Grampians Health Ballarat (GHB) is committed to the promotion of safe, high quality management and stewardship of blood and blood products. This policy outlines the responsibilities of GHB with regard to the responsible, sustainable and appropriate care of a patients own blood as well as blood and blood products.

GHB will meet the principles of Blood Stewardship and Blood Management

• Provide an adequate, safe, secure and affordable supply of blood products, blood related products and blood related services; and

• Promote safe, high quality management and use of blood products, blood related products and blood related services.

• Promote responsible, sustainable and appropriate care of a patients own blood

GHB Blood Management will align with the National Safety and Quality Health Service (NSQHS) Standards.

Blood products include

Fresh blood components

• red blood cells

• platelets

• clinical fresh, frozen plasma

• cryoprecipitate

• cryodepleted plasma

Plasma derivatives and recombinant products,

• albumin

• immunoglobulins and hyperimmune globulins

• coagulation proteins

• coagulation and complement inhibitors.

Blood Stewardship Principles

Blood will be managed in ways that ensure:

• All blood products are used in a clinically appropriate manner in accord with relevant professional guidelines and standards;

• Informed patient consent procedures are implemented for all patients;

• Processes, programs, and facilities are in place to minimise the wastage of blood products;

• GHB is accredited with the appropriate bodies to meet all quality and safety obligations; and

• Transfusion related adverse event information is collected and managed according to jurisdictional requirements.

Blood product planning, management, and governance are supported by:

• An ordering and receipt verification process in place which provides adequate financial accountability

• Inventory data provided on a regular and timely basis to assist in supply and demand planning, especially in times of national shortages.

Patient Blood Management Principles

Patient Blood Management views a patients own blood as a valuable and unique resource to be conserved and managed appropriately.

Patient Blood Management takes an individualised approach to the management of a patients blood by plans to:

• Optimise a patients own red cell mass, haemoglobin and iron stores

• Minimise blood loss by identifying and managing patients with, or at risk of bleeding

• Optimise patients physiological tolerance of anaemia

Responsibilities

Chief Executive

• Assigning responsibility to the Executive Sponsor responsible for ensuring that current policy and procedures are in place to underpin organisational efforts to comply with National Safety and Quality Standard Blood Management

Executive Sponsor

• Ensuring that current policy and procedures are in place to underpin organisational efforts to comply with National Safety and Quality Standard Blood Management

• Ensuring compliance with this Policy Directive is affected and monitored resulting in achieving and maintaining accreditation NSQHS V2 Standard

Clinical and operational directors and managers

• Ensuring staff are trained in procedures and practice to enable compliance with the policy and related procedures

• Ensuring departmental and ward clinical governance processes and procedures are in place to identify non-compliance and take appropriate action

Grampians Health Services Staff

• Complying with requirements for own training and professional practice

• Adhering to agreed policies and procedures to ensure safety and quality use of blood products

Legislative Compliance

• Therapeutics Goods Act 1989

• Human Tissue Act 1982 (VIC)

• National Blood Authority Act 2003