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Objectives We evaluated the impact of electronic medical record (EMR)–guided pooled cryoprecipitate dosing vs our previous practice of requiring transfusion medicine (TM) resident approval for every cryoprecipitate transfusion. Methods At our hospital, cryoprecipitate pooled from five donors is dosed for adult patients, while single-donor cryoprecipitate is dosed for pediatric patients (defined as patients Results In the 6 months prior to intervention, 178 ± 13 doses of pooled cryoprecipitate were used per month vs 187 ± 15 doses after the intervention (P = .68). Wastage of pooled cryoprecipitate increased from 7.7% ± 1.5% to 12.7% ± 1.4% (P = .038). There was no change in wastage of pediatric cryoprecipitate doses during the study period. These trends remained unchanged for a full year postimplementation. Conclusions Electronic dosing guidance resulted in similar cryoprecipitate usage as TM auditing. Increased wastage may result from reduced TM oversight. Product wastage should be balanced against the possibility that real-time audits could delay a lifesaving therapy.

Objectives The role of transfusion medicine consultative services in prospectively auditing (PA) orders for four-factor prothrombin complex concentrate (4F-PCC) was evaluated at an academic medical center. Methods Data from 4 years of 4F-PCC orders were obtained from the laboratory information system, and electronic health records of patients receiving concentrate were reviewed. Results 4F-PCC was ordered for 427 patients with warfarin-, apixaban-, or rivaroxaban-associated hemorrhage. Turnaround time (TAT) to prepare 4F-PCC was longer when PA-recommended dose adjustments were needed (85 vs 66 minutes, P = .03). There was no difference in TAT between patients who died and those who were ultimately discharged (60 vs 70, P = .22). TAT was shortest for orders originating in the emergency department (ED) compared with other locations (64 vs 85, P Conclusions PA can ensure 4F-PCC is dosed appropriately without affecting patient outcomes.

Objectives Increasingly complex medical care requires specialized transfusion support close at hand. Hospital growth can necessitate expansion of blood bank services to new locations to ensure rapid delivery of blood products. We describe the opening of a new satellite transfusion service designed to serve the needs of a pediatric hospital. Methods Institutional transition teams and stakeholders collaborated to discuss options for providing blood at a new pediatric hospital. A staffed satellite transfusion service met the diverse needs of multiple services and was considered a compromise between a full new transfusion service and automated solutions. Results Initial challenges in establishing the laboratory included regulatory uncertainty and interactions between two hospitals’ information technology services. Laboratory scientist staffing and actual use required adapting the satellite service to an emergency release–only model. Conclusions A flexibly staffed satellite transfusion service met the most urgent needs of a pediatric hospital expansion. Review of implementation revealed potential process improvements for future expansions, including comprehensive routine and massive transfusion simulations. The challenges experienced in supplying staff and specialized blood products track with national trends. Other institutions may consider establishing a satellite transfusion service in the context of both increasingly sophisticated automated solutions and complex blood needs.

Objectives Knowledge of transfusion medicine by medical students is limited. Transfusion medicine physicians developed, implemented, and evaluated a half-day elective on transfusion medicine for fourth-year medical students. Methods The course included a didactic lecture with integrated audience response questions and role-playing, as well as a "Jeopardy"-style game to review the material. The same 10-question knowledge quiz was administered before and after the elective. Results Both knowledge quizzes were taken by 102 students. An average score of 3.3 was obtained on the initial quiz, with only three (3%) students having a passing score (≥6 correct questions). The average score after the elective was 6.6, with 83 (81%) students having a passing score. Students found the elective was informative (62 students, 60.8%), very useful (56, 54.9%), and practical (51, 50%), although some thought it was challenging (22, 21.6%). Conclusions A short course for medical students that allowed repetition of concepts using several teaching modalities improved their knowledge in transfusion medicine.

Objectives For over 60 years, Harborview Medical Center (HMC) in Seattle has received its blood components and pretransfusion testing from a centralized transfusion service operated by the regional blood supplier. In 2011, a hospital-based transfusion service (HBTS) was activated. Methods After 5 years of operation, we evaluated the effects of the HBTS by reviewing records of hospital blood use, quality system events, blood product delivery times, and costs. Furthermore, the effects of in-house expertise on laboratory medicine resident and medical laboratory scientist student training, as well as regulatory and accrediting agency concerns, were reviewed. Results Blood use records from 2003 to 2015 demonstrated large reductions in blood component procurement, allocation, transfusion, and wastage with decreases in costs temporally related to the change in service. The turnaround time for thawed plasma for trauma patients decreased from 90 to 3 minutes. Transfusion medicine education metrics for residents and laboratory technology students improved significantly. HMC researchers brought in $2 million in transfusion research funding. Conclusions HMC successfully transitioned to an HBTS, providing world-class primary transfusion support to a level 1 trauma center. Near-term benefits in patient care, education, and research resulted. Blood support became faster, safer, and cheaper.

Objectives While critical value procedures have been adopted in most areas of the clinical laboratory, their use in transfusion medicine has not been reviewed in detail. The results of this study present a comprehensive overview of critical value reporting and communication practices in transfusion medicine in the United States. Methods A web-based survey was developed to collect data on the prevalence of critical value procedures and practices of communicating results. The survey was distributed via email to US hospital-based blood banks. Results Of 123 facilities surveyed, 84 (68.3%) blood banks had a critical value procedure. From a panel of 23 common blood bank results, nine results were selected by more than 70% of facilities as either a critical value or requiring rapid communication as defined by an alternate procedure. Conclusions There was overlap among results communicated by facilities with and without a critical value procedure. The most frequently communicated results, such as incompatible crossmatch for RBC units issued uncrossmatched, delay in finding compatible blood due to a clinically significant antibody, and transfusion reaction evaluation suggestive of a serious adverse event, addressed scenarios associated with the leading reported causes of transfusion-related fatalities.

Introduction/Objective To increase efficiency of blood product ordering and delivery processes and improve appropriateness of orders, a major project to implement clinical decision support (CDS) alerts in the electronic medical record (EMR) was undertaken. A design team was assembled including hospital and laboratory medicine information technology and clinical informatics, transfusion services, nursing and clinical services from medical and surgical specialties. Methods Consensus-derived thresholds in hemoglobin/hematocrit, platelet count, INR, and fibrinogen for red blood cell (RBC), platelet, plasma, and cryoprecipitate blood products CDS alerts were determined. Data from the EMR and laboratory information system were queried from the 12-month period before and after implementation and the data was analyzed. Results During the analysis period, 5813 RBC (avg. monthly = 484), 1040 platelet (avg. monthly = 87), 423 plasma (avg. monthly = 35), and 88 cryoprecipitate (avg. monthly = 7) alerts fired. The average time it took for a user to respond was 5.175 seconds. The total amount of time alerts displayed over 12 months was 5813 seconds (~97 minutes of user time) compared to 56503 blood products transfused. Of active CDS alerts, hemoglobin/RBC alerts fired most often with ~1:5 (31141 RBC units) alert to transfusion ratio and 4% of orders canceled (n=231) when viewing the alert, platelet alerts fired with ~1:15 (15385 platelet units) alert to transfusion ratio and 6% orders canceled (n=66), INR/plasma alerts fired with ~1:21 (8793 plasma units) alert to transfusion ratio and 10% orders canceled (n=41), cryoprecipitate alerts fired with ~1:13 (1184 cryoprecipitate units) alert to transfusion ratio and 10% orders canceled (n=9). Overall monthly blood utilization normalized to 1000 patient discharges did not appear to have statistically significant differences comparing pre- versus post-go-live, except a potentially significant increase in monthly plasma usage at one facility with p = 0.34, although possibly due to an outlier single month of heavy usage. Conclusion Clinical decision support alerts can guide provider ordering with minimal user burden. This resulted in increased safety and quality use of the ordering process, although overall blood utilization did not appear to change significantly.

Objectives To describe and evaluate a laboratory-based nursing education activity on transfusion to improve patient safety, an often-neglected opportunity. Methods Our transfusion service developed a day-long “Blood School” to provide knowledge, skills, and behaviors to nurses in four aspects of transfusion: blood ordering, sample collection, transfusion procedures, and recognition and reporting of transfusion reactions. We collected survey data on methods and effects of training and hard data on the number of reported patient safety events. Results Nurses want more hands-on experience to understand transfusion concepts, practice hospital procedures, recognize latent problems, and have behaviors to act effectively. We observed that engagement and understanding are best where participation is highest. Reported patient safety events were lower even as self-reported nursing mistakes increased. Conclusions Blood School is a well-received and effective site for nursing education in transfusion. We seek ways to extend and improve laboratory-based nursing training to improve patient safety.

Objectives We discuss two main categories of blood substitutes: perfluorocarbons and hemoglobin-based oxygen carriers. Methods We provide a review of the notable products developed in both categories and include their attributes as well as their setbacks. Results We contribute a case report tothe growing literature of the successful use of Sanguinate. Conclusions We find that artificial oxygen carriers are an attractive field of research because of the practical limitations and the multitude of potential complications that surround human blood transfusions.

Objectives Recently published data suggest that transfusion of RBCs stored for 22 days or longer was associated with increased mortality among massively transfused trauma patients. Methods We performed a 24-month retrospective review of medical transport service transfusion records and a 2-month, overlapping review of transfusions of uncrossmatched RBCs in the emergency department. Results RBC units issued to the transport program were older than RBC units issued to the emergency department trauma refrigerator (10.6 vs 8.7 days, P < .001). Similarly, RBC units were older at the time of transfusion during transport compared with the emergency department (20.3 vs 14.3 days, P < .001). Conclusions Transport programs and blood banks should jointly review their RBC inventory management programs. Issuing RBCs to a medical transport program is a logistical challenge that, unless actively managed, may not ensure access to blood that is as fresh as blood in the emergency department.

To evaluate the effectiveness of anemia management and audit with feedback practices in reducing overuse of RBC transfusion.This review follows the Centers for Disease Control and Prevention's Laboratory Medicine Best Practice Systematic Review (A-6) method. We searched the literature and solicited unpublished studies on practices to reduce overuse of RBC transfusions as measured by reductions in units transfused and proportion of patients transfused.Thirteen studies on preoperative anemia management and three studies on audit feedback practices met inclusion criteria. Strength of evidence was high to moderate for reducing the number of units and proportion of patients transfused.Preoperative anemia management reduces the proportion of patients transfused and units of RBCs transfused. Audit with feedback across cases, physicians, and/or service areas, as part of a continuous quality improvement practice, reduces the proportion of patients and units of RBCs transfused.

Objectives: While many studies have demonstrated problems with informed consent in current practice, there remains controversy on how to address this. The aim of this study was to evaluate the opinions, attitudes, practices, and training for informed consent. Methods: Medical students, residents, advanced practice providers, and attending physicians at an academic institution were invited to complete a survey on informed consent for transfusions and procedures through an electronic platform. Results: Most (94%, n = 304) respondents indicated previous training in informed consent, only 60% (n = 192) felt the training was adequate, and 35% (n = 92) indicated difficulties with informed consent. When asked what would aid in obtaining consent, 59% (n = 189) selected a written guideline, and 36% (n = 117) selected patient simulation. Conclusions: Only 60% of respondents felt their informed consent training was adequate. Multiple areas of difficulty in obtaining proper informed consent were identified that should be addressed with focused training or written guidelines.

Objectives: To describe a 4-day laboratory medicine course for clinicians given at Addis Ababa University, Ethiopia, designed to improve the use of laboratory-based diagnoses. Methods: Each day was dedicated to one of the following topics: hematology, blood bank/transfusion medicine and coagulation, chemistry, and microbiology. The course included lectures, case-based learning, laboratory tours, and interactive computer case-based homework. The same 12-question knowledge quiz was given before and after the course. Results: Twenty-eight participants took the quiz before and 21 after completing the course. The average score was 5.28 (range, 2–10) for the initial quiz and 8.09 (range, 4–11) for the second quiz ( P = .0001). Two of 12 and 8 of 12 questions were answered correctly by more than 60% of trainees on the initial and second quiz, respectively. Conclusions: Knowledge and awareness of the role of the laboratory increased after participation in the course. Understanding of laboratory medicine principles by clinicians will likely improve use of laboratory services and build capacity in Africa.

No clinical consult raises the heart rate of a transfusion medicine specialist quite like that involving thrombotic microangiopathy (TMA) concerning for thrombotic thrombocytopenic purpura (TTP). The differential diagnosis is complex and challenging, the patients tend to be very ill, and effective treatment requires providing therapy directed at the underlying pathology as quickly as possible. Clinical pathologists are well positioned to provide guidance in these cases since they are usually alerted to all patients in the hospital with suspected TTP and therefore have considerable experience to offer. In contrast, the consulting physician may be somewhat less experienced in formulating a diagnostic and therapeutic plan of care for these patients and might opt for therapeutic plasma exchange (TPE) when in fact a more careful evaluation is merited and other therapies might be more effective. The article by Williams and Marques1 in this issue of the Journal highlights the key role played by the clinical pathologist in the care of patients with TMA, focusing on the important distinction between TTP, hemolytic uremic syndrome (HUS), and atypical uremic syndrome (aHUS) and providing a clear and logical approach to these disorders. TMA should be viewed as a manifestation of diverse pathologies involving either hemostasis (inappropriate platelet activation or thrombin generation) or the endothelium (exposure to Shiga toxin, uncontrolled complement deposition).2 Treatments differ depending on the underlying mechanism of disease. Whereas TPE is an effective treatment for TTP,3,4 eculizumab has emerged as an important new therapy for aHUS,5 providing superior renal survival in comparison to outcomes observed following treatment with TPE alone.6 The understanding that aHUS results from dysregulation of the alternative complement pathway and is associated with inherited mutations in complement regulatory proteins while TTP results from severe deficiency of the ADAMT13 enzyme caused by autoantibodies to this … Corresponding author: Robert S. Makar, MD, PhD, Massachusetts General Hospital Blood Transfusion Service, GRJ-148, 55 Fruit St, Boston, MA 02114; rmakar{at}mgh.harvard.edu.

Objectives: The Blood Utilization Committee implemented a standardized protocol for the preoperative blood order for cardiac patients. The aim of our study was to assess the improvement in blood utilization using the crossmatch to transfusion ratio (C:T). Methods: Four months of retrospective data were collected, which included all RBC crossmatch requests and all RBC units transfused. Similar data were gathered for the period of the intervention. The difference in C:T was calculated. Results: The retrospective group had 166 patients for whom blood products were ordered. There were 560 crossmatch requests and 237 transfused RBC units with a C:T of 2.36. The prospective group had 127 patients with 297 crossmatch requests, 190 transfused units, and a C:T of 1.56. There was a statistically significant difference in the C:T. The cost difference was $12,244.00. Conclusions: Implementing exact guidelines, with the introduction of a type-and-screen concept, allowed more efficient blood usage.

Red blood cell (RBC) transfusion practices vary widely amongst institutions across the US, resulting in many unnecessary transfusions. Patient blood management strategies are being promoted to address this issue, including use of prospective audit (PA) to prevent such unnecessary transfusions. We present an audit of the current RBC transfusion practice at our institutions and evaluate how our review process …

Objectives : To review the differential diagnosis and laboratory issues for women with a large calculated dose of Rh immune globulin (RhIG). Methods: A case-based approach is used to review the differential diagnosis of patients with a large calculated dose of RhIG, RhIG dosing for women with baseline elevations in hemoglobin F, the formulations of RhIG, and issues for the transfusion medicine service with the release of large doses of RhIG. Results: A large fetomaternal bleed after delivery requiring multiple doses of RhIG is rare. Such patients may require intravenous RhIG to avoid multiple injections. Patients with a large percentage of circulating fetal RBCs should be evaluated for a disorder of hemoglobin synthesis and, if present, should have quantification of the circulating fetal RBCs by flow cytometry. Conclusions: Accurate laboratory evaluation of women with large fetomaternal bleeds is essential for appropriate RhIG administration.

Objectives: Pathologists specializing in transfusion medicine, apheresis medicine, and/or coagulation are often consulted by clinicians to reach a diagnosis for patients with thrombotic microangiopathy (TMA), so that disease-specific, often life-saving therapy can be initiated as promptly as possible. Methods: This article describes how to proceed when treating a patient with TMA. The differential diagnosis is broad and potentially very challenging. Thrombotic thrombocytopenic purpura (TTP), atypical hemolytic uremic syndrome (aHUS), and typical hemolytic uremic syndrome (HUS) are three such TMAs that require timely diagnosis and treatment. Results: TTP is treated with daily therapeutic plasma exchange (TPE) and commonly with adjunctive immunosuppressive therapy, while aHUS may initially be managed with TPE but is best controlled with eculizumab once a presumptive diagnosis is made. TPE has no proven role in typical HUS, which is most commonly treated with supportive measures only. Conclusions: Prompt and accurate diagnosis of TMA subtypes optimizes treatment and improves patient outcomes.

African Americans with factor VII (FVII) deficiency, as defined by clinical laboratory values, are frequently asymptomatic. To date the genotypes underlying this FVII defect in asymptomatic African Americans have not been established. We show in 3 unrelated African American patients that the defect is due to a G to A nucleotide change resulting in an arginine to glutamine mutation in Factor VII amino acid 304. This defect results in low FVII coagulant activity levels using rabbit brain thromboplastin but not using human thromboplastin. This report may aid transfusion and hematology specialists to evaluate patient results and prevent unnecessary transfusions to treat patients with abnormal laboratory values.

The comments of clinical physicians regarding patients to whom they attend are typically written in the medical record and, therefore, are visible to many colleagues. Clinicians making an incorrect diagnostic or therapeutic recommendation or a procedural error are often promptly identified and counseled. They sometimes become defendants in malpractice cases as a result of their actions. Such comments also apply to the largely diagnostic specialties of anatomic pathology and radiology. Specialists in those fields provide written reports that are reviewed by many other physicians, and, if erroneous diagnostic conclusions lead to an adverse outcome for the patient, the case is again typically brought to attention and reviewed to assess the clinical competence of the pathologist or radiologist.1,2 However, what about a clinical laboratory director (LD) who provides advice to clinicians on laboratory test selection or interpretation? With the exception of those coming from clinically engaged directors of transfusion medicine and coagulation laboratories, the recommendations of laboratory medicine specialists are not usually recorded in written form. As a result, information provided by clinical LDs is usually not easily reviewed by other parties. Occasionally, a close professional colleague, who is disinclined to point out mistakes by a fellow staff member, may know of the error but not report it. Figure 1 shows a cycle wherein clinicians must first determine independently which tests are appropriate for addressing a particular differential diagnosis. They then independently assess the diagnostic significance of the …

Traditional quality-adjusted life year (QALY) cost analysis is complex and assigns arbitrary dollar values to catastrophic outcomes such as death. Analysis of transfusion medicine technologies by an alternative approach that focuses on costs to avoid fatal outcomes might be a useful adjunct to QALY analysis for allocating limited financial resources. We estimated the cost per death averted for the following interventions: apheresis platelets vs random platelets, solvent detergent-treated plasma vs untreated plasma, and leukocyte-reduced vs unmodified transfusions in cardiac surgery. As a control, similar data were calculated for current donor viral testing. The estimated incremental costs per death avoided were as follows: single-donor apheresis platelets, $15 million; solvent detergent plasma, $17 million; leukocyte-reduced transfusions in cardiac surgery, $11,000; HIV-1 antibody testing, $22,000; and HIV-1 antigen testing, $3.9 million. The estimated number of deaths averted per year in our hospital were as follows: apheresis platelets, 0.1; solvent detergent plasma, 0.044; leukocyte-reduced transfusions, 14; HIV-1 antibody testing, 6.0; and HIV-1 antigen testing, 0.033. HIV-1 antibody testing and leukocyte-reduced transfusions in cardiac surgery are comparably cost-efficient means of averting mortality in patients receiving transfusions. Solvent detergent plasma and apheresis platelets are comparatively expensive approaches to reducing mortality from transfusion complications.

The nation's blood supply system has undergone major change during the last decade. As a result, the blood supply is extremely safe. To accomplish this, the centers that supply most of nation's blood have made extensive changes in their regulatory affairs and quality assurance programs, personnel, or organizational structure, process control systems, computer and data management systems, and overall philosophy. The emphasis on a medical and patient focused organizational culture has been replaced by a more manufacturing and business culture. Research in transfusion medicine and related fields is bringing potential new transfusion therapies and blood components closer to reality. The blood system and the organizations and people who compose it must continue to evolve in ways to implement these new therapies.

After the March 2004 implementation of American Association of Blood Banks standards regarding platelet bacterial detection, we began quantitative glucose screening of whole blood–derived platelets (WB-P). The glucose level was measured immediately before component release—often storage day 4 or 5—using the Glucometer SureStep Flexx Meter (LifeScan, Milpitas, CA), with a positive cutoff of less than 500 mg/dL; failing units were cultured and not transfused. During 29 months (March 1, 2004–July 31, 2006) 93,073 units of WB-P were tested. Initially, 929 units (0.998%) screened positively. Bacterial growth was culture-confirmed in 6 units, for a bacterial contamination incidence of 0.006% and a true-positive rate of 6.4/100,000. Three additional culture-confirmed contamination cases were detected in transfused units causing febrile nonhemolytic reactions, for a false-negative rate of 3.2/100,000. Our overall contamination prevalence was 9.6/100,000 units of platelets transfused, lower than ordinarily cited, and showed a false-negative rate remarkably congruent to that of culture: 3.2/100,000. A low-sensitivity screening test applied late in platelet shelf-life can be comparable to culture in preventing bacterial-related morbidity.

Laboratory medicine has historically emphasized “laboratory” over “medicine.” Professional activities and competencies largely center on analytic techniques and bench science. Outside of transfusion medicine, few laboratory professionals regularly engage clinicians to actively influence diagnostic and management decisions. Some of us in the laboratory diagnostic community are concerned about this gap. In addition to marginalizing laboratory medicine/clinical pathology within the health care professions, it represents a huge missed opportunity to apply laboratory expertise for more effective patient care. In value-based health care delivery, to which accountable care organizations and other forward-thinking institutions aspire, pathologists and other laboratory professionals will be measured against the outcome-related value we create for patients, as assessed by our clinical colleagues and others. As money tightens, it may become more difficult to justify an existence based primarily on inward-facing activities such as specimen management, quality control of instrumentation, and technical proficiency of laboratory staff (important though these are). The good …

The dictionary defines a consultant as “one who gives professional advice or services; expert.”1 More than most medical specialists, the role of a clinical pathologist can be heterogeneous: overseeing laboratory testing processes; hands-on patient care, especially in transfusion medicine and hemostasis; performing traditional microscopic pathology; developing algorithms for optimized testing and diagnosis; or some unique combination of these functions. One pathway that unites all clinical pathologists is that they are consultants in the process of testing that provides more than three quarters of the data used for clinical decision making.2 It is customary to divide the testing process into preanalytic, analytic, and postanalytic phases.3 The second component is traditionally considered the domain of clinical pathologists. The laboratory technical staff and activities within the laboratory are clearly paramount to ensure quality patient care.4 However, the first and third components of testing are just as squarely in the purview of clinical pathologists as they are for the health care providers who order laboratory testing and receive the results. In the preanalytic phase, the primary physician poses a clinical question and selects a laboratory assay to answer it, but it is the clinical pathologist who must build and validate the assay such that there is clinical value to its answer. Moreover, …

This report details the results of a 1995 survey of the 40 fellowship training programs in blood banking and transfusion medicine in the United States approved by the Accreditation Council for Graduate Medical Education. Fellows primarily enter transfusion medicine training after completing a pathology residency, and are subsequently employed in an academic or university setting, or a blood donor center. Program directors indicated that either the current level, or fewer, transfusion medicine specialists will be needed in the future. The educational content of fellowship training was examined, as well as aspects of proficiency and competency in several areas. Research is an important part of most fellowship programs, and a majority of program directors felt that some formal training in clinical medicine should be a part of fellowship training in transfusion medicine. The information obtained from this survey should be helpful to both fellowship applicants and program directors in delineating important aspects of fellowship training in blood banking and transfusion medicine.

Over the last 15 years, the field that was once known as blood banking has evolved into the discipline of transfusion medicine. Because of AIDS and a greater appreciation of other transfusion-transmitted diseases, attitudes toward transfusion therapy have changed significantly. Advances in the understanding of the pathophysiology of anemia and thrombocytopenia, as well as new tools for transfusion support have created new roles for the transfusion medicine physician. The transfusion medicine consultant has the opportunity to influence and improve transfusion safety, and contribute positively to cost containment by providing expertise as an educator, auditor of blood component usage, and providing leadership or oversight of therapeutic modalities (such as autologous transfusion, intraoperative red cell salvage, and therapeutic apheresis).