This article describes how Trafford General Hospital developed an electronic blood-tracking system that enables it to comply with new blood-transfusion regulations. It also records every stage of the transfusion process.
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article found under “related files”
Marie Green, RGN, is transfusion practitioner, Trafford General Hospital, Trafford Healthcare NHS Trust, Manchester.
Green, M. (2008) Introducing an electronic blood-tracking system. This is an extended version of the article in Nursing Times; 104: 6, 33-34.
This article describes how Trafford General Hospital developed an electronic blood-tracking system that enables it to comply with new blood-transfusion regulations. It also records every stage of the transfusion process. The new system has reduced the risk of staff error in the checking process and has improved patient safety. Information can also be transferred to electronic patient records. The initiative was a multidisciplinary project involving a range of specialties within the trust and the support of an external consumption-management company. It showed the benefits of effective team-working in initiating ch
In 2005, health authorities were required to introduce new systems to comply with directives from both the European Union and the UK (European Parliament, 2002; Office of Public Sector Information, 2005). These set the standards for quality and safety for the collection, testing, processing, storage and distribution of human blood components. Two aspects of the regulations directly impact on hospitals involved in blood transfusion:
Traceability - unambiguous evidence of the final fate of every blood component issued and records kept for 30 years. This evidence must provide a complete audit trail from donor to recipient.
Haemovigilance requires laboratories to report any adverse event or reaction to a blood transfusion through the Serious Hazards of Transfusion scheme (SHOT, 2004).
Every year around three million blood components are prepared for transfusion in the UK (McClelland, 2002). While this process saves lives and improves quality of life, there are still a number of associated risks. Every year patients die from adverse incidents in the blood-transfusion process.
With this in mind Trafford Healthcare NHS Trust began investigating ways of achieving compliance. Its role in traceability would be to provide evidence of all staff involved in transfusion procedures, confirm donor blood was given to the correct patient and confirm the blood component received. This information must then be stored retrievably for 30 years.
The response to government guidelines on traceability was primarily addressed by paper trail. The transfusion practitioner followed every unit of blood to the wards to confirm that blood was given to the patient. This information was then manually updated on the hospital’s TelePath system, then the fate of each blood unit would be confirmed. This was time-consuming and, in the transfusion practitioner’s absence, traceability decreased, showing weakness in the system. If the system had been inspected at this time, it would have identified non-compliance. The decision was taken to begin looking at electronic systems.
The trust did not have funds to purchase an existing electronic product. However, we had already been working with a consumption-management company on tracking equipment in our one-stop resource centre. The teams involved in this project were impressed with the company and suggested a meeting. After discussing and demonstrating our requirements and the need for compliance, we presented a business case to the trust showing alternatives, costing and plans.
It was agreed that finances would be made available to develop a system that not only complied with the regulations but also met the hospital’s needs. This would reduce risks in the transfusion procedure and improve patient safety. There was some doubt over whether we would be able to resolve our non-compliance but the team felt the outcome would be worthwhile as the project was innovative. We developed flow charts of the transfusion process, showing how we would want the system to work. Recent national comparative audits had shown areas for improvement in the transfusion process at ward level. These issues were also added to the programme – the aim was to address these changes now in order to show improvements in future audits.
The objective was to introduce handheld computers into the ward areas that held the programme for the blood-transfusion process. In addition, a main computer programme would be accessible, auditable and maintain records for 30 years.
Multidisciplinary working was essential in developing the team, using the knowledge of our information and technology department and blood bank along with a consumption-management company.
Belbin’s (1997) description of team-working has been well known for many years and is unusual in that it is strongly grounded in research. He identified nine roles that are available to team members and found that effective achievement of tasks relied on having a balanced team with a mix of roles among members. Usually an individual tends to have one role within a team with which they are most comfortable but here they also have a secondary role they can take on readily. All members of the team were technically leaders in their own specialised area.
Regular project meetings were essential and timelines for progress were adhered to. The project leadership showed a strong team approach and improving patient safety provided the motivation to succeed.
We needed to introduce barcoded patient wristbands that computers could scan to check patient details. We had also previously bought 10 barcode printers that were awaiting installation in ward areas. This took place over two weeks and involved training and education in accessing the system. All nursing staff can now access and print name bands for their wards or departments. Following implementation, an audit on wristbands showed excellent results.
All ward and department areas had to be barcoded to show where the transfusion took place. This was already in progress as wards and departments were registering what took place in each area of the hospital. This enabled us to include the area where a transfusion takes place in the programme, in order to confirm the ward carrying out the procedure and the bed area for patients’ stay. The barcodes were not placed on any transferable equipment.
We have had to change people’s mindsets to move away from ritualistic practice and show that change can be a good thing. Huber (2006) discussed rituals and resistance to change, explaining that this can occur because people are afraid of being disorganised or of having routine disrupted. Good communication and demonstrating the benefits of the system can help to solve these problems.
We used our knowledge and skills on the clinical aspects of hospital work and processes, taking into account the final information and evidence required but also thinking about what else we could do to improve patient care. Staff from MSoft, the consumption-management company, used their knowledge of previous equipment tracking. Together we formulated a software solution that can be adapted to many clinical situations. The trust is now working on case-note tracking in a similar way.
The project has been running for 18 months. Following a successful pilot in the chemotherapy unit, we have now begun to introduce the system across the trust and implement changes in transfusion practice by standardising procedures. The result is a transparent and evidence-based audit trail of the care provided for each patient, as well as clear improvements in nurse documentation following blood-transfusion training. There are now 10 wards/departments using a live system. We plan to roll out the system to one or two wards a week, depending on support needed. This means we can delay some areas if the workload becomes too high.
Developments in transfusion
Since May 2007 and the redesign of the transfusion training package, nursing staff are now trained and competency-tested on sample-taking, collection of blood and blood products, administration and patient care throughout the process. Not only is this important for the procedure but it also ensures compliance with National Patient Safety Agency (2006) instructions on blood transfusion. This is also discussed by the RCN (2005).
All staff involved in the transfusion process attend the blood bank and work through the collection programme. They are provided with an authorisation barcode when assessed as competent, which identifies them throughout the procedure so we now know which nurse is providing care.
Adding barcodes to transport boxes also enables us to confirm use and the transport method selected. This then shows how long it takes for the blood to reach the ward or department. On arrival at the ward, the blood is scanned using the ward receipt programme. This confirms in the audit trail how long the blood has been out of the refrigerator; nurses are aware that transfusion should start within 30 minutes of collection (British Committee for Standards in Haematology, 1999). The blood is taken to the patient’s bedside with supporting documentation to start the procedure – this should include the medical prescription.
The patient’s barcoded wristband is scanned, and nurses then scan their identification code and the blood. The patient details appear and confirm that the blood about to be used is the correct blood for the patient concerned. Should there be any discrepancies in the information, the user will be alerted and the programme will not proceed any further. Nursing staff would then contact the blood bank or transfusion practitioner for advice and support.
This part of the procedure has proved to be invaluable for patients. It has provided reassurance, making them feel involved in the process but, most importantly, it has broken down barriers and improved communication. Showing patients a screen that confirms their identity has given them more confidence in the process.
For the rest of the procedure, nursing staff enter information into the handheld computer as required. This ensures that no stages are missed and also provides reassurance to staff involved. At the end of the process nurses place the handhelds back into the docking cradle and synchronise the information with the hospital’s main system server. This information is then available for audit trail and provides evidence that transfusion has been completed. It shows the blood unit number transfused, nursing actions and patient observations throughout the treatment period.
Other benefits of the programme
Additional parts of the programme identify alerts that can be triggered. An example here would be after the first 15 minutes of the transfusion. The handheld beeps and advises nursing staff that observations are now required for this patient. Nurses can press the ‘snooze’ button but would be alerted again after two minutes. All this information is sent to an alert page on the main computer programme – the alerts can be viewed by members of the pathology team who then act on the information if necessary.
Training can also be recorded on the system and reminders or access dates set. For example, if training is annual then after 12 months the authorisation for a staff member will cease until retraining has occurred. Alternatively, by using the reporting tool we can request a list of staff members for whom authorisation of the system is due to expire.
The transfusion practitioner continues to provide training. A simple reference guide for nursing staff is available in the blood bank on collection and return of blood procedures, and wards have a reference booklet on use of the handhelds and the transfusion process. This is in addition to support in the wards and departments during use.
Staff found some aspects of the new system difficult, as they had been familiar with a handwritten procedure that remained unchanged for years. It has been challenging to introduce this system but now we can look back as a team and see what we have achieved.
Our work has already been recognised by other parts of the NHS. Other trusts have seen how it can be adapted in their hospitals; over the past year we have had 20 site visits to see the work in progress and the system’s flexibility.
For the hospital the project has been good value for money. It has used teams’ specialist knowledge as well as the support of an outside company with tracking expertise and an award-winning software engine. This approach has resulted in an effective team dynamic that has worked well. The solution will not only improve the service but also help to save lives.
Our project manager believes that the most important factor has been the involvement of a specialist transfusion practitioner with a nursing background. Acceptance of the system would have been much harder to achieve without someone who can engage the ward staff effectively from a change-management perspective. Having software based on up-to-date, web-based technologies fits well with other systems. This will allow seamless transfer of each transfusion process to the corresponding electronic patient record. In addition, the reporting tools will allow information relating to performance, patient safety and financial issues to be available in real time.
A project team consisting of all the interlinking disciplines has been successful;
We encountered difficulties in changing mindsets and moving away from ritualistic nursing practice. At times fear of technology has been an issue – particularly when nursing staff are facing workload pressures. We have needed to provide support and reassurance that this will save nurses time and improve patient safety;
There is a need for training packages and reference materials for out-of-hours support;
Arranging training for all staff grades on their responsibilities within the transfusion process is vital. This must recognise the importance of each person’s role in the procedure and include them in all the training and competences, from phlebotomy staff onwards;
Support and feedback from patients was invaluable;
Patience was vital when waiting for each stage of the project to be completed;
The introduction of a wireless network will improve the system further, as all patient data received will be sent to the audit trail as it occurs rather than having to be synchronised at the end of the programme.
The system has reduced risk of staff error during the checking procedure and improved patient care. Education, training and support are essential to reduce the possibility of deaths in hospitals. Nurses must take their accountability seriously in this area.
Belbin, M. (1997) Changing The Way We Work. Oxford: Butterworth Heinemann.
British Committee for Standards in Haematology(1999) Transfusion taskforce. Guidelines for the administration of blood components and management of the transfused patient. Transfusion Medicine; 9: 227–238.
European Parliament (2002) European Council Directive (2002/98/EC) of the European Parliament and of the Council of 27 January 2003. Setting standards of quality and safety for the collection, testing, processing, storage and distribution of human blood and blood components.
Huber, D. (2006) Leadership and Nursing Care Management (3rd ed). Philadelphia, PA: Elsevier.
McClelland, D.B. (2002) Handbook of Transfusion Medicine (3rd ed). London: Stationery Office.
National Patient Safety Agency (2006) Safer Practice Notice. Right Patient, Right Blood. London: NPSA.
Office of Public Sector Information (2005) The Blood Safety and Quality Regulations 2005. London: OPSI. www.opsi.gov.uk/SI/si2005/20050050.htm
Royal College of Nursing (2005) Right Blood, Right Patient, Right Time. London: RCN.
Serious Hazards of Transfusion (SHOT) (2004) Annual Report 2002–03. Manchester: SHOT.