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Post-transplant care units in JACIE Accreditation

JACIE Committee

The JACIE Committee has agreed that from March 2024, any Clinical Programs that transfer patients to post-transplant care units prior to stable engraftment will be inspected for compliance against Standard B7.10.1 (8th Edition of the Standards). Centres will need to provide evidence that they have verified the post-transplant care unit is compliant as described in the Standard. The post-transplant care units will not be included in the scope of Accreditation and the Inspectors will not visit these sites. 

B7.10 There shall be policies or Standard Operating Procedures in place for planned discharges and provision of post-transplant care.
           B7.10.1 When a recipient is discharged prior to engraftment, the Clinical Program shall verify that the following elements are available:
                         B7.10.1.1 A consult between the attending physician and the receiving health care professionals regarding the applicable elements in Standard B7.7.
                         B7.10.1.2 Facilities that provide appropriate location, adequate space, and protection from airborne microbial contamination.
                         B7.10.1.3 Appropriate medications, blood products, and additional care required by the recipient 

Discharges should normally take place after hematopoietic engraftment. A Clinical Program may adopt a policy for discharging recipients before engraftment, with ongoing inpatient care undertaken at another facility. It may be necessary to collaborate with health care providers in local or regional facilities to provide a portion of post-transplant care. This may not involve direct provision of care but must work operationally within the Quality Management systems of the facility. 

The working relationships between the Clinical Program and receiving facility shall be clearly documented, including explicit criteria for transfer back to the program. Communication used to fulfill the requirement for a consult must be documented and available for inspectors.

The Clinical Program QM Plan should describe the process for collaborative care arrangements, including criteria for participation by specific patients, health care providers and facilities. Recipient outcomes under this type of arrangement must be monitored. Inspectors will determine if receiving facilities are adequately assessed for post-transplant care. 

They will evaluate the receiving facility to verify all elements are met through documentation (e.g.,
consult notes, agreements, SOPs). If an inspector determines that an on-site assessment of a collaborating facility is necessary or desirable, specific arrangements must be made in advance through the FACT or JACIE office.