Determining the outcomes for clinicians completing a postgraduate diploma in transfusion medicine

BackgroundMuch is known about outcomes and content of training programs in blood banking, but only a limited amount of formal research has been done on the outcomes required for a postgraduate training program aimed at medical doctors working in clinical practice.Study design and methodsA formal qualitative and semi-quantitative research approach was followed to determine and test the factors considered important in determining the outcomes for clinicians completing a postgraduate diploma in transfusion medicine, and consisted of a literature survey, followed by semi-structured interviews and a Delphi survey.ResultsAfter a series of semi-structured interviews, based on an extensive literature survey, 42 factors were identified. These factors were categorized into eight groups and tested in a Delphi survey to determine which of these would be essential outcomes of a postgraduate training program in transfusion medicine. After three rounds of the Delphi survey, consensus was reached on 27 factors and stability on 14 factors. On one factor, neither consensus nor stability could be reached. Twenty-six factors were identified as essential outcomes.ConclusionThis research provides support for the essential outcomes to be considered in any postgraduate training program in transfusion medicine aimed at clinicians.     

Red blood cell transfusion practice in patients presenting with acute upper gastrointestinal bleeding: a survey of 815 UK clinicians

BACKGROUND: Acute upper gastrointestinal bleeding (AUGIB) accounts for 14% of all red blood cell (RBC) transfusions in the United Kingdom, despite little evidence to guide optimal blood transfusion strategies and few data on the variation in practice. We aimed to survey UK clinicians about their RBC transfusion practice in AUGIB. STUDY DESIGN AND METHODS: A survey describing six clinical vignettes of AUGIB was sent to practicing gastroenterologists, acute care physicians, and upper gastrointestinal surgeons. Respondents were asked to select a hemoglobin (Hb) trigger at which they would ordinarily transfuse RBCs. RESULTS: The response rate was 48% (815/1709). Transfusion triggers differed significantly between all six cases (p < 0.001). There was significant variation in the selected Hb trigger between different clinical specialties for five of the six scenarios. Surgeons were more likely to select a lower Hb transfusion trigger than physicians across all six scenarios (p < 0.005), as were clinicians who had graduated more recently (p < 0.05 for Scenarios 1‐3). The responses suggested the belief that restrictive use of RBCs is appropriate, which is in part discordant with actual observed practice. Only 70% of respondents reported familiarity with national guidelines for AUGIB. CONCLUSIONS: There is significant variation in the reported approach to transfusion practice among clinicians caring for patients with AUGIB, with both patient‐ and clinician‐related factors accounting for these differences. Further studies are needed to evaluate the safety and efficacy of differing blood transfusion strategies in patients presenting with AUGIB.     

Mitigating opioid errors in inpatient palliative care: A qualitative study

BackgroundOpioids are a high-risk medicine used in high doses and volumes in specialist palliative care inpatient services to manage palliative patients’ pain and other symptoms. Despite the high volume of opioid use in this care setting, serious errors with opioids are exceedingly rare. However, little is known about the factors that mitigate opioid errors in specialist palliative care inpatient services.AimTo explore palliative care clinicians’ perceptions of factors that mitigate opioid errors in specialist palliative care inpatient services.Methods and designA qualitative study using focus groups and semi-structured interviews.Participants and settingRegistered nurses, doctors, and/or pharmacists (‘clinicians’) who were involved with and/or had oversight of the services’ opioid delivery and/or opioid quality and safety processes, employed by one of three specialist palliative care inpatient services in metropolitan NSW.FindingsFifty-eight participants took part in this study, three-quarters (76%) of which were palliative care nurses. A positive opioid safety culture was central to mitigating opioid errors in specialist palliative care inpatient services. This culture of opioid safety was founded on clear and consistent safety messages from leadership, clinicians empowered to work together and practise safely, and a non-punitive approach to errors when they occurred. The clinical nurse educator was seen as pivotal to shaping, driving and reinforcing safe opioid delivery practices across the palliative care service.ConclusionCreating and sustaining a positive opioid safety culture, and promoting a non-punitive approach to opioid error and reporting, is essential to mitigating opioid errors in the specialist palliative care inpatient setting.     

Informed consent for blood transfusion as a transfusion medicine educational intervention

SUMMARY. The aim here was to determine the effectiveness of a transfusion medicine educational intervention in a medicine core clerkship program.
Third-year medical students enrolled in their medicine core clerkship rotations at tertiary care hospitals affiliated with our institution underwent a two-part educational intervention that incorporated a transfusion medicine curriculum within the context of the medicolegal, ethical and educational elements of informed consent. Part one was a 1-h didactic session on standards of practice for red blood cell transfusion. Part two was a 90-min multidisciplinary workshop on informed consent. The effectiveness of the educational intervention was analysed by an objective structured clinical evaluation.
The student group receiving the educational intervention scored significantly higher than in the comparison group (65.8 ± 9.2 vs. 54.1 ± 10.56, P <0.001). When student scores were used to determine changes in student response patterns over time, the largest change occurred in identifying possible other options to allogeneic blood transfusion.
These results suggest that a transfusion medicine curriculum using an informed consent model can be used effectively as an educational intervention in a medicine core clerkship programme.     

RHD genotyping and its implication in transfusion practice

BackgroundThe limitations of serology can be overcome by molecular typing. In order to evaluate the contribution of RH systematic genotyping and its implication in transfusion practice, a genotyping of D? blood donors was initiated.MethodsBlood samples were collected from 400 unrelated D? individuals. All samples were tested by RHD exon 10 PCR. In order to clarify the molecular mechanisms of RHD gene carrier, we applied molecular tools using different techniques: PCR-multiplex, and PCR-SSPs.ResultsAmong 400 D? subjects tested, 390 had RHD gene deletion; and 10 had RHD exon 10 of which seven were associated with the presence of the C or E antigens. Among D? carriers, we observed in five cases the presence of RHD-CE-Ds hybrid, in four cases the presence of pseudogene RHD ψ and in one case the presence of weak D type 4.ConclusionSince the majority of aberrant alleles were associated with C or E antigens and the preliminary infrastructure for molecular diagnostic were absent in all Tunisia territory, we recommend to reinforce transfusion practice to consider D? donors but C+/E+ antigens as D+ donors and the application of RHD molecular typing only to solve serologic problems.     

Pre-transfusion testing for Ebola virus disease patients in serious communicable infectious diseases hospitals in Tokyo: A cross-sectional study

BackgroundEbola virus disease (EVD) was endemic to Africa in 2014–2016. Supportive therapies have been shown to improve the outcome of EVD, and additional supportive therapy including blood transfusion therapy and external circulation could be needed in the event of a future global outbreak. However, pre-transfusion testing policies and guidelines have not yet been established in Japan.MethodsWe conducted a cross-sectional study of blood transfusion therapy for EVD patients at three designated hospitals for serious communicable diseases in Tokyo. In each hospital, we surveyed blood transfusion therapy policy, blood transfusion protocol, presence of a specialist in the department of transfusion medicine, facility capacity for pre-transfusion compatibility testing, and types of personal protective equipment available.ResultsOne hospital had a cross-matched compatible blood transfusion policy, one had a cross-matched compatible blood transfusion policy only when the patient's ABO and RhD type is previously known, and the third had not created a policy. Two hospitals had a department of transfusion medicine. These two hospitals had a special testing unit for serious communicable diseases, while the other had a portable unit for testing. There were no major differences noted in available personal protective equipment.ConclusionPolicies and protocols differ among hospitals. The choice of blood transfusion policy and pre-transfusion testing is largely dependent on equipment and human resources. Further discussion is required to develop national guidelines for blood transfusion therapy in patients with serious communicable diseases, including countermeasures against complications and ethical issues related to the safety of patients and healthcare workers.     

An exploration of the influences on clinical decision making and the culture of blood transfusion practise in cancer-related anaemia using an ethnographic methodology

Purpose

This study seeks to explore the cultural practises, which shape the culture of transfusion, and to identify the key elements, which influence clinical decision making in blood transfusion in haemato-oncology and lung cancer patients.

Methods

The assessment and decision making processes for blood transfusion were explored using fieldwork observation, six patient and nine clinician interviews based on ethnographic methodology. Data were analysed using thematic analysis.

Results

First, the findings suggested that despite anaemia and transfusion being ubiquitous in this cancer setting, it sits low in the hierarchy of clinical concerns (The unimportance of anaemia). Second, there is a great deal of uncertainty surrounding the diagnosis and management of this clinical problem; but this uncertainty was acknowledged by both patients and clinicians (Acknowledging uncertainty). Third, clinicians and to some extent patients, are socialised into the practise of the sub-discipline (Socialisation in practise). Fourth, the haemoglobin level was used as a distinct fragment of information on which to assess for the presence of anaemia and base the decision to treat with blood transfusion (Disaggregation of the body).

Conclusion

The management of anaemia is not a priority in this setting; however, by understanding the complexity of factors for variation in practise in the clinical context, new models for learning transfusion skills can be developed. Furthermore, different collaborative groups could be organised to develop optimal transfusion practises, for example to include nurse-prescribing of blood components or by developing patient-centred decision making systems.     

Neonatal exchange transfusion: Experience in Korea

BackgroundExchange transfusion (ET) is an established, efficacious, and reliable practice for severe neonatal hyperbilirubinemia, hemolytic disease of the newborn, and neonatal sepsis. This study assessed the indications and clinical outcomes of ET performed in a tertiary hospital in Korea.Materials and methodsWe studied 64 ET sessions performed on 23 neonates between March 1999 and March 2018. ET was performed based on estimated double volume exchange transfusion using fresh red blood cells and fresh frozen plasma. Patients’ clinical information, including demographic data and ET indication, and laboratory data were collected pre- and post-ET.ResultsThe most common ET indication was hyperbilirubinemia with hemolytic anemia due to non-ABO maternal blood group discrepancies. In three preterm babies, ETs were performed for severe anemia, leukocytosis, and hyperkalemia cases. Before ET, the patients showed slightly high WBC counts, low hemoglobin levels, and low platelet counts. After ET, blood examination revealed normal WBC counts, increased hemoglobin levels, and decreased platelet counts (all P < 0.001). Bilirubin levels decreased immediately after ET (P < 0.001). Electrolyte and C-reactive protein levels showed no significant changes after ETs. Adverse events occurred in 11 (47.8 %) patients; the most common were hypoxemia and hypotension. One infant experienced cardiorespiratory arrest due to hypercalcemia and was successfully resuscitated. No one died within 24 h of ET. However, five infants showed hyperbilirubinemia aggravation.ConclusionsET is an effective treatment modality for leukocytosis and hyperbilirubinemia with low mortality but involves common adverse events post-ET. This report provides an overview of current ET practices in Korea.     

Evaluation of an intervention to increase clinician knowledge and confidence to support breastfeeding,kangaroo care and positive touch within neonatal units

Breastfeeding and kangaroo care rates in neonatal units across the United Kingdom vary despite evidence for the clinical benefits. Clinicians have reported a need for evidence-based training to support parents with these practices. The aim of this study was to evaluate the Small Wonders Change Programme (SWCP), an intervention that aims to increase clinician knowledge and confidence to support parents in neonatal units to undertake breastfeeding and kangaroo care. Two neonatal intensive care units participated and 47 clinicians completed the Neonatal Unit Assessment Tool (NUCAT) pre and post-intervention. 18 of these clinicians also participated in a semi-structured interview to further explore the impact of the intervention on clinician's practice. Both clinician knowledge (t(46) = 4.61, p ≤ 0.000) and confidence (t(46) = 4.82, p < 0.000) significantly increased following the intervention. Analysis of the interviews revealed that clinicians directly attributed subsequent individual and unit-wide change in practice to an increase in knowledge and confidence as a result of the intervention. This study suggests that a clinician focussed intervention can lead to positive changes in clinician confidence, knowledge and practice in supporting parents to undertake breastfeeding and kangaroo care in neonatal units.     

Clinical impact of massive transfusion protocol implementation in non-traumatic patients

BackgroundMassive transfusion protocol (MTP) has been used to provide plasma and packed red blood cells (pRBCs) rapidly. MTP also has been adapted for non-traumatic patients. The effects of hospital-wide MTP implementation on clinical outcomes were reviewed.MethodsThis was a retrospective study of patients who received massive transfusion before and after MTP implementation, between August 2010 and May 2018. Massive transfusion was defined as 10 or more units of pRBCs within 24 h. Recipients of massive transfusion were divided into periods before and after MTP implementation. The 24 -h death rate, thirty-day death rate and several laboratory findings were investigated.ResultsEighty patients whose massive transfusion occurred before MTP implementation and 63 patients whose massive transfusion occurred after MTP implementation were compared. No statistically significant difference was found in 24 -h death rate (15.0% vs. 23.8%, p = 0.181), or 30-day death rate (43.8% vs. 36.5%, p = 0.381). Use of an anti-fibrinolytic agent was more frequent in patients after the MTP implementation (31.3% vs. 55.6%, p = 0.003). A statistically significant difference was found in the lowest body temperature of the two groups during the 24 -h period (34.7 °C vs. 35.6 °C, p < 0.001). Transfusion ratio of plasma to pRBC was numerically improved after the MTP implementation (1:1.91 vs. 1:1.58, p = 0.173). Earlier initiation of pRBC transfusion was achieved after implementation (51 min vs. 40 min, p = 0.042).ConclusionsMTP implementation showed improved coagulation profiles, but did not show a statistically significant death-rate reduction in non-traumatic patients.     

Effect of a primary care continuing education program on clinical practice of chronic obstructive pulmonary disease: translating theory into practice

ObjectivesTo describe the development and implementation process and assess the effect on self-reported clinical practice changes of a multidisciplinary, collaborative, interactive continuing medical education (CME)/continuing education (CE) program on chronic obstructive pulmonary disease (COPD).MethodsMultidisciplinary subject matter experts and education specialists used a systematic instructional design approach and collaborated with the American College of Chest Physicians and American Academy of Nurse Practitioners to develop, deliver, and reproduce a 1-day interactive COPD CME/CE program for 351 primary care clinicians in 20 US cities from September 23, 2009, through November 13, 2010.ResultsWe recorded responses to demographic, self-confidence, and knowledge/comprehension questions by using an audience response system. Before the program, 173 of 320 participants (54.1%) had never used the Global Initiative for Chronic Obstructive Lung Disease recommendations for COPD. After the program, clinician self-confidence improved in all areas measured. In addition, participant knowledge and comprehension significantly improved (mean score, 77.1%-94.7%; P<.001). We implemented the commitment-to-change strategy in courses 6 through 20. A total of 271 of 313 participants (86.6%) completed 971 commitment-to-change statements, and 132 of 271 (48.7%) completed the follow-up survey. Of the follow-up survey respondents, 92 of 132 (69.7%) reported completely implementing at least one clinical practice change, and only 8 of 132 (6.1%) reported inability to make any clinical practice change after the program.ConclusionA carefully designed, interactive, flexible, dynamic, and reproducible COPD CME/CE program tailored to clinicians' needs that involves diverse instructional strategies and media can have short-term and long-term improvements in clinician self-confidence, knowledge/comprehension, and clinical practice.     

Training in aspiration abortion care: An observational cohort study of achieving procedural competence

BackgroundStudies in multiple countries have found that the provision of aspiration abortion care by trained nurses, midwives, and other front-line health care workers is safe and acceptable to women. In the United States, most state abortion laws restrict the provision of abortion to physicians; nurse practitioners, nurse-midwives, and physician assistants, can legally perform medication abortion in only twelve states and aspiration abortion in five. Expansion of abortion care by these providers, consistent with their scopes of practice, could help alleviate the increasing difficulty of accessing abortion care in many states.ObjectivesThis study used a competency-based training model to teach advanced practice clinicians to perform vacuum aspiration for the abortion care. Previous research reporting on the training of providers other than physicians primarily focused on numbers of procedures performed, without assessment of skill competency or clinician confidence.DesignIn this prospective, observational cohort study, advanced practice clinician trainees were recruited from 23 clinical sites across six partner organizations. Trainees participated in a standardized, competency-based didactic and clinical training program in uterine aspiration for first-trimester abortion.SettingsTrainee clinicians needed to be employed by one of the six partner organizations and have an intention to remain in clinical practice following training.ParticipantsCalifornia-licensed advanced practice clinicians were eligible to participate in the training if they had at least 12 months of clinical experience, including at least three months of medication abortion provision, and certification in Basic Life Support.MethodsA standardized, competency-based training program consisting of both didactic and clinical training in uterine aspiration for first-trimester abortion was completed by 46 advanced practice clinician participants. Outcomes related to procedural safety and to the learning process were measured between August 2007 and December 2013, and compared to those of resident physician trainees.ResultsEssentially identical odds of complications occurring from advanced practice clinician-performed procedures were not significantly different than the odds of complications occurring from resident-performed procedures (OR: 0.99; CI: 0.46–2.02; p > 0.05) after controlling for patient sociodemographic and medical history. The number of training days to foundational competence ranged from six to 10, and the number of procedures to competence for those who completed training ranged from 40 to 56 (median = 42.5).ConclusionsA standardized, competency-based trainingprogram can prepare advanced practice clinicians to safely provide first-trimester aspiration abortions. Access to safe abortion care can be enhanced by increasing the number of providers from cadres of clinicians other than physicians.     

Plasma transfusion in critically Ill patients with abnormal coagulation tests before invasive procedures: A propensity-adjusted cohort study

ObjectiveTo evaluate the association between plasma transfusion and bleeding complications in critically ill patients with an elevated international normalized ratios undergoing invasive procedures.MethodsA retrospective study was conducted to evaluate a consecutive sample of critically ill adult patients undergoing invasive procedures (N = 487) with an international normalized ratio ≥ 1.5 between January 1, 2019 and December 31, 2019. Among the followed patients, 125 were excluded due to incomplete case records and 362 were finally included in this investigation. The exposure was whether plasma had been transfused within 24 h before the invasive procedure. The primary outcome was the occurrence of postprocedural bleeding complications. Secondary outcomes included transfusion of red blood cells within 24 h of the invasive procedure, and additional patient-important outcomes such as mortality and length of stay. Tests were performed with univariate and propensity-matched analyses.ResultsOf the 362 study participants, 99 (27.3 %) received a preprocedural plasma transfusion. In the propensity score-matched analysis, the rate of the occurrence of postprocedural bleeding complications between two groups was not statistically different (OR, 0.605[95 % CI, 0.341–1.071]; P = .085). The rate of postoperative red blood cell transfusion in the plasma transfusion group was higher than that in the non-plasma transfusion group (35.5 % vs 21.5 %; P < .05). No statistically significant difference in mortality was observed between the two groups (29.0 % vs 31.6 %; P = .101).ConclusionsProphylactic plasma transfusion failed to reduce postprocedural bleeding complications in ill critically patients with a coagulopathy. Meanwhile, it was associated with increased red blood cell transfusion after invasive procedures. Findings suggest that abnormal preprocedural international normalized ratios should be managed more conservatively.     

Transfusion-associated graft-versus-host disease:Who is at Risk?

This issue marks the beginning of a new section in Transfusion Science entitled “Evolving Concepts in Transfusion Medicine.” This section is designed to feature critical discussions (2 pages or less) of evolving areas within transfusion medicine. It is meant to highlight new developments and areas of controversy within the broad scope of the medical, scientific, technical, epidemiologic, and public health aspects relating to the rationale for provision of blood component therapy. Recent and continued advances in our understanding of the biology of hematopoiesis, infectious diseases, and molecular genetics now provide the scientific basis for an evolution of our principles and practices within transfusion medicine. Ongoing technical advances, i.e. more effective leukodepletion methods and recombinant techniques, will make it possible to provide new components for transfusion. New sensitive and specific techniques for the detection of infectious disease, i.e. polymerase chain reaction technology, may have broad impact on the safety of transfusion. It is the goal of “Evolving Concepts in Transfusion Medicine” to relate these and other new research findings to their current and future impact on transfusion practice.     

Clinical trial variability: quality control in a randomized clinical trial

IntroductionA major issue in clinical trials in manual medicine is treatment variability. The challenge is to insure that the bounded treatment options are both representative of field practitioner behavior and consistent among research clinicians. This investigation assesses the treatment comparability of field practitioners and research clinicians, for a flexion-distraction treatment procedure, as quality control for a randomized clinical trial.MethodsUsing a series of vignettes, we studied the level of agreement of treatment protocols between field clinicians, research clinicians and a reference clinician regarding treatment location, range of motion during treatment, and number of repetitions used within the flexion-distraction protocol.ResultsResults indicated that reliability around decision making for anticipated location of spinal treatment was highest regardless of clinician group. For the research clinicians this level of agreement was ICC = 0.88. Decision-making for treatment direction was second highest, at kappa = 0.64 for the research clinicians. Reliability around the number of repetitions is poor ranging from ICC = 0.18 to 0.34 depending on clinician type.DiscussionUnderstanding the disparity in treatment protocols is of value in the construction and maintenance of quality control in an actual randomized clinical trial setting. More work was recommended in the preparation of clinical trials and the understanding of clinical decision-making because these disparate factors may dramatically impact the generalizability of clinical trial results.     

Exploring the opinions of registered nurses working in a clinical transfusion environment on the contribution of e-learning to personal learning and clinical practice: Results of a small scale educational research study

AimTo explore the opinions of registered nurses on the Learnbloodtransfusion Module 1: Safe Transfusion Practice e-learning programme to meeting personal learning styles and learning needs.MethodA qualitative research methodology was applied based on the principles of phenomenology. Adopting a convenience sampling plan supported the recruitment of participants who had successfully completed the e-learning course.AnalysisThematic analysis from the semi-structured interviews identified common emerging themes through application of Colaizzis framework.ResultsSeven participants of total sample population (89) volunteered to participate in the study. Five themes emerged which included learning preferences, interactive learning, course design, patient safety and future learning needs. Findings positively show the e-learning programme captures the learning styles and needs of learners. In particular, learning styles of a reflector, theorist and activist as well as a visual learner can actively engage in the online learning experience. In an attempt to bridge the knowledge practice gap, further opinions are offered on the course design and the application of knowledge to practice following completion of the course.ConclusionThe findings of the small scale research study have shown that the e-learning course does meet the diverse learning styles and needs of nurses working in a clinical transfusion environment. However, technology alone is not sufficient and a blended approach to learning must be adopted to meet bridging the theory practice gap supporting the integration of knowledge to clinical practice.     

Benchmarking: applications to transfusion medicine

Benchmarking is as a structured continuous collaborative process in which comparisons for selected indicators are used to identify factors that, when implemented, will improve transfusion practices. This study aimed to identify transfusion medicine studies reporting on benchmarking, summarize the benchmarking approaches used, and identify important considerations to move the concept of benchmarking forward in the field of transfusion medicine. A systematic review of published literature was performed to identify transfusion medicine-related studies that compared at least 2 separate institutions or regions with the intention of benchmarking focusing on 4 areas: blood utilization, safety, operational aspects, and blood donation. Forty-five studies were included: blood utilization (n = 35), safety (n = 5), operational aspects of transfusion medicine (n = 5), and blood donation (n = 0). Based on predefined criteria, 7 publications were classified as benchmarking, 2 as trending, and 36 as single-event studies. Three models of benchmarking are described: (1) a regional benchmarking program that collects and links relevant data from existing electronic sources, (2) a sentinel site model where data from a limited number of sites are collected, and (3) an institutional-initiated model where a site identifies indicators of interest and approaches other institutions. Benchmarking approaches are needed in the field of transfusion medicine. Major challenges include defining best practices and developing cost-effective methods of data collection. For those interested in initiating a benchmarking program, the sentinel site model may be most effective and sustainable as a starting point, although the regional model would be the ideal goal.     

Massive transfusion protocol in adult trauma population

BackgroundAcute blood loss in trauma requires quick identification and action to restore circulating volume and save the patient. Massive transfusion protocols (MTPs) have become standard at Trauma Centers, in order to rapidly deliver blood products to bleeding patients. This literature review presents current standards of transfusion ratios, as well as insights into adjuncts during massive transfusions.MethodsPubMED was searched for articles from 2005 to 2020 on MTPs, the article were assessed for single vs. multi-institutional, mechanism of injury, type of MTP, timing in which blood products should be administered, timing of delivery of blood products to trauma bay, pre-hospital treatment and adjuncts, and outcomes.ResultsEleven studies addressed transfusion ratios. Seven studies looked at timing of blood products. Nine studies addressed MTP pre-hospital treatment and adjuncts. Prior to 2015, studies supported the benefits of a balanced transfusion ratio, which was then confirmed by the PROPPR randomized controlled trial. The shorter the time to blood product delivery the better the outcomes. New advances in technology have allowed us to measure different patterns of coagulation, allowing more individualized approaches to the bleeding patient.ConclusionCurrent massive transfusion protocols should utilize between 1:1:1 and 1:1:2 ratios of the 3 main products; plasma, platelets, and red blood cells. Massive transfusion protocols are effective in decreasing mortality. Better resuscitation efforts were seen when blood products were readily available in the trauma bay when the patient arrived and the faster the replacement of blood, the better the outcomes.     

Automatic special case consultations in transfusion medicine

In the past, consultations in immunohematology were usually delivered only when there was a blood or component shortage, or when the time required for compatibility testing was prolonged due to the presence of a difficult recipient antibody problem. More recently, transfusion medicine physicians have increased their role as clinical consultants concerned about the appropriate indications for blood transfusion. This communication presents a way to begin a sound program of clinical transfusion medicine consultation. The program can fit with community-wide teaching efforts, community or hospital transfusion audits, and specific physician education programs. Automatic or unsolicited consultations appear to have been both accepted well and beneficial in large hospitals and in communities where they have been provided for more than 7 years.