staff From our analysis it can be concluded that the ethnicity of the donor mother, the individual collection staff and the type of delivery all have a significant impact in consistently producing a high quality UCB donation. These findings may be useful in improving the collection efficiency by potentially targetting high-quality UCB donations. This would then result in an high-quality inventory in the cord bank and improved cord blood transplant rates.

SI21 A Study of the Reversibility of Cation Imbalance and Microvesicle Production in Stored Red Cells W. Bawazir,1 L. Bruce2 & J. Flatt2 1

Bristol Institute for Transfusion Sciences, National Health Service Blood & Transplant, UK, and 2School of Biochemistry, University of Bristol, UK

Introduction: During storage at 4 °C red blood cells (RBCs) develop a storage lesion affecting their integrity and functionality. Some of these defects can be reversed using Rejuvesol as previously reported. This investigation examines the reversibility of the cation imbalance and other parameters in stored red cells using additives to mimic Rejuvesol. Methods: Packed RBCs suspended in SAGM were stored at 4 °C over 35 days. Each week the RBCs were sampled and either not treated (Nt) or rejuvenated (Rj) by adding inosine and pyruvate and incubating for 1–2 h at 37 °C. Haemoglobin affinity for oxygen (p50), mean cell volume (MCV) and morphological variations (RDW) over the storage period were measured. Flame photometry was used to measure the cation concentrations. Microvesicles were isolated and quantified. Confocal microscopy imaging of stored red cells was used to evaluate the morphology of the RBCs and the release of microvesicles. Results: The oxygen affinity of haemoglobin increased during storage (reduced p50), probably due to loss of 2,3-DPG, but was corrected by rejuvenation. MCV and RDW both increased during storage but were not significantly changed by rejuvenation. Potassium concentration in the supernatant was elevated to 40–60 mM with incomplete correction by rejuvenation. The total amount of protein released via microvesicles increased significantly between day 20–35 of storage. Microvesicle release was not reversible. Loss of stomatin from echinocytic spicules was confirmed using confocal microscopy. Conclusion: Metabolic products (ATP, 2,3-DPG) are known to be replenished by rejuvenation. Our data show that rejuvenation of stored RBCs also restores the oxygen affinity of haemoglobin. However, rejuvenation had little effect on cation distribution, and no measurable effect on RBC morphology or membrane remodelling. References 1. Bosman GJ, Werre JM, Willekens FL, Novotny VM. Erythrocyte ageing in vivo and in vitro: structural aspects and implications for

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transfusion. Transfusion Medicine (Oxford, England) 2008;18:335– 47. 2. Meyer EK, Dumont DF, Baker S, Dumont LJ. Rejuvenation capacity of red blood cells in additive solutions over long-term storage. Transfusion 2011;51:1574–9.

SI22 Evaluation and Introduction of Non-Invasive Haemoglobin Testing for Blood Donor Screening Y. Murray,1 A. Kinsella,2 T. Selby,2 E. Darragh,2 B. Doyle,2 E. Johansson,2 G. Egan2 & W. Murphy2 1

Irish Blood Transfusion Service & School of Biological Sciences, Dublin Institute of Technology, and 2IBTS

Introduction: We hypothesised that haemoglobin levels in blood flowing in larger blood vessels at the base of the anterior aspect of the terminal phalanx of the finger would be higher than haemoglobin levels in blood from the lateral finger pulp in the range close to the cut-off points in male and female blood donors, due to the haemoglobin-lowering F ahraeus effect in vessels narrower than 300 µ. Methods: Haemoglobin levels were measured close to the base of the anterior phalanx using the Haemospect non-invasive device; in blood samples from the lateral finger pulp using Hemocue; and from venous blood samples on a CELLDYN Sapphire. 175 donors – 60 failing the Hemocue test and 115 passing the Hemocue within 1 g dL 1 of the lower cut-off level – had all three measures compared. Subsequently, to assess the false pass rate, 744 consecutive donors who passed the Haemospect test also underwent a venous FBC at donation. Results: Mean (SD) haemoglobin levels for the 175 donors tested by all three methods were: Hemocue 13.05 (0.83) g dL 1, Haemospect 13.71 (0.97) g dL 1, CELLDYN 13.99 (1.04) g dL 1; P < 0.0001 for differences between all pairs. Of the 60 donors who failed the Hemocue, 45 passed a venous FBC, and 41 passed the Haemospect test. The false pass rate of Haemospect in routine donor screening was 18/744 (2.4%, 95% C.I. 1.5–3.9%). Conclusions: Measuring haemoglobin levels using finger pulp blood samples by Hemocue lacks precision and accuracy in blood donors and patients; the best published rate for false passes is 3.1%, and false fail rates are high. Non-invasive haemoglobin testing using the Haemospect device directed at the base of the anterior aspect of the distal phalanx was superior to Hemocue testing in specificity and sensitivity to an FBC haemoglobin level of ≥12.5 (female) and ≥13.5 (male) g dL 1 and has been adopted for routine use throughout the IBTS.

SI23 The Interval Study: Preliminary Analysis of Haematological Profiles D. Allen,1 D. J. Roberts2 & on behalf of the INTERVAL study group1,2,3,4 1

Nuffield Department of Clinical Laboratory Sciences, John Radcliffe Hospital, 2Department of Public Health and Primary Care, University of Cambridge, 3Department of Haematology, University of Cambridge, and 4NHS Blood and Transplant

Introduction: INTERVAL is a randomised controlled trial in up to 50,000 blood donors to determine whether donation intervals can be reduced whilst maintaining the health of the donor. Here we present our findings on apparently healthy donors enrolment samples.

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

XXXII Annual Scientific Meeting of the British Blood Transfusion Society 17 Methods: All donors recruited into INTERVAL met NHSBT haemoglobin (Hb) screening criteria (males: >13.5, females: >12.5 g dL 1). Full blood counts (FBCs) were performed on all donors using a Sysmex XN2000 analyser. In the first year of the study only donors with white cell counts >11.0 9 109 L 1 were assessed for possible haematological malignancies and potential referral to their general practitioner (GP). Review of FBC data after one year showed many donors with other abnormal indices and ‘normal ranges’ for Hb, haematocrit (Hct) and platelet count (PLT) were established by a panel of expert haematol-

ogists. All enrolled donors with abnormal indices were invited to donate a further sample for evaluation. Donors with repeatedly abnormal results were assessed by our Clinical Support Team and if necessary referred to their GP. Thresholds used were 3SD from the mean (Hb, Plt) or BCSH guidelines (Hct). Results: 1,664 donors required re-sampling; 1,335 attended. Conclusions: The majority of donors had normal values upon retesting. However 0.5% of enrolled donors had repeatedly abnormal counts and required GP referral for further investigation.

Number (%*) Parameter 1

Hb (g dL ) Hct (L L 1) Plt (109 L 1)




Samples rec’d

Normal result

GP referral

No data

Female Male Female Male Female Male Female Male

0.52 450

39 36 597 737 58 116 66 15

25 30 481 597 49 96 49 8

17 23 415 499 42 75 16 2

8 5 59 91 7 20 32 6

0 2 7 7 0 1 1 0

(32.0) (16.7) (12.3) (15.2) (14.3) (20.8) (65.3) (75.0)

As percentage of samples received.**From ~45,300 donors.


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SI24 Simulation Training in Adult, Obstetric and Paediatric Major Haemorrhage Protocols N. Gallacher,*,1 V. Mistry,*,1 R. Green2 & N. Curry3 1

Oxford University Clinical Academic Graduate School, John Radcliffe Hospital, Oxford, UK, 2Department of Public Health, London School of Tropical Medicine and Hygiene, London, UK, and 3Oxford Haemophilia and Thrombosis Centre, Churchill Hospital, Oxford, UK *Indicates equal contribution from authors Major haemorrhage is a medical emergency associated with significant morbidity and mortality. Early recognition and initiation of effective actions are vital if hypovolaemic shock and its consequences are to be avoided. One strategy is the activation of a major haemorrhage protocol (MHP), which triggers a coordinated chain of events involving clinical and laboratory teams, leading to the rapid release of blood and blood components. Activation of a MHP is only one aspect contributing to good outcomes; success also relies upon efficient communication, effective teamwork and thorough knowledge of the protocol amongst all contributing healthcare professionals. Simulation is a process that attempts to recreate characteristics of real world medical emergencies but in a controlled environment. Previous studies have shown that simulation training leads to improved procedural performance, greater adherence to protocols and increased knowledge. In this study, high-fidelity simulation scenarios were used to train doctors on the existing Oxford University Hospitals NHS Trust’s MHPs as follows; Foundation Year 1 doctors (adult MHP), Foundation Year 2 doctors (obstetric MHP) and multi-disciplinary speciality trainee doctors (paediatric MHP). Knowledge and confidence of the respective protocols were assessed using pre- and post-simulation questionnaires (completed 1 month before and after training) and compared to control groups who were not given simulation training. While knowledge increased in both intervention and control groups, there was a significantly greater increase in knowledge of, and adherence to, existing MHPs among those that attended simulation training. Further, protocol revisions were required as a result of the simulation programmes. In conclusion, high-fidelity simulation training is an effective means of improving knowledge of MHPs in adult, obstetric and paediatric settings and thus has the potential to benefit patient safety in both these and other specialties. Furthermore, simulation offers a novel tool for assessing robustness of protocols prior to their use in clinical practice.

SI25 2013 National Comparative Audit of Anti-D Ig Prophylaxis M. Rowley,1 T. Davies,2 T. Hawkins,3 J. Hibbert4 & J. Grant-Casey5 1 NHSBT, Colindale, 2NHSBT and SHOT, 3Royal Berkshire NHS Foundation Trust, 4UK National Screening Committee, and 5NHSBT Anti-D immunoglobulin prophylaxis (anti-D Ig) is given to RhDnegative pregnant women to prevent the development of haemolytic disease of the fetus and newborn due to immune anti-D. SHOT has

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raised significant concerns about omission, incorrect dosing and/or timing of anti-D Ig which could result in sensitisation. Midwives and transfusion teams in participating hospitals audited the transfusion laboratory and maternity records of pregnant RhDnegative women during one month in 2013 against four audit standards based on UK guidelines on anti-D Ig prophylaxis. 161 sites audited 5972 cases (median, 33 cases per site). RAADP: Of 4887 RhD-negative women eligible for single-dose 1500 IU anti-D Ig at 20–30 weeks, 99% received the injection and 89.9% received the right dose at the right time. Of 389 eligible for two-dose 500 IU at 28 and 34 weeks, 98.7% received anti-D Ig but only 58.6% received the right dose at the right time. Post-Delivery: Of 3392 women delivering RhD-positive babies, 98.5% received post-delivery anti-D Ig and 91.6% received the right dose at the right time. 97% had a post-delivery FMH test. Only 0.5% (19 cases) should have been given anti-D Ig and weren’t. Potentially Sensitising Events: Of 1052 individual PSEs, 95.7% were given anti-D Ig, 79% within 3-days of the event. 3.7% did not get the correct dose for gestational age and only 87% PSEs at 20 weeks or later had an FMH test. Information and Consent: Of 5972 women, there was documentation of patient information (36%) and consent (57%) for RAADP being given. 131 women declined anti-D Ig and 74% had a reason recorded. This audit shows good compliance with anti-D Ig but some women are put at risk of sensitisation. Cases that failed to meet standards should be investigated and SHOT-reported. 80% had reported one or more cases in the anti-D category in 2013.

SI26 #Transfusion @London_RTC – The London RTC and the Use of Twitter J. Heyes, A. Dhesi & C. Denison NHSBT, Tooting, London, UK

Introduction: Social media is the social interaction among people in which they create, share or exchange information and ideas in virtual communities and networks. It is recognised that the use of Twitter to access current information is increasing with 255 million monthly active users and 500 million tweets sent per day across the world. In London, 14 NHS Hospital Trusts have an active Twitter account with collective total of 140k followers comprising clinicians, patients and academics. It was recognised by the London Regional Transfusion Committee (RTC) that social media such as Twitter could facilitate transfusion information to a wide audience across London and allow quick and direct interaction with users. Londons Twitter Activity: The London RTC established a Twitter channel (@London_RTC) in May 2013 to advertise new transfusion resources, guidelines, education events and patient information. This account has attracted over 75 followers and has tweeted over 100 transfusion related messages.

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

XXXII Annual Scientific Meeting of the British Blood Transfusion Society 19 To celebrate World Blood Donor Day 2014, all London Hospital Trusts using Twitter were asked to participate in a Twitter transfusion campaign. 5 Trusts signed up and a series of transfusion tweets were prepared in advance for their use. The tweets included local transfusion statistics, blood donation information, links to patient information leaflets and information about local transfusion events. The Transfusion Practitioners from each of the Trusts involved were approached to get permission to share local transfusion data. #transfusion was used to connect the tweets which were also sent out via the London RTC account. Future Plans: The London RTC plans to hold live Twitter events from education days to provide information to those that cannot attend the event. All educational videos that are currently hosted on the London RTC YouTube channel will also be tweeted to encourage use and improve access to transfusion education across the London region.

correlated to the severity of the adverse event and potential outcome for the patient. Conclusion: The awareness of human factors requires to be incorporated into training packages to ensure that staff are aware of the risks that these bring into procedures in busy ward environments. The reactions and feelings of staff involved in an adverse event can be overwhelming; support provided to the staff is a crucial aspect of the lessons learned in the wake of an error.

References 1. Ahlqvist T, Back A, Halonen M & Heinonen S. (2008) Social Media Roadmaps. Exploring the futures triggered by social media. VTT Tiedotteita – Valtion Teknillinen Tutkimuskeskus (2454) 2. Twitter company statistics. Available at company (accessed 31st May 2014).

Near miss incidents, where errors are caught before harm is done, can be described as “free lessons” (James Reason, 2008). The UK’s national haemovigilance scheme, Serious Hazards of Transfusion (SHOT) has been collecting data since 1999 on errors detected before the transfusion commenced. These near miss incidents have been fully analysed since 2010 when the electronic database began. Method: The number of near miss incidents reported in the fouryear period, 2010–2013, were compared with actual events that resulted in the patient receiving an unsafe transfusion. Results: An incorrect blood component transfused (IBCT) is the most dangerous transfusion error. Overall 4124 near miss events were recorded, of which 3082 (74.73%) prevented IBCT compared to 741 actual incidents (a ratio of 4.16 near miss to 1 IBCT); therefore errors with potential to cause IBCT are detected at a rate of 80.6% (3082/3823). Many of the near miss IBCTs are related to ‘wrong blood in tube’ (WBIT) incidents, detected by the vigilance of staff, particularly in transfusion laboratories when discrepant results are noted. Previously it has been shown that 100 near miss WBITs are detected for every one transfused, but in 2013 there were 643 with no IBCT events. Similar checks detect potential incidents of specific requirements not met before transfusion. A majority of other incidents, such as anti-D immunoglobulin or component storage and labelling errors are not being detected before patient harm. Conclusions: The quality management systems within hospitals, particularly those in the transfusion laboratories, are detecting many IBCT errors and preventing unsafe transfusions. However, there are parts of the transfusion process where quality systems might be improved to detect more errors before they lead to patient harm. Near misses are ‘free lessons’ that cause no danger to patients, so increased reporting of these may highlight where quality improvements could be made.

SI27 An Exploratory Research Study into the Effects of Staff Feelings and Perceptions Following a Transfusion Incident Investigation D. Creighton1 & M. Wright2 1 SNBTS Edinburgh, and 2Glasgow Caledonian University, Glasgow, Scotland, UK

Introduction: Patient safety is a fundamental aspect of statutory requirements and clinical governance. The focus of investigations is usually on procedural errors and not the human factor aspect of the error or the emotions felt by the staff member involved in the error. Aim: The aim was to identify the emotional impact that the error and the subsequent investigation has on the member of staff involved, review contributing factors to the errors. Method: An exploratory qualitative approach was utilised using a critical incident technique approach to semi-structured interviews. A non-random purposive method was used by the Transfusion Practitioners (TPs) to recruit participants where a transfusion error had happened. Ethics approval was obtained. Following recruitment the participants were interviewed using the Luu et al (2012) template. All interviews were recorded and transcribed and thematic analysis was undertaken using the Braun and Clarke (2006) approach. Findings and Discussion: Twelve staff were invited to take part at the recruitment phase, of which five agreed, representing a 42% response rate. Following analysis and coding (Saldana, 2009) nine emergent themes were identified. The main human factors acknowledged from four participants were distraction and a busy work environment at the time of the event. All five expressed feeling of disbelief that they had been involved, which impacted on four of the participants emotionally, experiencing physiological symptoms like insomnia. Their confidence was impacted by the event and most were worried about confidentiality and other staff knowing that they had made an error. Support was in the main positive although two participants experienced negative reactions from colleagues. All had learned lessons which they would carry forward into the future work life and share with colleagues. The participants’ reactions directly

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

SI28 Free Lessons from Near Miss Transfusion Errors A. Watt1 & P. H. B. Bolton-Maggs1,2 1

Serious Hazards of Transfusion Office, Manchester, UK, and University of Manchester, UK, on behalf of the SHOT Steering Group


SI29 Wrong Blood in Tube - Where Does the Process Go Wrong? S. Alimam,1 S. Hafez,2 K. Pendry1 & P. Bolton-Maggs3 1

Central Manchester University Hospitals NHS Foundation Trust, University of Manchester, and 3Serious Hazard of Transfusion Scheme, UK 2

Transfusion of ABO incompatible blood can lead to major mortality and morbidity. Up to 20% of all wrong transfusions are traced to patient misidentification and/or sample mislabeling errors that occur before a sample even arrives in the laboratory. At Central Manchester University Hospitals NHS Foundation Trust (CMFT), the Trust

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has taken the initiative and made wrong blood in tube (WBiT) a ‘never’ event, yet WBITs continue to happen. We mapped out the process of blood sampling at CMFT to identify human factors that could contribute to WBiT. Through quality improvement (QI) methodology, the intelligence will be used reduce the incidence of WBiT at the Trust. 1. Observational analysis: 92 individuals were observed taking blood. 2. Multidisciplinary focus group on why WBiT occur. 3. Process mapping of the blood sampling process with a phlebotomist, doctor and nurse.

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The observational study revealed that only 28% of samples were labelled at the patient’s bedside. In inpatients, only 35% of wristbands were checked and 48% of patients were asked an open question to confirm identity. There was dissatisfaction amongst key members of the blood taking team – the phlebotomist reported a punitive culture and felt overworked. From the observational analysis and the focus group it was noted there was absence of correct mechanisms in place for labelling samples at the bedside hence making it impossible to follow the hospital protocol. Doctors and nurses, who do not perform the blood sampling on a regular basis, were seen mostly to omit the vital step of correct patient identification.

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

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SI30 Patients with a History of Transplantation T. Tomlinson NHSBT Colindale, UK Advances in the fields of stem cell and solid organ transplantation means that more patients are now being offered transplant as a treatment option. This has created its own challenges for the transfusion laboratory. From maintaining transfusion support throughout treatment, dealing with complex grouping abnormalities and manipulating the patient’s blood group to help improve chances of engraftment, the transfusion laboratory is now playing a greater role in supporting this treatment. In this presentation the role the transfusion laboratory plays in supporting stem cell and solid organ transplantation will be explored. Case studies will be used to demonstrate the additional complications these treatment methods bring, and the impact these have on the laboratory. For these patients, it is not always possible to perform the standard group, screen and crossmatching methods employed by the laboratory. Alternative techniques may therefore be required. Specific ABO blood group matching protocols need to be developed for different transplant types to ensure that blood products of the most appropriate blood group are issued for transfusion. The treatment process itself and the extensive transfusion support given to these patients can result in additional complications when performing group, screening and crossmatching tests. Finally, greater emphasis on maintaining quality of life means that care may be shared between hospitals. This makes it more difficult to obtain a complete diagnosis, disease history or transfusion history, which makes it more difficult to resolve grouping abnormalities. It is essential that clinical areas communicate effectively with the laboratory when dealing with these complex cases to ensure that the patient receives optimal care.

SI31 The Trouble with Trauma P. Grist Barts Health NHS Trust, London, UK It is the responsibility of the transfusion laboratory to ensure that we provide a safe and efficient service for all patients that present to hospital. This is achieved in part with detailed transfusion history on all patients and clinical details, special requirement rules and patient

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

flags that prompt staff in the case of sickle patients for example to provide phenotypically matched, fresh, HbS negative blood. Without a doubt, patients admitted with trauma are a unique set of individuals due in part to the unique numbering and naming system required for emergency medical support. With the new unique numbers and unknown identifiers they (typically) appear without clinical history (other than the presenting complaint) no special requirements rules and no patient flags. Add to this the possibility that they may have received emergency O Negative blood either at the scene of the call or at a referring hospital and in the commotion failed to inform the laboratory. This provides further challenges for the laboratory to provide a ‘safe’ blood transfusion in what is often a live threatening situation. This presentation will demonstrate how the laboratory copes without the relevant clinical and transfusion history when also faced with the challenges of conforming to the BCSH guidelines for compatibility testing and provision of red cells and blood products. Furthermore with the hope of preventing possible transmission of vCJD the decision must be made at an early stage what is more important following the guidelines or saving trauma patient’s lives? The cases reported show how trauma patients have presented at The Royal London and the steps taken to ensure a safe transfusion in the face of trauma.

SI32 The Trouble with Transfer P. Eyton-Jones Great Ormond Street NHS Foundation Trust, London, UK Founded in 1852 by Dr Charles West, Great Ormond Street was the first hospital in the UK dedicated solely to the treatment of children. Today, thousands of children are referred to the Trust from all over the UK and abroad for highly specialised treatment. Patients who have been transferred or referred from other Trusts give rise to a variety of challenges, both serological and clinical. Many of these patients are admitted with life threatening conditions and obtaining an accurate transfusion history from either the staff or the parents/carers can be difficult and time consuming. Failure to obtain an accurate clinical and transfusion history may result in inappropriate blood or components being issued. The cases presented provide an insight into some of these challenges faced by the laboratory and highlight the need to be vigilant when dealing with transferred patients. The importance of good communication between Trusts around shared care patients will also be highlighted.

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PL04 Diagnosis & Treatment of Coagulopathies in the Bleeding Patient: We Want it Quick and We Want It Now – The Copenhagen Concept! J. Stensballe1,2 1 Copenhagen University Hospital, and 2Capital Region Blood Bank, Copenhagen University Hospital, Copenhagen, Denmark Bleeding complicated with coagulopathy is associated with increased mortality in major surgery and trauma, but coagulopathy is potentially reversible. Our understanding of haemostasis during the last 10 years has emphasized that its monitoring should be performed in accordance with the cell-based model. Clotting can be assessed by functional whole-blood test such as the viscoelastical haemostatic assays (VHA) thrombelastography (TEGâ) (Haemonetic Corp, Niles, IL, USA) and rotational thrombelastometry (ROTEMâ) (Tem International, Munich, Germany). In the VHA tests, a close association exists between thrombin generation and the profile of amplification and propagation, providing evidence that VHA are able to detect coagulopathies secondary to impaired thrombin generation. More than 30 clinical studies, primarily in major surgery, but also evaluating trauma and other types of massively bleeding patients, have shown that a transfusion therapy based on VHA is associated with decreased bleeding and transfusion requirement, and possibly also a lower mortality, as compared to patients treated according to plasma based coagulation test Stensballe et al. (2014) In 2004, we implemented goal-directed haemostatic therapy according to TEGâ, denominated as the Copenhagen Concept Johansson et al. (2009). The concept introduced not only VHA but also transfusion packages encompassing thawed FFP allowing for early balanced transfusion therapy with RBC:FFP:PLT in ratio 1 : 1 : 1 in the very early phase of massive bleeding, and adjusted according to TEGâ goal-directed therapy. Our data showed a survival benefit in patients with massive bleedings, which may be related to different factors. Recently, we reported on a follow-up cohort re-confirming the survival benefit in trauma Johansson et al. (2013). In conclusion, VHA have in clinical studies shown to reduce bleeding, transfusion of FFP and platelets, and possibly mortality. VHA in the Copenhagen Concept have shown a survival benefit, related to the quick diagnosis of coagulopathy, the mode of and goal-directed manor of resuscitation.

PL05 Bloody Perioperative Case Scenarios: Vote for Personalized Care S. Kozek-Langenecker Evangelical Hospital Vienna, Vienna, Austria The mission of the Network of Advancement of Transfusion Alternatives (NATA) can be understood as promoting the multidisciplinary

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approach to manage anaemia, minimise blood loss, optimise haemostasis, and maximise the use of transfusion alternatives in order to improve patient outcomes. NATA’s focus on transfusion alternatives include critical assessment of upcoming patient-oriented coordinated management approaches, technologies, and medications, as well as the avoidance of unjustified allogeneic blood product use. Traditional bleeding management based on liberal transfusion of plasma and platelet concentrates, e.g. in a formula-based 1 : 1 : 1 ratio with red blood cell concentrates increases patients’ exposure to allogeneic blood products without utilizing alternatives. Compared to a non-individualized ratio-based approach, personalized management demands more pathophysiological understanding and targeted actions from the physician caring for the patient. Accumulating evidence supports these efforts by indicating improved patient safety, clinical outcomes, and cost savings, as summarized in the guidelines on the management of severe perioperative bleeding from the European Society of Anaesthesiology. Personalized care requires infrastructure, harmonized processes, and is facilitated by institutional algorithms. Education and exposure can be promoted by interprofessional team trainings in the medical simulator centre. Low-grade evidence indicates enhanced job satisfaction and increased clinicians’ stress tolerance in the emergency of severe bleeding. In this interactive part of the NATA session, severe bleeding scenarios from clinical reality will be presented. The audience will be invited to vote on pathomechanisms of bleeding, monitoring and management options focussing on transfusion alternatives.

PL06 Diagnosis and Treatment of Coagulopathies in the Bleeding Patient, and Evidence on Effectiveness of Component Therapy S. Stanworth NHS Blood and Transplant/Oxford University Hospitals NHS Trust, John Radcliffe Hospital, Oxford; Radcliffe Department of Medicine, University of Oxford, UK The last few years have seen an explosion of publications describing an entity variously termed ‘acute traumatic coagulopathy’ (ATC) or trauma induced coagulopathy (TIC). Most trauma specialists would consider this to describe early coagulation abnormalities, typically defined by abnormalities in prothrombin time, which are associated with higher bleeding risk and poorer outcomes. In all clinical situations which lead to major haemorrhage, including trauma, there are other causes of worsening coagulation, which include consumption, dilution, hypoxia, acidosis, hypothermia. No single approach to the diagnosis and treatment of coagulopathies in different patient groups with major bleeding is likely to be optimal. Patients with gastrointestinal or post-partum bleeding have different clinical features, or burden of co-morbidities, and the pathophysiology of haemostatic breakdown will differ from trauma. Plasma-based tests such as prothrombin time only evaluate the early part of coagulation and do not evaluate thrombin potential. Furthermore, average turn-aroundtimes have been reported to be delayed beyond direct value. Given

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

XXXII Annual Scientific Meeting of the British Blood Transfusion Society 23 that standard coagulation tests may have limited value, alternative methods to assess coagulopathy have been developed, including visco-elastic (point-of-care) devices to provide additional information about the haemostatic contribution of red cells, platelets and fibrinolysis. Systematic reviews have been undertaken to summarise the clinical study data evaluating the value of these devices in clinical settings such as cardiac surgery, trauma and post-partum. There remains uncertainty about the effectiveness of viscoelastic testing to

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

improve clinical outcomes including mortality. Tranfusion policies for haemostatic resuscitation in trauma are defined in massive haemorrhage protocols and include early empiric (simultaneous) delivery of red cells and plasma with platelets in high ratios, in conjunction with tranexamic acid. The benefit of higher doses of plasma (and platelets) is being addressed in the PROPPR randomised trial (NCT01545232) in North America. The role of other pro-haemostatic agents remains an area of on-going research.

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SI33 The Impact of Providing Blood to the Scene of an Accident on Transfusion Laboratory Practice S. Wolf,1 K. Kennedy,1 M. Lawn,2 T. McLoughlin,1 K. Feane,3 J. Uprichard,3 A. Weaver,1 S. Allard4 & L. Green4 1 Bartshealth NHS Trust, 2King’s College Hospital, 3St George’s Healthcare, and 4Bartshealth NHS Trust/NHS Blood and Transplant

Haemorrhage is the leading cause of death during trauma, with ~25% of patients dying within the first 6 hours. Early transfusion is vital to improving morbidity and mortality rates. In March 2012, the Helicopter Emergency Medical Service (HEMS) were the first British civilian air ambulance service to introduce the Flying With Blood Project (FWBP) and transfuse group O RhD neg red cell units (RBC) to trauma patients at the scene of an accident. This study aimed to assess the impact of FWBP on the: number of unacceptable/mixed field blood samples received by the laboratory; number of group O RhD neg RBC transfused to non-group O patients; and ratio of RBC: FFP transfused within 24 h of trauma. Three London Major Trauma Centres (Royal London, King’s College and St George’s hospitals) collected and compared code red trauma patients’ data between August 2008–February 2012, prior to FWBP (retrospective) and between March 2012–October 2013, after FWBP (prospective). Results: 233 (188 male, 45 female; median age 30) and 66 trauma patients (40 male, 24 female, 2 unknown; median age 40) were identified in the retrospective and prospective arms respectively. There was no significant difference in the number of group O RhD neg RBC transfused to non-group O patients or the RBC:FFP ratio (prospective median 0.5 [IQR 0.4–0.7]; retrospective median 0.8 [IQR 0.6–1.2]) within 24 h between the 2 groups. There was an increase in numbers of unacceptable and mixed field samples received in the prospective group (unacceptable 20%; mixed field 42%) compared with the retrospective one (unacceptable 14%; mixed field 23%). Conclusion: The introduction of FWBP has not changed the number of group O RhD neg RBC transfused or the RBC:FFP ratio despite an increase in the number of unacceptable/mixed field samples received. To improve this, ongoing communication between hospital transfusion and pre-hospital emergency teams, and regular audits, are required.

SI34 Breaking the Cycle – Multiple Errors Resulting in Transfusion of Incorrect Blood Components J. Ball,1 H. Mistry,2 C. Gallagher,3 D. Poles2 & P. Bolton-Maggs2 1

SHOT, Manchester, 2SHOT, and 3NHSBT, UK

Serious adverse events including ABO-incompatible transfusion often follow multiple errors where there were many opportunities to detect and correct the initial mistake. SHOT reports of incorrect blood component transfused in 2013 were analysed with reference to 9 critical steps: a correct and specific request, collection of the sample,

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laboratory processes including sample receipt, testing, component selection and labelling, collection from the laboratory, and clinical reference to the prescription and identifcation of the patient at the time of administration. Results: A total of 247 reports were analysed where 220/247 showed failures in these critical steps. The additional 27/247 were due to other causes such as communication failures and different policies for shared care patients. Multiple errors occurred in 167/220 (75.9%) with a median of 3 (in 117/220 (53.2%)) and a range of 1 to 5. In 92/220 (41.8%) reports, the primary error was made in the request and was not detected at subsequent steps prior to transfusion. Both laboratory and clinical errors occurred in 31/220 (14.1%). In 155/220 (70.5%) cases, the error could have been detected at the final pre-administration check at the bedside, but may be missed due to fragmentation of medical care and multiple doctors who may not know the specific requirements and assume that all the prior steps were correct. Conclusion: Transfusion follows a series of interlinked steps where laboratory and clinical staff work in partnership as one integrated multi-disciplinary team. Safe transfusion practice depends on accuracy at every step. Effective communication and a solid foundation of transfusion knowledge, including patient specific requirements, are key requirements for all staff involved in the transfusion process. A simple 5-point aide memoire at the final step would remind staff to check for the correct patient identifiers and the prescription for the correct component and confirmation of specific requirements.

SI35 Interpretation of Weak D in Young Female Patients – are UK Transfusion Laboratories Making Correct Decisions? Evidence from a UK NEQAS (BTLP) Exercise C. Milkins,1 J. White,2 A. Mavurayi2 & M. Rowley2 1

West Herts Hospitals NHS Trust, UK, and 2UK NEQAS, BTLP, UK

Contrary to our historical understanding, some weak D individuals, e.g. types 15 and 4.2, have produced anti-D. As it is not possible with standard anti-D typing reagents to distinguish between D variants unlikely to make anti-D and those that might, BCSH guidelines now recommend that young females be treated as D negative until weak reactions with routine anti-D reagents have been confirmed by extended serological or molecular testing. UK NEQAS (BTLP) distributed a weak D ‘patient’ sample in exercise 14R1 to assess reactivity of different reagents, and compliance with guidelines with respect to both interpretation of weak D and choice of red cells for transfusion to a young female patient. 356/394 (90%) laboratories recorded anomalous D typing reactions, i.e. at least one weak or mixed field reaction, or one positive and one negative reaction; of these, 27% made an interpretation of D positive (only 6% of these stated that they used an extended D typing kit), 53% D variant, 1% D negative and 19% said they were unable to interpret. D typing reactions grades

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

XXXII Annual Scientific Meeting of the British Blood Transfusion Society 25 reported varied, even between laboratories using the same reagents and technology. 81/270 (30%) participants who made an interpretation other than D positive, and who also undertook crossmatching, would have transfused the D positive donation without knowing the weak D subtype of the patient. Weak D types 1, 2 and 3 can safely be regarded as D positive. However, where anomalous D typing reactions are obtained for a young female patient, the D type should be reported as negative, and D negative red cells should be selected for transfusion, until molecular typing or an extended panel of monoclonal antibodies has been used to determine the subtype. 27–30% of UK laboratories are not complying with the guidelines, putting young women at risk of sensitisation to the D antigen.

median of 4 (3–6) and 7 RBC units (6–9), respectively. 45% of women underwent hysterectomy, 2 died, 82% were admitted in ITU/ HDU, and 28% developed additional major morbidity. Conclusion: Guideline criteria for plasma/platelet transfusion were fulfilled in ~25% of cases (even though these were severe MOH cases), indicating that further research is needed to define transfusion triggers in MOH.


R. Allan1 & M. Karakantza2

Transfusion Management and Haemostatic Changes in Major Obstetric Haemorrhage in the UK L. Green,1 M. Knight,2 F. M. Seeney,3 P. Collins,4 R. Collis,5 C. Hopkinson3 & S. Stanworth6 1

NHSBT and Barts Health NHS Trust, 2National Perinatal Epidemiology Unit, University of Oxford, 3Statistics and Clinical Studies, NHS Blood and Transplant, 4Arthur Bloom Haemophilia Centre, School of Medicine, Cardiff University, 5Department of Anaesthetics, Cardiff and Vale University Health Board, and 6NHS Blood and Transplant, Oxford University Hospitals NHS Trust, UK Blood transfusion is fundamental to improving outcomes during major obstetric haemorrhage (MOH). Current guidelines recommend that fresh frozen plasma (FFP), cryoprecipitate and platelet be transfused when PT/APTT is >1.59 baseline, fibrinogen A, encoding p.Gln149Lys, associated with the DOB-SH-Gln149Lys allele. Sequencing of the DO gene of the remaining aunt, uncle and brother revealed no mutations. Conclusion: A patient with anti-Gya in her plasma revealed a novel Gy(a-) genotype resulting from an insert c.729insGfsX8. The inheritance of this null allele is shown through two generations of the patient’s family.

SI39 An Individual with the R2R0HAR Phenotype was Positive with Three Monoclonal Anti-e and Produced Alloanti-e S. Grimsley,1 T. Bullock,1 S. Search,2 A. McNeill,1 I. Marais,1 K. De-Say,1 N. Thornton1 & G. Daniels1 1


Introduction: The presence of autoanti-e in e+ patients is not uncommon, however when the autologous control is negative the presence of alloanti-e with a variant e antigen should be considered. Historically, these variants have been recognised by weakness of e, however here we report the e variant R0HAR was positive with three anti-e clones. Methods: Standard serological techniques, standard allelic discrimination genotyping and genomic DNA Sanger sequencing were performed. Results: Serological investigation identified the presence of alloanti-e, a negative autologous control and the phenotype: C- c+ D+ E+ e+/-. The monoclonal anti-e antibodies produced by clones MS16, MS21 and BS260 were moderate-strongly positive, all other monoclonal and polyclonal anti-e were negative. Genotyping and sequencing indicated RHCE*cE/cE, no mutations were found in exons 1–10 of RHD and RHCE. Serial titration of the patient’s cells with anti-E gave a lower titration score than E+e+ cells. The extended phenotype Rh:-32,33,50 suggested the presence of the rare RHCE(1-4)-D(5)-CE(6-10) hybrid allele R0HAR, therefore indicating the genotype RHD*D, RHCE*cE/ceHAR. Discussion: Genotyping and sequencing failed to identify the e variant hybrid allele as its presence was masked by the normal RHCE*cE and RHD*D genes. Despite the apparent genotype, and negative results with some anti-e reagents, serial titration with anti-E indicated heterozygous rather than homozygous expression of E, with a lower titration score than E+e+ cells. This weakness may be due to altered interactions of the normal cE and variant R0HAR proteins within the Rh macrocomplex. Identification of this e variant

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

was complicated by the variable reactivity with anti-e reagents; literature states that the R0HAR variant is very weak with all anti-e. We now report that three anti-e clones are moderate to strongly positive with R0HAR, and therefore possibly other e variants. This observation places extra importance on checking the autologous control when assigning an antibody as auto or allo.

SI40 Novel Alleles at the Kell Blood Group Locus that Lead to Kell Variant Phenotype B. Veldhuisen,1 Y. Ji,2 P. Ligthart,1 J. Jongerius,1 M. Boujnan,1 A. Ait Soussan,1 G. Luo,3 Y. Fu,3 E. van der Schoot1 & M. de Haas1 1 Sanquin Blood Supply, 2Sanquin Blood Supply and Guangzhou Blood Center, and 3Guangzhou Blood Center

Background: In the Netherlands, the expression of the KEL1 antigen is routinely determined in all blood donors. To identify sufficient donors with the KEL1, -2 phenotype, all KEL1 positive donors are phenotyped for KEL2. KEL:1,-2 donors are genotyped to confirm negativity for KEL2. In this exercise KEL*02 variant alleles are identified. Aims: To investigate the genetic background of the variant KEL*02 alleles in the Dutch population. Methods: From 2010 to 2014, 407 donors with the KEL:1,-2 phenotype were genotyped for the KEL*01/02 polymorphism using a Taqman allelic discrimination assay. In case a KEL*02 allele was detected, sequencing of KEL exons was performed. In addition, two K0 patients were included in this study. Transcript analysis was done for two probands with the KEL*02.M05 allele (G573G). Flow cytometry analysis was used to determine the expression level of Kell antigens in five samples with variant phenotypes. Results: In thirty out of 407 serologically KEL:1,-2 donors (7%) a KEL*02 allele was identified. In these donors and in two K0 patients, seven novel alleles (KEL*02(436delG)null, KEL*02(R492X)null, KEL*02(R700X) KEL*02(R86Q, KEL*02(R281W)null, KEL*02 (L133P)null, KEL*02(F418S)null, KEL*02(L611R)null), and nine variant alleles described before (KEL*02N.06, KEL*02N.15, KEL*02N.17, KEL*02N.19, KEL*02N.21, KEL*02M.02, KEL*02M.04, KEL*02M.05, KEL*02(Q362K)null) were identified. An abnormal transcript lacking exon 16 was detected in KEL*02.M05 probands, explaining the KEL:1,2mod phenotype. Red cells with KEL:1,2null and KEL:1,2mod phenotypes, flow cytometric analysis showed a decrease of total Kell expression, but, compared to KEL:1,2 a relatively increased KEL1 expression was found in KEL:1,2null or KEL:1,2mod individuals. Conclusions: In ~7% of KEL:1,-2 donors (30/407) a variant KEL*02 allele was found, comparable to studies in French (7.4% Martin-Blanc 2013) and higher compared to Austrian donors (3.5% Kormoczi 2007). An increased KEL1 antigen expression in KEL:1,2null and KEL:1,2mod individuals suggest that the XK protein is the rate-limiting factor for surface expression of Kell antigens. SI41 Homozygosity for a Variant SEMA7A Allele Resulting in Loss of a Novel High Frequency JMH Antigen L. Tilley,1 R. Laundy,2 J. van der Mark-Zoet,3 C. Folman,3 M. de Haas,3 N. Thornton2 & G. Daniels1 1

IBGRL, NHSBT, Bristol, UK, 2IBGRL, NHSBT. Bristol, UK, and Sanquin, Amsterdam, The Netherlands


Introduction: The JMH blood group antigens are carried on glycoprotein semaphorin 7A (Sema7A). The JMH:-1 phenotype is

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usually acquired and may be transient, but five rare, inherited variants of JMH also exist, lacking antigens JMH2-6. These have been identified in JMH+ individuals producing alloantibodies to high frequency antigens that do not react with JMH- cells. Such variants result from homozygosity for SEMA7A mutations, encoding amino acid substitutions in the Sema7A protein. Methods: Blood samples from a patient of North African descent were investigated due to the presence of an unidentified antibody in the plasma. Serological tests were performed by standard LISS tube IAT technique using in-house reference antisera. Genomic DNA was extracted and DNA sequencing performed for all exons (1–14) of SEMA7A. Results: The patient’s antibody reacted by IAT with untreated cells but not with papain treated cells and was identified as anti-JMH. Several examples of JMH- cells were compatible with the patient’s plasma and no additional antibodies were detected. The autologous

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control was negative. The cells reacted variably with a panel of 12 anti-JMH antibodies, with reactions ranging from very weak to normal strength. Genomic DNA sequencing revealed homozygosity for an exon 7 mutation, 709G>A, encoding Asp237Asn in the Sema7A protein. A further homozygous silent mutation, 1545A>G, was identified in exon 12. Conclusions: The presence of anti-JMH in the patient’s plasma, despite his cells typing as JMH+, together with variable reactivity of a panel of anti-JMH reagents, indicate expression of a variant JMH antigen. This conclusion is supported by sequencing of SEMA7A revealing homozygosity for 709G>A and 1545A>G. Homozygosity for this allele appears to result in the loss of a novel high frequency JMH antigen, against which this patient’s antibody is directed. We propose this antigen may represent the seventh antigen in the JMH blood group system.

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

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SI42 Management of Anaemia Reduces Red Cell Transfusion in NI

5. DHSSPS, Circular HSS(MD)17/2011, August 2011, Better Blood Transfusion 3 Northern Ireland (BBT3 NI). hss-md-17-2011.

S. Atkinson on behalf of NI Transfusion Committee, Northern Ireland, UK The 2006 NI Regional Audit of the Appropriateness of Transfusion identified a high incidence of inappropriate and over transfusion of red cells. The implementation of regional Transfusion Guidelines in 2007, supported and monitored by a Haemovigilance Team and the NI Transfusion Committee (NITC), has contributed to a sustained reduction in unnecessary red cell exposure within Healthcare Trusts. Transfusion index decreased from over 37 per 1000 of the population pre audit to 30 per 1000 in 2010. Eighty percent of patients included in the 2006 Audit were anaemic on admission to hospital and opportunities to treat anaemia and avoid transfusion were missed in 19% of cases in another NI regional audit, which investigated the Management of Anaemia and Avoidance of Transfusion (2010). Hence there was scope to make further reductions in unnecessary red cell transfusions by timely management of anaemia. NI Healthcare Trusts are now implementing a regional pathway for the detection, investigation and management of anaemia, which was endorsed by the Chief Medical Officer in 2012 and stipulated in Better Blood Transfusion 3 (NI). The pathway includes guidance on pre-optimisation of haemoglobin and haemostasis prior to major surgery. Key improvements are already evident with more aggressive management of iron deficiency anaemia in some pre-assessment clinics and a continuing downward trend in red cell issues to less than 28 per 1000 of the population. Overall red cell issues have decreased by 24% in NI in the last 10 years. The NITC intends to continue the cycle of regional audit and guideline implementation by undertaking an organisational audit of haematological optimisation in all NI Healthcare Trust Pre-assessment Clinics. Conclusion: The processes of regional audit and implementation of clinical practice guidelines can provide a powerful mechanism for sustained improvement in transfusion practice. References 1. Regional Appropriateness of Blood Transfusion Audit 2006: The Northern Ireland Transfusion Committee. 2. Guidelines and Audit Implementation Network (GAIN) March 2009, Better Use of Blood in Northern Ireland. Guidelines for Blood Transfusion Practice. blood%20guidelines.pdf. 3. Guidelines and Audit Implementation Network (GAIN) February 2010, Management of Anaemia and Avoidance of Transfusion. A Regional Audit by the NI Regional Transfusion Committee. http:// 4. DHSSPS, Circular HSS(MD)22/2012, June 2012, Detection, Investigation and Management of Anaemia. hss-md-22-2012.pdf.

© 2014 The Authors. Transfusion Medicine © 2014 British Blood Transfusion Society

SI43 Identification and Treatment of Transfusion Reactions – A Collaborative Regional Approach F. Sear Acknowledgement to The East of England Transfusion Practitioner’s Group UK The East of England Regional Transfusion Committee, UK In 2013 a regional Transfusion Reaction algorithm was implemented for the East of England. A need was identified within the region for standardised guidance on the identification and treatment of transfusion reactions. It was recognised that it would be advantageous for medical and nursing staff moving around hospitals within the region to find common and familiar guidance and procedure. A working group was set up within the Transfusion Practitioner’s group to form the guidelines. A concise algorithm containing the relevant clinical information was established to be the most effective resource for hospitals to use effectively. An algorithm was developed based on the BCSH Guidelines on Acute Transfusion Reactions 2012 (BCSH 2012) The algorithm was ratified by the Regional Transfusion Committee on 20th June 2013 and has since been utilized by the majority of hospitals in the region. The algorithm was produced as a 2-sided A4 color document which was sent to hospitals to use electronically or as a hard copy. The way in which to best utilize and implement the tool was left up to individual hospitals to decide. Examples of methods currently in practice include; poster display, handouts, use in resource packs, a link on the intranet, inclusion in training presentations, inclusion on blood administration charts, and handouts with collection of blood components. Interest was also expressed in seeing this in an ‘app’ type format. It can also be accessed via Conclusion: The formulation of this algorithm through a collaborative regional approach has provided a multifunctional tool which hospitals can utilize in the way most suited to their practice and it enables staff moving around hospitals within the region to find common guidance for identifying and treating transfusion reactions. It is an example of how the Regional Transfusion Committee can implement best practice and facilitate collaborative working within the region. Familiarisation with the algorithm promotes improved patient safety with greater recognition of transfusion reactions and the appropriate action required. References 1. Guideline on the Investigation and Management of Acute Transfusion Reactions (2012). British Committee for Standards in Haematology.

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XXXII Annual Scientific Meeting of the British Blood Transfusion Society

SI44 Skills for Health Collaboration to Develop a Transfusion Training Passport A. Hobson,1 A. Dhesi,2 S. Cole,3 T. Riley,4 J. Nanuck,5 V. Fulkes,6 S. Carr7 & K. Coffey2 1 Barnet & Chase Farm Hospitals NHS Trust, 2NHS Blood & Transplant, 3Princess Royal University Hospital, 4Royal Brompton Hospital, 5Queen Elizabeth Hospital, 6Guy’s & St Thomas’ NHS Foundation Trust, and 7St George’s Hospital, UK

Background: The aim of this work was to include a ‘Blood Component Transfusion’ subject guide into the Skills for Health (SFH) Clinical Skills Passport. As the passport is UK-wide, national engagement was necessary. Inclusion of Blood Transfusion will support locally delivered blood transfusion training and ensure a minimum standard. It will also allow for previously achieved, recognised and standardised training to be transferable to other hospitals and Trusts. This idea originally started following a discussion at The London Transfusion Practitioners (TP) group. Method: LearnBloodTransfusion e-learning, existing regional passports and a regional training requirements survey were initially assessed and evaluated. Once a regional draft was developed SFH were contacted who worked with us to develop this into a national section in their Clinical Skills Passport. National subject matter experts (SMEs) were engaged for feedback. Results: All feedback was addressed and working with SFH the passport was put into their template. The content reflects the minimum requirements for training and allows each Trust to add extra elements or increase frequency of training as appropriate to them. The passport was accepted as completed by SFH in March 2014 for England only. It will be launched in autumn 2014 and sent to Education Departments to discuss implementation with the local transfusion teams. Discussion: It is hoped that the updated clinical skills passport will both raise the profile of transfusion training within Trust Education Departments and support TPs who have experienced reductions in allocated training time, to be able to deliver the minimum requirements that the learner need to know. It will not change the mode or style of delivery that TPs are currently using. Next steps: to see if transfusion organisations and groups will provide statements of support for the passport before its launch.

SI45 An Audit of the Management of Massive Haemorrhage in the Yorkshire and the Humber Region S. Baker,1 P. Cook,2 A. Davidson,3 B. Hockley,4 C. Ivel,5 M. Karakantza6 & D. Smith4 1 Sheffield Teaching Hospitals NHS Foundation Trust, 2Bradford Teaching Hospitals NHS Foundation Trust, 3NHSBT Leeds, 4NHSBT Sheffield, 5York Teaching Hospital NHS Foundation Trust, and 6Leeds Teaching Hospitals NHS Trust/NHSBT, UK

Yorkshire and The Humber Regional Transfusion Committee undertook a prospective regional audit of the management of massive haemorrhage events focussing on the requirements of the NPSA RRR2010/017 and the recommendations from the CRASH-2 trial. Organisationally, all of the Trusts in the region had Hospital Transfusion Committees (HTCs) and a massive haemorrhage protocol (1 in draft stage). Three of the HTCs did not review their massive haemorrhage protocols. Thirteen trusts submitted data on 131 massive haemorrhage events. The protocol was triggered in 53 (40.4%) of the events.

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Communication during the massive haemorrhage event improved if the protocol was activated. Fewer red blood cells were administered with the use of TEG/ROTEM or cell salvage, there was no significant difference in the use of cryoprecipitate, but more platelets were used with TEG/ROTEM . Blood component wastage averaged 3% (in line with reported wastage from the Blood Stocks Management Scheme). One trauma case was reported. Tranexamic was not used in this event but was used in 17(12.9%) of other cases. Compliance with audit standards (CRASH-2 and NPSA RRR2010/ 017) ranged from 47 to 100%. Individual feedback was provided to participating hospitals and 10 improvement recommendations were made including-: 1. Massive haemorrhage protocols should include specific actions for sites without a transfusion laboratory. 2. Trusts that do not comply with NPSA RRR2010/017 requirements regarding drills should address this issue. 3. Communication between the clinical area and the laboratory needs to be improved. 4. Further audit focussed on massive haemorrhage secondary to trauma cases is recommended.

SI46 Pre-Operative Assessment Clinics: Management of Anaemia 2005, 2007 and 2012 A. Harris West Midlands Regional Transfusion Committee NHSBT Birmingham, UK

Background: Successive Better Blood Transfusion Health Service Circular’s have recommended that mechanisms should be in place for the pre-operative assessment (POA) of patients for the identification, investigation and treatment of anaemia (DH 2002 and 2007). This is also recommended by the NHS Enhanced Recovery (ER) Programme (NHS Quality Improvement 2013). Methods and Results: The West Midlands Regional Transfusion Committee (WMRTC) have undertaken 2 regional surveys (2005 and 2012) and one audit of practice (2007) examining POA clinics within the WM region in relation to managing pre-operative anaemia. The 2005 survey highlighted that only 39% of POA clinics had policies for the management anaemia. The 2007 audit indicated that anaemia is not being recognised, and it was suggested that there perhaps needs to be a culture change in this respect, as the correction of anaemia would appear to be given a very low priority. In response to this, in 2007 the WMRTC launched their regional ‘Guideline for the management of anaemia in pre-operative assessment clinics’. During 2009/10, members of the WMRTC also assisted with the initiative to include pre-operative anaemia management in the NHS ER Programme. The 2012 survey indicates that little improvement has been made. There has been a small increase in hospital policies for management of anaemia pre-operatively and administering iron pre-op, but anaemia is still not being recognised, with 80% having a Hb trigger

Abstracts of the XXXII Annual Scientific Meeting of the British Blood Transfusion Society, 24-26 September 2014, North Yorkshire, UK.

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