Delivering a High quality Intraoperative Cell Salvage Service. Malcolm Chambers Transfusion Practitioner Lead for Cell Salvage UHL. UKCSAG

Objectives Current practice in the UK. Risks. Training. Quality Control/Assurance. Audit. Teamwork.

Current Practice in the UK Introduced in NHS early 1990’s Health Service Circulars BBT1 /BBT2 1998- 2002. Operating Department Practitioners (ODP) usually the main operators of the ICS equipment. Staff in UK tend to operate ICS machines in conjunction with other roles/tasks. Now used routinely in the UK. Safe. (SHOT 2014)

Current Practice in UK Mainly used in elective setting. No real need for designated operators in these cases. Able to Plan ICS in advance. Within normal working hours. Should be safe to undertake ICS in conjunction with other tasks responsibilities ?.

ICS Incidents reported to SHOT 2010-2017 Number of Incidents reported = 151. 68 related to equipment or operator error. 27 – hypotension. (Most related to the use of LDF). SHOT 2014 Cell salvage using modern equipment is clearly very safe as the denominator (number of cell salvage procedures) is very high. SHOT 2016 Cell salvage appears to be a very safe procedure when undertaken by trained personnel but an increased awareness of the importance of reporting adverse events to SHOT seems to be needed.

SHOT reported incidents ICS blood had not been labelled with the correct patient identification. Collection of Blood following use of FibrillarTM (Topical cellulose-based haemostatic agent) Member of staff suspended as a result of incorrect assembly of equipment and use. ICS not being set up early enough during a caesarean section resulting in major morbidity and intensive care admission. Use of Hartmann’s solution to wash swabs. ICS Blood stored in a blood fridge. Cases of operator error where some of these could have potentially caused patient harm if not recognised.

SHOT Recommendations All cell salvage operators must undertake initial and regular update training and be assessed as competent (there should be documented evidence of competence in the form of a training record). Organisations should review on going competence and institute re-training or update training as necessary to ensure patient safety. Monitoring of patients is as important for the reinfusion of red cells collected by ICS as it is for allogeneic red cells. Cell salvage should be performed to standard protocols identified by the organisation to reflect best practice. All organisations should develop a robust system for reporting all adverse incidents/reactions during the use of autologous blood techniques, preferably reporting to the hospital transfusion committee and onward to SHOT.

What needs to be reported

Incident Reporting Who needs to Know? Blood Bank Trust Incident reporting system. Transfusion Practitioner/Team SHOT

ICS Training Which groups of staff need training in ICS?. Formal training programme. (UKCSAG Workbook) Formal competency assessment. ( UKCSAG) Use of ICS restricted to appropriately trained staff. Training material /Assessment tools mapped to National standards. (KSF)

NOS / KSF https://tools.skillsforhealth.org.uk/competence_search/ PCS19 Prepare equipment for intra-operative blood salvage collection. PCS20 Operate equipment for intra-operative blood salvage collection. PCS21 Prepare equipment for processing intra-operative salvaged blood. PCS22 Operate and monitor equipment for processing intra-operative salvaged blood and complete salvaged blood processing.

Training Learn Cell Salvage https://nhs.learnprouk.com Learn Cell Salvage is designed to offer any learner the opportunity to gain a broad understanding of the principles of cell salvage and increase your awareness of a range of blood conservation of intraoperative cell salvage (ICS) and postoperative cell salvage (PCS). This course is aimed primarily at doctors, nurses, operating department practitioners, cell salvage operators, clinical perfusionists, and clinical support workers. One session split into four units: Basic Blood Facts Blood Conservation Intraoperative Cell Salvage Postoperative Cell Salvage (PCS)

ICS Quality Assurance Maintenance of machines. Standard Operating Procedures. Formal training programme. Sample of ICS Blood for re-infusion taken monthly from each machine and the Hct - Hb levels recorded. Register of trained staff. Record of ICS cases on individual patient’s.

Team Approach to ICS Whole theatre team is aware of the contraindications in ICS, not just the member of staff operating the machine. UKCSAG: 2014 A Survey of Equipment and Practice across the UK 59% of anaesthetic trainees said they did not receive any theory or practical training in ICS. Increase safety/reduce risks. Invaluable in Emergency/Acute ICS cases.

ICS in Emer/acute settings.

SHOT Incident Major morbidity and intensive care admission as a result of cell salvage not being set up early enough during a caesarean section.

Main issues with ICS in Emer/acute setting Unable to Plan in advance. Dynamic & quick changing situation. Staff have multiple tasks to perform. Often out of hours. Minimal amount of staff available/on duty. Unable to mobilise staff. Stressful situation. High blood loss.

Undertaking ICS in Emer/Acute setting requires Team Work

ICS in Emer/Acute Setting HCA More urgent tasks to do!!! With this amount of staff it should be easy to set up ICS in this emergency situation?

Key to ICS in emergency cases is setting up the Collection set

Utilizing the team to set up ICS collection set Non Registered Staff (HCA’s). Trained to set up Collection. (May need to use Citrate (ACDA) as Anticoagulant). Formal Training Including formal assessment.

Using ICS outside of Theatres

In Summary. Clear standard operating procedures for all techniques/areas. (separate SOP for Ob’s) Use of techniques restricted to appropriately trained staff (competency assessed). Team Work. (Utilise the whole team) Quality Assurance/Control. Audit – data collection and analysis. Incident monitoring/reporting system. Ensure all patients that are eligible for ICS get ICS.

Thank You