Blood and Tissue Resources

New York State Council on Human Blood and Transfusion Services

Guidelines for Transfusion Committees

Guidelines (PDF file size: 44k)

Introduction

Section 58-2.16(b) of 10 NYCRR requires that each facility that transfuses blood or supplies blood to limited transfusion services have in place a transfusion committee, composed of at least five members. The committee is responsible for reviewing transfusion practices, evaluating adverse transfusion events, and monitoring the adequacy of the blood supply, at all sites to which the facility provides blood products.

I. Appointment

The body must be a standing professional committee whose members are appointed according to institutional bylaws.

II. Composition

1. The blood bank director or transfusion service director (if different) must be a member of the transfusion committee.
2. It is recommended that the committee include representatives of the facility's services/departments that participate in the transfusion process, such as a(n):
   • surgeon
   • anesthesiologist
   • pediatrician or neonatologist (if applicable)
   • laboratory director
   • hematologist
   • internist
   • obstetrician
   • emergency medicine physician
   • intensivist (if applicable)
   • blood bank supervisor
   • nurse
   • member of hospital administration
   • representative of home transfusion services (if applicable)
   • pharmacist
   • perfusionist (if applicable)

III. Responsibilities

1. The transfusion committee should submit periodic reports to the institutional oversight body, as indicated, in accordance with institutional policy, concerning all of the following:
   • general statistics, including, but not limited to, the total number of transfusions, and the number and type of components transfused
   • number of blood units outdated or discarded
   • crossmatch/transfusion ratio
   • number of autogeneic (autologous) collections, if performed, and number of transfusions
   • hemodilution procedures performed in the operating room; intraoperative blood recovery procedures; and postoperative blood recovery procedures, including the number of procedures performed and the devices, technologies or methods used
   • number of reinfusion procedures (e.g., diagnostic procedures requiring radioisotope-labeled cell reinfusion) and any associated adverse events
   • number of blood products used for local application, such as fibrin glue and platelet gel
   • significant new or revised patient-related policies and procedures pertaining to transfusion services
   • all patient adverse reactions, including cases of suspected infectious disease transmission attributed to transfusion of blood, blood components or blood derivatives, providing details of serious reactions and the results of their investigation
   • all events required to be reported to regulatory agencies or accrediting organizations
   • results of proficiency testing and inspections conducted by external agencies
   • adequacy of and significant changes in blood services staff and
   • guidelines for appropriate use of blood components.
2. The committee may establish guidelines for reservation (compatibility or crossmatching) of blood and for typing and screening of patients scheduled for commonly performed elective surgical procedures for which blood transfusion may be anticipated. At a minimum, the committee must establish guidelines for each surgical procedure performed more than five times in the preceding calendar year, and set the maximum number of hours that crossmatched blood will be held on reserve.
3. The committee must have in effect a utilization and review plan for review of transfusion appropriateness and of all transfusion-related services, including intraoperative and postoperative recovery procedures, and all off-site transfusions for which blood components or derivatives have been issued. A prospective review plan is recommended.
4. Research-based blood products or substitutes (used in protocols approved by the Institutional Review Board) intended for transfusion should be reviewed by the transfusion service medical director, or referred to the transfusion committee by the medical director for further consideration by its members prior to implementation.

IV. Meetings

The committee must meet at least quarterly, and a majority of its members must be present at each meeting.