North Thames Regional Transfusion Committee Survey of the Implementation of the EU Blood Directive Jan Green, National Blood Service Erika Rutherford, National Blood Service Dr. Shubha Allard, Northwick Park Hospital David Mold, Northwick Park Hospital

Introduction Although the EU Blood Safety Directive became law in February 2005 the UK was allowed to maintain existing arrangements for a further 9 months until November 2005. Many trusts are finding parts of the directive (traceability) difficult to implement. The RTC have been asked by its members to survey Trusts within region about their plans and experiences.

Methodology A questionnaire, adapted from the questionnaire created by the West Midlands RTC, was circulated to the Hospital Transfusion Teams at all hospitals, both NHS and private sector, within the region. Sixteen questionnaires were returned. Thirteen NHS Trusts responded which represented 18 Hospitals. Three private sector hospitals also responded.

Do you have a project lead for the implementation of the Directive? Has the Chief Executive and Clinical Governance/Clinical Risk Lead of your Trust been informed of the Directive and their responsibilities under it? Do you have a project lead for the implementation of the Directive? Yes - 16 Not recorded No Yes Total 1 14 16

Project leads Assistant Director of Operations, Emergency Services 1 Hospital Transfusion Team 4 Chief BMS Transfusion 2 SPOT Chief BMS Transfusion and SPOT Transfusion consultant and Chief Transfusion BMS Transfusion consultant Senior Manager of directorate Director of Clinical Governance Total   14 Director of Nursing

Traceability Systems Manual 2 respondents using blood register/book 9 respondents using or planning to use Luggage Labels.-Only one Trust has budgeted for extra staff 5 respondents using Returned Bags. 2 respondents planning to use carbon copies of Compatibility Sheets. Please note that one trust is using both returned bags and luggage labels

Traceability Systems Electronic In the short term there is currently no Trust implementing or planning to implement an electronic tracking system. The main reason given is cost. Four respondents are looking at electronic tracking systems in the long term

Quality Management 14 respondents have access to a Quality Manager. Seven respondents thought the amount time allocated to Quality Management was sufficient whilst five did not. WTE 1 6 Shared with rest of Pathology - 4 WTE 0.7 1 Shared with rest of Pathology WTE 0.5 3   WTE 0.1 Needs 0.5-currently being negotiated WTE Not recorded

Processing Only one hospital has registered as a Blood Establishment (For Irradiation). Two respondents have stopped processing blood. (one –PAD, one -irradiation).

Adverse Events All respondents (16) report both incidents and near misses to SHOT. 14 respondents have a representative of Clinical Governance/Risk Management on their Hospital Transfusion C’tee All respondents report adverse events to the Clinical Incident System. 13 respondents have a formal link between Clinical Risk and the HTT

Training Induction Only Induction/Update Not trained Junior Doctors 8   Induction Only Induction/Update Not trained Junior Doctors 8 6 2 Consultants 3 7 Nurses 13 - Porters HCAs 10 BMS Phlebotomy 1  - Catheter Laboratory staff and Perfusionists - 

Training Records All fifteen respondents maintain training records. However only five respondents keep their records on a central training database.