• Hepatitis C virus-infected patients with a persistently normal alanine aminotransferase: do they exist and is this really a group with mild disease?

      Lawson, A (2010-01)
      Opinion varies on whether or not hepatitis C virus (HCV) infected patients with persistently normal aminotransferase (PNALT) levels represent a group with mild disease. To evaluate the risk of ALT flare and fibrosis progression in patients with PNALT followed up as part of the Trent HCV cohort. Treatment-naïve patients with an elevated ALT (n = 1140) or PNALT, the latter defined as either an ALT < or = 30 IU/L (n = 43) or an ALT < or = 40 IU/L (n = 87) on > or =2 occasions in the 6 months following diagnosis, and no ALT > 40 U/L were included. The likelihood of maintaining a PNALT < or = 30 IU/L was 42.2% and PNALT < or = 40 IU/L 41.7% at 3 years. The Ishak fibrosis score was > or =3 in 3.7%, 8.3% and 29.6% of patients with PNALT < or = 30 IU/L, PNALT < or = 40 IU/L and elevated ALT, respectively. Fibrosis progression between paired biopsies was similar for patients with PNALT < or = 30 IU/L (0.33 +/- 0.94 Ishak fibrosis points/year), PNALT < or = 40 IU/L (0.35 +/- 0.82) and elevated ALT (0.19 +/- 0.48). The majority of those defined as PNALT subsequently have an abnormal ALT. They have a similar risk of disease progression to other HCV infected patients and, therefore, warrant the same consideration with regard to treatment.
    • A comparison of the natural history and outcome of treatment for Asian and non-Asian hepatitis C-infected patients.

      Lawson, A (2011-07)
      Ethnicity is an important host variable, but its impact on disease progression and response to therapy in Hepatitis C infection is unclear. Here we compare the natural history and outcome of therapy in white and Asian (Indian subcontinent) Hepatitis C infected patients. A total of 2123 White and 120 Asian HCV infected patients were identified within the Trent HCV study. Response to therapy was assessed in 224 white and 46 Asian patients with genotype 3 infection who received pegylated interferon and ribavirin. Asian patients were more likely to be older, female, infected with genotype 3 and to consume no alcohol. At time of first biopsy, fibrosis stage was significantly higher in Asian patients than in Whites (3.0 ± 2.3 vs 1.8 ± 2.0, P < 0.001), as were necro-inflammation and steatosis scores. However, in those patients where duration of infection could be estimated, fibrosis progression was similar for both groups (0.25 ± 0.31 vs. 0.16 ± 0.54 Ishak points/year, P = 0.068). 78.3% of Asian and 67.9% of White genotype 3 patients had a sustained virological response following Pegylated Interferon and Ribavirin. Cirrhosis and increased levels of GGT, but not ethnicity were associated with a reduction in the likelihood of a sustained virological response on multivariate analysis. Asian patients with Hepatitis C are more likely to be female, less likely to give a history of risk factors, present to medical services at an older age, and have more severe liver disease at diagnosis, but disease progression and response to treatment are similar to white patients.
    • Late discovery of a case with TAR syndrome who presented with an additional potential bleeding risk other than thrombocytopenia

      Van Staden, Bernhard; Ahmad, Humayun (2013-04)
      The name of this syndrome based on an acronym describing the so called 'most obvious' clinical features: Absent Radii & Thrombocytopenia (TAR). There may however be more to TAR cases than what the name says. Development of molecular genetics has provided us with more information and given us a better understanding of these rare conditions. The deletion of chromosome 1q21.1 associated with TAR syndrome, involves the RBM8A gene which is associated with the production of certain cellular proteins. A newly referred 33 year old woman presented with conspicuous upper limb deformities in the presence of thrombocytopenia (platelets 63) at one of our clinics. The patient was never diagnosed nor given a specific name for her abnormal physical appearance in the past. Plain x-rays of the forearms confirmed absent radii. An ultrasound of the abdomen to exclude splenic sequestration of the platelets surprisingly revealed lesions in keeping with arterio-venous malformations/ haemangioma of the liver. It was uncertain if this finding was related to TAR syndrome, however not unlikely as these cases may present with other arterio-venous malformations, like facial haemangiomas and intracranial vascular malformations. The bleeding risk associated with this finding and particularly in this patient with thrombocytopenia was of great concern. The case was also referred to the hepatology team for further management of the hepatic haemangioma. One can conclude from this case that patients with suspected TAR syndrome may require more detailed imaging as there are many other features, some quite life threatening, which are not included in the short acronym based name.
    • Two case studies showing the importance of Coumarin tracing blood assays to investigate acquired coagulopathies in patients with selfharm behaviour

      Ahmad, Humayun; Van Staden, Bernhard; Channa, Jawaid (2013-04)
      We have recent experience of two cases who presented with unexplained coagulopathies. Neither of them had a family or previous personal history of a bleeding tendency. They both denied the use of any medication. One case presented with unexpected menstrual bleeding after a contraceptive coil insertion. The other case presented with severe post-surgical bleeding following a gynaecological procedure for infertility. She ended up in ITU with a near fatal outcome. Both had a prolonged APTT and PT/INR which corrected with the addition of normal plasma and thus in keeping with factor deficiencies. Further factor assays revealed low levels of Factor II, VII, IX and X as one could expect with Coumarin-like drugs. With normal CTD screens and a high index of suspicion it was decided to send samples for Coumarin drug tracing/assays. With the latter, results of the first case mentioned above, showed to have Difenacoum present in the blood. Difenacoum is a rodenticide and has a significant longer half-life than Warfarin. The other case had traces of ordinary Coumadin (Warfarin) in her blood. They both responded significantly to Vitamin K therapy. Self-harm, per definition, includes self-injury and self-poisoning and is defined as the intentional, direct injuring of body tissue most often done without suicidal intentions. It is estimated that about 10% of admissions to medical wards in the UK are as a result of self-harm, the majority of which are drug overdoses. Both of the cases mentioned above had near fatal outcomes and it is important that one should consider Coumarin tracing assays as part of the work-up in patients with new acquired coagulopathies.
    • Understanding patterns of ordering common blood tests in patients admitted to hospital-an audit to evaluate number and frequency of common blood tests in admitted patients in a medium sized DGH

      Ahmad, Humayun; Proud, Rebecca; Lennerova, Tereza; McDougall, Alexandra; Spence, Chloe (2013-06)
      Blood tests play a very important part in the diagnosis and management of most diseases and pathology costs form significant proportion of the health service budget. The Independent Review of Pathology Services in the National Health Service UK by Lord Carter postulated that savings of 500 million annually are possible by reducing wastage. In cost reduction strategies most savings are predicated on economies of scale and service redesign, creating larger pathology units with Hub and Spoke models to reduce waste and improve efficiency by up-scaling automation and downscaling staffing levels etc. However, inappropriate and unnecessary blood tests also contribute significantly to waste but there is a dearth of literature or guidance on this subject. Aims: The aim was to evaluate number, frequency and appropriateness of common blood tests in adult patients admitted to the hospital in order to assess for possible wastage Methods: In our study we conducted a retrospective audit on approximately four hundred patients admitted to a medium sized District General Hospital. Obstetric and paediatric patients were excluded from this study. The remaining 309 patients were evaluated using the electronic patient records. . The purpose was to study the number and frequency of common blood tests e.g. Full Blood Count, Renal and Liver blood tests. The data on Length of stay was also evaluated. The cohort was subdivided into following subgroups for data analysis: Medicine, Care of the Elderly, Orthopaedics & Surgery. Results: Our results showed that over 50% of admitted patients were medical patients who also had a longer average length of stay than the surgical cohort. Consequently, average number of tests per patient was higher in medical patients but frequency of repeating blood tests appeared broadly similar in medical and surgical groups. The repeat ordering of blood tests did not appear to be influenced by abnormal results as similar frequency of repeat blood tests was noted in patients with normal and abnormal results. The repeat ordering appeared to follow a recurring pattern rather than being reactive to the results of the previous test. There was significant wastage as blood tests were frequently repeated even when recent results were within normal range. On the contrary in some patients repeat tests were not ordered despite abnormal results. It was also interesting to note that there was no significant difference in repeat ordering of blood tests between cases showing severe abnormalities of Full Blood Count and those with milder abnormalities. Summary / Conclusion: Although our audit had a number of limitations, it highlights the need for further studies to evaluate the pattern of ordering common blood tests in hospitalised patients with a view to identify wastage and minimise it. There is also need for developing evidence-based consensus on how to reduce unnecessary testing without compromising patient safety. Published literature on this subject is limited and much innovative research is possible.
    • Cholesteryl ester storage disease: a rare and possibly treatable cause of premature vascular disease and cirrhosis

      Reynolds, Tim (2013-09)
      Cholesteryl ester storage disease (CESD) is an autosomal recessive lysosomal storage disorder caused by a variety of mutations of the LIPA gene. These cause reduced activity of lysosomal acid lipase, which results in accumulation of cholesteryl esters in lysosomes. If enzyme activity is very low/absent, presentation is in infancy with failure to thrive, malabsorption, hepatosplenomegaly and rapid early death (Wolman disease). With higher but still low enzyme activity, presentation is later in life with hepatic fibrosis, dyslipidaemia and early atherosclerosis.Identification of this rare disorder is difficult as it is essential to assay leucocyte acid phosphatase activity. An assay using specific inhibitors has now been developed that facilitates measurement in dried blood spots. Treatment of CESD has until now been limited to management of the dyslipidaemia, but this does not influence the liver effects. A new enzyme replacement therapy (Sebelipase) has now been developed that could change treatment options for the future.
    • Sweat Testing Since The Introduction Of Newborn Screening In West Midlands, UK

      Ahmed, Mansoor; Reynolds, Tim (2014)
      Background Cystic Fibrosis (CF) is an autosomal recessive condition caused by gene mutation which affects sodium and chloride transport across the membrane of secretory epithelial cells. New born screening for CF was introduced in the West Midlands, UK in November 2006. ~20% of CF patients may present with meconium ileus. The majority of the remainder are expected to be picked through new-born screening. Sweat test remains the gold standard for the diagnosis of CF and is a critical component of +ve newborn CF screening protocol. Aim To investigate the positive yield of sweat test at Queen’s Hospital Burton Upon Trent (in patients with negative new born CF screen) since the introduction of new born CF screening. Methods We retrospectively collected local data on all the sweat test results since the introduction of new born CF screening in the West Midlands. Results Out of 129 sweat tests performed, only one case yielded positive result (born before new born CF screening). Another patient had a borderline test result which was subsequently repeated and found to be normal. Therefore, we effectively have no positive sweat test results so far since the screening commenced. Conclusion Even though our data is encouraging and suggests increasing the threshold required for performing a sweat test (in individuals born after Nov 2006), this investigations should still be carried out in patients with high index of clinical suspicion as occasional cases will be missed despite universal new born CF screening programme.
    • Identifying patients with non-valvular atrial fibrillation & poorly controlled INR on warfarin who are suitable to be switched to NOACs

      Ahmad, Humayun; Van Staden, Bernhard (2014-05)
      There are quite a significant number of patients of non valvular Atrial Fibrillation (AF) who are on Warfarin for stroke prevention but fail to achieve stable INR control and hence remain at risk. In recent years at least three different New Oral Anticoagulants (NOACs) have been shown to be effective as well as non inferior to Warfarin for stroke prevention in AF. These drugs despite not having effective antidotes yet are considered to have lesser risk of serious bleeding than Warfarin. Although work may be in progress, no clear guidelines have yet been established to decide which patients require switching to NOACs and when. We decided to address this in the form of an audit of Percent time in therapeutic INR range (TTR) amongst AF patients attending our Warfarin Dosing Service. Using our electronic patient records a total of 797 patients were identified as non-valvular AF patients on Warfarin at our dosing service. We found that 79% of these patients had a TTR of more than 60% and 53% above 70%. The 21% patients who did not meet the TTR target were arguably still at a higher risk of stroke. Moreover the fluctuation in their INRs also put them at a higher risk of bleeding. We went on to check the records for abnormalities of renal (eGFR) and liver blood tests (LFTs) in this cohort. Our results showed that 94% of these patients had normal LFTs, 97% had eGFRs of >30 and 59% had eGFRs of >60. Thus majority of the patients in this cohort were eligible for switching to NOACs. Although our data is limited to a single center, it suggests that approximately 20% of the AF patients on Warfarin may require switching to a NOAC due to poor INR control.
    • Experience of romiplostin use in the management of ITP in a district general hospital setting-can fixed doses be used during stable phase to reduce wastage?

      Van Staden, Bernhard; Ahmad, Humayun (2014-05)
      The thrombopoetin receptor agonist, Romiplostim is indicated in chronic ITP patients with refractory ITP. We reviewed and analysed the data from two refractory ITP patients managed with Romiplostim. Using current manufacturer guidelines, we started with weekly dosing adjustments aiming for the recommended baseline platelet count of at least 50 9 109. Guidelines recommend an initiating dose of 1mcg/kg per week with increase in 1mcg increments to a maximum of 10 mcg/kg weekly until platelet count is stabilized above mentioned baseline. Hereafter, monthly blood tests are recommended and readjustment made if platelet count exceeds 200 x 109. Our patients commenced on 1mcg/kg, though once the platelet count was consistently above baseline, after a few dose adjustments, we found in both patients that during the stable phase, 250 mcg hence between 3 and 4 mcg/kg per patient respectively was an ideal maintenance dose that consistently kept the platelet count above 50 x 109 without requiring need for regular dose adjustment. Therefore these two patients have now been continued on this fixed dose and have shown an excellent response. Though our experience is limited, we have found a standard dose of 250 mcg to be an effective in maintenance of safe platelet counts. Also, as Romiplostim is available only in 250 and 500 mcg vials, variable doses will invariably lead to some wastage of this expensive drug. Given the economic climate and to simplify self-administration we propose further studies are required to assess whether a fixed dose of Romiplostim can be established for stable phase management of chronic ITP.
    • Paper based system can achieve 100% traceability in transfusion-an audit report

      Jeyachandran, Jeby; Li, Ellen; Buchan, Julie; Harlow, Glenys; Ahmad, Humayun (2014-10)
      The Blood Safety and Quality Regulations 2005 require 'unambiguous traceability' of all blood and blood components from a donor to patient, or the final destination of all blood and its components if not transfused. Achieving 100% traceability is considered difficult and often electronic blood tracking system has to be purchased to maintain 100% traceability. The electronic blood tracking system has a varied degree of success and only few studies have achieved 100% traceability. Given the current financial climate in the NHS it is difficult to obtain funding and the mis-scanning of blood product and skipped steps during the process highlights the vulnerability of the electronic tracking system. At Burton Hospitals NHS Foundation Trust we have used the paper based system effectively and we have been able to achieve 100% traceability We reviewed our paper based system and the process for haemovigilance and looked at a month's data. A retrospective audit was done during the month of April to evaluate the effectiveness of the paper based system. The data was collected from the data warehouse through LABS project and from the issue transfusion follow up sheet. Our audit shows that we had 423 transfusions including blood and blood products in the month of April. 413(97.4%) issue transfusion forms were returned within the stipulated 3 day period. On further follow up by phoning the ward 4 more forms were returned on the 6th day from transfusion. An adverse incident was logged for the remaining transfusions and the transfusion practioner was able to end fate the unit by obtaining information from the patient's drug administration notes. Conclusion: Our audit shows that paper based system can be effective in achieving 100% traceability of transfusion in a medium sized district general hospital.
    • Varying ability of monoclonal anti-D reagents and weak RhD discrepancies-our experience

      Jeyachandran, Jeby; Li, Ellen; Rady, Richard; Vintila, Oana; Ahmad, Humayun (2014-10)
      Rh is one of the important blood group system and D antigen is the most immunogenic and clinically significant because of the ability to cause haemolytic disease of new born and transfusion reactions. The monoclonal anti-D reagents used to detect D antigen vary widely in their ability to detect both partial and weak D but can detect the weakest Rh D type. Variation of clones used in the monoclonal anti- D reagent may cause discrepancies when variant D is detected. Recently as part of our cost saving measure we introduced the use of DiaClon ABD (DVI-) confirmatory cards for patients with a known historical blood type but the different clone of monoclonal anti-D reagent used in the confirmatory card led to significant discrepancies between the historical and current RhD type on weak RhD patients. In order to assess the level of discrepancy on weak RhD patients a prospective audit was carried out from 01.11.2013 to 30.04.2014 on all samples that were reported RhD weak positive and on samples that did not match the historical RhD type. All antenatal samples which gave a weak reaction were referred to NHSBT for confirmation. 23 samples were identified to have weak RhD type and out of the 23 samples 3 did not have previous history therefore it was excluded from the study. Out of the 20 samples 6 (30%) gave a discrepant RhD type. Four of them gave RhD positive result and 2 of them Rh D Negative results. The samples which gave a negative result were referred to NHSBT and confirmed as Weak RhD type. Conclusion: Our audit shows significant discrepancies between the monoclonal reagents used and highlights the need for manufacturers to standardise the monoclonal reagents to minimise the weak RhD type discrepancies.
    • Health Assessment Questionnaire disability progression in early rheumatoid arthritis: systematic review and analysis of two inception cohorts.

      Deighton, Chris (2014-10)
      OBJECTIVE: The Health Assessment Questionnaire is widely used for patients with inflammatory polyarthritis (IP) and its subset, rheumatoid arthritis (RA). In this study, we evaluated the progression of HAQ scores in RA (i) by systematically reviewing the published literature on the methods used to assess changes in functional disability over time and (ii) to study in detail HAQ progression in two large prospective observational studies from the UK. METHODS: Data from two large inception cohorts, ERAS and NOAR, were studied to determine trajectories of HAQ progression over time by applying latent class growth models (LCGMs) to each dataset separately. Age, sex, baseline DAS28, symptom duration, rheumatoid factor, fulfilment of the 1987 ACR criteria and socio-economic status (SES) were included as potential predictors of HAQ trajectory subgroup membership. RESULTS: The literature search identified 49 studies showing that HAQ progression has mainly been based on average changes in the total study population. In the HAQ progression study, a LCGM with four HAQ trajectory subgroups was selected as providing the best fit in both cohorts. In both the cohorts, older age, female sex, longer symptom duration, fulfilment of the 1987 ACR criteria, higher DAS28 and lower SES were associated with increased likelihood of membership of subgroups with worse HAQ progression. CONCLUSION: Four distinct HAQ trajectory subgroups were derived from the ERAS and NOAR cohorts. The fact that the subgroups identified were nearly identical supports their validity. Identifying distinct groups of patients who are at risk of poor functional outcome may help to target therapy to those who are most likely to benefit.
    • Prognostic significance of lymphatic invasion in lymph node positive breast carcinoma: findings from a large case series with long-term follow-up using immunohistochemical endothelial marker.

      Menon, Sindhu (2014-12)
      The poor prognostic significance of lymphatic invasion (LI) in breast carcinoma (BC) as a whole and in lymph node (LN)-negative patients in particular has been recognized in several studies; however, its prognostic role in LN-positive patients is still questionable. Aim of the current study was to assess prognostic role of LI in LN-positive BC specimens. Sections from non-selected 557 LN-positive BC specimens were stained with antibody to podoplanin/D2-40. LI was identified and correlated with clinicopathological features and patients' outcome. Twenty-year overall survival (OS), disease-free interval (DFI), and development of distant metastasis (DM) or recurrence were known for all patients. LI was detected in 262/557 (47%) of specimens ranging from 1 to 350 lesion per tumor section. Its presence was associated with higher grade tumors (P<0.0001), negative hormonal receptors (P<0.0001), high HER-2 expression (P=0.006), and with increased number of positive LNs (P=0.019). In the whole LN-positive BC, presence of LI was a poor prognostic factor for OS, DFI, and development of DM both in univariate and in multivariate analysis. In further stratification of patients, LI was associated with poorer prognosis in patients with single positive LN and not in patients with >1 positive LN. In T1N1 stage, LI was highly associated with poor OS (P=0.002), DFI (P<0.0001), and DM (P<0.0001). In T2N1 patients, LI was associated only with poorer DFI (P=0.037) but not with death or DM. In the two former patient groups, LI lost significance in multivariate analysis. In conclusion, LI is a poor prognostic factor in LN-positive BC particularly for patients having single positive LN. LI therefore would add further prognostic significance when considered in treatment in those patients. We recommend incorporation of LI in breast carcinoma staging and in prognostic indices.
    • Do the EULAR Sjögren's syndrome outcome measures correlate with health status in primary Sjögren's syndrome?

      Regan, Marian (2015-04)
      OBJECTIVE: This study sets out to investigate the relationship between health status [EuroQol five-dimensions questionnaire (EQ-5D)] in primary SS and three of the European League Against Rheumatism (EULAR) SS outcome measures-the disease activity index (ESSDAI), the patient reported index (ESSPRI) and the sicca score. In particular, the goal was to establish whether there is a relationship between the EULAR outcome measures and quality of life. METHODS: Health status was evaluated using a standardized measure developed by the EuroQol Group-the EQ5D. This permits calculation of two measures of health status: time trade-off (TTO) values and the EQ-5D visual analogue scale (VAS) scores. We used Spearman's rank correlation analysis to investigate the strength of association between health status and three EULAR measures of physician- and patient-reported disease activity in 639 patients from the UK primary SS registry (UKPSSR) cohort. RESULTS: This study demonstrates that the EULAR SS disease-specific outcome measures are significantly correlated with health outcome values (P < 0.001). Higher scores on the ESSDAI, EULAR sicca score and ESSPRI are associated with poorer health states-i.e. lower TTO values and lower VAS scores. While all three are significantly correlated with TTO values and EQ-5D VAS scores, the effect is strongest for the ESSPRI. CONCLUSION: This study provides further evidence supporting the use of ESSDAI, EULAR sicca score and ESSPRI measures in the clinic. We also discuss the need for disease-specific measures of health status and their comparison with standardized health outcome measures.
    • Successful creation of an electronic decision support tool to educate clinicians and develop a database to monitor the appropriate use of blood components at Burton Hospitals NHS foundation trust

      Jeyachandran, Jeby; Buchan, Julie; Hopley, Alex; Ahmad, Humayun (2015-06)
      In the UK 2.9 million blood components are issued every year and only 4% of the eligible population give blood. When used safely and appropriately, blood transfusion saves and improves patient's lives however it is not risk free as death and major morbidity can occur when things go wrong with transfusion. The national audits show that 15-20% of red blood cell transfusions and 20-30% of plasma/platelets transfusions are inappropriate. One of the methods to restrict the inappropriate use of blood and blood component is through an electronic decision support tool to provide education at the point of requesting blood product with feedback message. The use of National Blood Transfusion Committee (NBTC) indicationcodes allow accurate audit Aims: The principal aim was to create an electronic decision support system with feedback messages based on the selection of the indication codes for transfusion to assist with appropriate use of blood products. Methods: Using our electronic patient record system (Meditech) a new custom defined screen wascreatedas a step in the blood ordering processto support decision making. The indication codes for the use of blood components recommended by National Blood Transfusion Committee were included as part of ordering process. The electronic decision support system allows us to integrate the codes in the ordering process. Feedback messages were programmed to provide information on the use of blood component. To capture this data a functional database was created from the Meditech data repository application. This functional live database includes the reason for transfusion, patient's recent Hb level, indication codes, ordered by and other parameters required for monitoring the appropriate use of blood and blood components. Results: We have successfully created a custom defined screen to help the clinicians make the right decision on the appropriateness of blood and blood component transfusion. A live functional database has been created to monitor the use of blood components. The data from this database will be used to provide feedback to other teams. Conclusion: Decision making on the appropriate use of blood components is a critical process and should be based on the clinical findings, laboratory parameters and in line with national guidelines. We believe the use of newly created electronic decision support system as part of the blood ordering process can help clinicians to make the correct decision. The database will provide further insight in to the ordering behaviour of clinicians which we believe will help the Hospital Transfusion team to monitor the use of blood components. Although this was created with Meditech electronic patient record system the same method and principle can be applied to other electronic patient record systems.
    • Successful use of a charity to transport blood samples and blood components between a district general hospital and the national health service blood and transplant Birmingham

      Jeyachandran, Jeby; Woodward, Karen; Ahmad, Humayun (2015-06)
      The transport of blood components are required to meet stringent standards as set out by the Blood Safety and Quality Regulations (BSQR) 2005 based on the 002/98/EC and 2004/33/EC European directive. In UK the blood components are provided by NHSBT which also provides the transport for these products. Such a standard transport of blood component has a significant cost implication to NHS. Moreover hospitals will have to rely on courier services to send urgent referral samples to NHSBT which adds additional cost to NHS. This is further compounded by the fact by some blood component such as platelets which has a short shelf life unlike red blood cells and fresh frozen plasma. Some charities are keen to help in the delivery of health care systems and we present this abstract in collaboration with Shropshire and Staffordshire Blood Bikes. Aim: The main was to create a robust and validated system for transport of blood components and urgent samples to NHSBT using the volunteers from the charity who use the motor bikes for this purpose. The challenge was to ensure full adherence to the BSQR 2005. Methods: After the expression of interest from the charity various meetings were held between the Hospital Transfusion Team and charity leadership to complete the feasibility. Advice was sought from the trust legal and governance team as well as professionals from NHSBT and blood bank managers from this region. A clinical risk assessment was completed and once the safety and feasibility was established we embarked on the validation of the transport boxes. Clinimed UBP-110 & UBP-130 boxes were selected for validation. The acceptance criteria for red blood cell is that the blood surface temperature was maintained between 2C and 10degreeC for up to 4 h and 20-24degreeC for platelets. Once the validation was completed we embarked upon a training programme for all volunteers on the charity. A well structured programme was developed which includs annual training on Good Manufacturing Practice (GMP) and 2 yearly training and competency assessment on safe transport of blood components, spillage management, security breach and delivery and collection arrangements. Results: We have successfully established a transport system for blood and blood components between our hospital and NHSBT Birmingham. There are 36 competent volunteer riders who have been trained and an on call rota has been established by the charity to provide an uninterrupted service. While we still use NHSBT blue light service for urgent deliveries the SSBB charity has taken over 75% of the adhoc deliveries. In the last 6 months the charity has so far completed around 90 deliveries to and from NHSBT Birmingham saving more than 5000. Conclusion: This is a novel project with a charity that is not costing any money and providing a safe transport system. We are the first hospital in the west midlands region to do this novel project and this project has helped to develop processes and systems that can be copied by other NHST Trust and charities.
    • Organisational change - Implementation of the two-sample rule for ABO/D grouping prior to the issue of RBC

      Buchan, Julie; Jeyachandran, Jeby (2015-06)
      ABO grouping is an important serological test performed on pre-transfusion samples. Unless secure electronic patient identification systems are in place, a second sample should be requested for confirmation of the ABO group. Burton Hospitals Blood Bank does not utilise a patient identification system. The 2 Sample Rule was introduced following a near-miss event of a Wrong Blood in Tube sample identified by a nurse providing a sample. Aim: The aim of this study was to evaluate the effectiveness of the introduction of a two-sample rule for transfusion of red blood cells (RBC) in a 450-bedded acute hospital. The purpose of this was to reduce the risk of ABO incompatible transfusion. Methods: A review of the Trusts practices was undertaken prior to implementing the 2 Sample Rule. A small-scale local audit was undertaken for three months post implementation to evaluate effectiveness of implementation. An organisational change management implementation approach was utilised. A systematic diagnosis of the current situation identified that current practice did not adhere to national pre-transfusion compatibility testing recommendations, and could potentially result in a transfusion of an incorrect blood product (Never Event). Approximately 80% of patients had a historical ABO group identified. Ability to identify specific patient groups who did not have this allowed for targeted implementation steps. Managing the change required involvement from the Hospital Transfusion Team, Hospital Transfusion Group and the Trusts Governance Groups to ensure support from the Directors and the utilisation of Governance structures to manage risk. A launch date for the 1st of August 2014 was agreed; chosen as it coincided with the Doctors change over period. A Patient Safety Week was held which included information stands, visits to clinical areas, distribution of information flyers and attending team meetings. Specific training was delivered directly to key areas where change in practice was required. Results: During the three month period 320 patients required transfusion of RBC's. This equated to 750 units of blood. 29 patients received 92 units without a 2nd sample due to emergency transfusion (9% of patients, or 12.2% of units transfused). Of these 92 units issued, 56 were issued to group O patients. 36 units were issued to patients with other blood groups (15 patients or 4.8% of red blood cells issued). During the implementation phase, use of O-Neg blood increased by 0.5%, and use of OPos increased by 11.7%. On-going monitoring shows this is reducing. Conclusion: Implementation of the 2 Sample Rule required planning and assessment. Initially there was minimal resistance, but this was soon overcome when people understood the benefits and the numbers of patients affected. The ability to understand where to target change was hugely beneficial. Clear guidance is needed to define '2 samples'. The audit showed that there was an improvement in the understanding of the 2 Sample Rule, and that initial concerns regarding an increased usage in O-Neg/O-Pos blood was justified, but not to the extent expected.