The transfusion medicine specialist as a coagulation consultant: a new variant of therapeutic pathology

Practitioners in transfusion medicine, long involved in consultations emphasizing clinical issues such as alloantibody reporting and transfusion reaction evaluation, have more recently been engaged as experts and consultants in hemostasis and coagulation. Given the growing complexity in laboratory coagulation testing and its interpretation, the shortage of specialists in this arena, and the increasing costs associated with patient management, we believe that there are vital clinical roles in hemostasis that can be readily fulfilled by transfusion medicine practitioners. The aim of this article is to briefly outline three possible models by which transfusion medicine practitioners can begin to integrate coagulation consultation into their regular clinical practice. Moreover, we discuss a novel curriculum that we are developing at our institution to more fully train transfusion medicine fellows in the fields of hemostasis and thrombosis.     

TREACT. An expert system consultation program to aid in the diagnosis of transfusion reactions

We have developed a rule-based, expert system consultation program, TREACT, to aid in the diagnosis of transfusion reactions. Given clinical signs, symptoms, and laboratory results, the program generates diagnoses, alerts the user when a medical director should be called, suggests follow-up actions, and makes recommendations for future transfusion. Diagnoses made by TREACT, including 121 reactions, were compared with those of the medical directors over a 6-month period. The overall diagnostic concordance between the medical directors and the program was 0.777. When this was corrected for chance association (kappa statistic), the concordance was 0.703 (p less than 0.0001), which can be interpreted on a qualitative scale as substantial agreement. The program has also been used successfully as a tool for training new technologists. Other advantages and possibilities that expert systems offer to transfusion medicine are discussed.     

Designing and Implementing a 5-Year Transfusion Medicine Diploma Program in China

The need for physicians and technical consultants specialized in transfusion medicine is urgent in China, as there are 20 000 hospitals and 500 blood centers in need of staff with this expertise. The progress made in transfusion medicine as a specialty has been relatively slow in China. Current Chinese medical education and service systems have not developed transfusion medicine as a stand-alone medical specialty. Most physicians receive only minimal training in transfusion medicine in medical school. This training is usually integrated into surgical training and addresses the most common technologies. In 2008, a 5-year bachelor's diploma program in transfusion medicine was established as an undergraduate specialty in Southern Medical University, Guangzhou, China. This article intends to summarize the 8 years of experience educating undergraduates in the specialty of transfusion medicine.     

Managing recalls and withdrawals of blood components

Donor centers are issuing a growing number of recalls and market withdrawals to hospital transfusion services about blood components. More than 1 in 2,000 units were recalled in the late 1990s in the United States. The most common reason for these notices from donor centers is postdonation donor information. Most of these units had been transfused, and many present a "risk of a risk" (ie, a problem might have been present that might have affected the recipient). A few regulations and standards address recalls in general terms, but transfusion services generally have wide discretion in the management of specific common recall problems. The Food and Drug Administration (FDA) is now including posttransfusion evaluations in its guidelines for emerging infectious threats to the blood supply. We suggest that hospital transfusion services should have standard operating procedures for managing recalls and that the hospital transfusion committee and the quality management program should provide local input or oversight. Using the FDA's categories of donor center biological product deviations, we provide recommendations to consider for when to notify the recipient's physician, after postdonation information is received about a previously transfused blood component. More study of this important everyday issue in transfusion medicine is highly desirable.     

Risk management in transfusion medicine: a hospital transfusion service perspective

The hospital transfusion service has always been at the heart of the blood component therapy chain. It has had the multiple roles of not only maintaining an inventory of a wide range of blood components, monitoring their storage conditions and ensuring compatibility when appropriate, but also being the source of expertise in transfusion medicine, and attempting to follow up any adverse consequences of transfusion. Hospital transfusion medicine has been seen essentially as a scientific and technical specialty with a minimal component of medical input. This is now changing and transfusion medicine is becoming an all embracing specialty where the hospital transfusion service still remains at the heart of transfusion medicine, but a much higher level of understanding is necessary at the clinical and consumer level.     

Decision making in perioperative transfusion.

Clinical decision making in transfusion medicine has received greater attention in recent years driven by concern about the potential hazards, especially since the recognition that HIV can be transmitted by homologous blood transfusion. These concerns about the risks of homologous transfusion has precipitated interest in the appropriateness of many transfusions and in the decision making processes in transfusion medicine. There has been increasing expenditure on the blood supply side to address the real or perceived potential infectious hazards. This has at times been to the detriment of the patient demand side of the homologous donor blood chain. This imbalance is now being addressed with the development of evidence based clinical guidelines for individual blood components, transfusion monitoring systems and quality assurance programmes. In this review of the process of clinical decision making in transfusion medicine and the factors involved in the ensuring a patient receives a safe and effect transfusion are addressed. The responsibilities of the patient's clinical carers are emphasised.     

Transfusion recipient epidemiology and outcomes research: possibilities for the future

The National Heart, Lung, and Blood Institute (NHLBI) supports major research programs related to the field of transfusion medicine, which encompass blood banking, the practice of transfusion medicine itself, and cellular therapies. Specific programmatic elements have included 1) the Transfusion Medicine/Hemostasis Clinical Trials Network (TMH CTN) charged with conducting clinical trials in transfusion medicine and hemostasis; 2) the Retrovirus Epidemiology Donor Study-II (REDS-II), which includes domestic and international efforts dedicated to blood donor safety and blood availability issues; 3) the Specialized Centers of Clinically Oriented Research (SCCOR) in Transfusion Biology and Medicine that include two major projects, the Biologic and Immunologic Aspects of Transfusion Medicine Program and the Transfusion and Lung Injury Program, and 4) the Transfusion Therapy Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair (FOCUS), a Phase III clinical trial that has as its major goal to determine whether a more aggressive transfusion strategy in surgery patients with cardiovascular disease (or risk factors) is associated with improved functional recovery and decreased risk of adverse postoperative outcomes. Notably, none of these programs supports epidemiologic and clinical outcomes research focused on transfusion recipients. Thus, on October 31, 2007, a Working Group on Transfusion Recipient Epidemiology and Outcomes Research was convened by the NHLBI. This group was asked to discuss the current status of the field, identify critical research needs, and make recommendations to the NHLBI program staff.     

Implementation of the Inspection and Accreditation Program of the American Association of Blood Banks: Experiences in Pennsylvania

The circumstances which have led to the establishment of an Inspection and Accreditation Program by the American Association of Blood Banks are outlined. The need for such a program has been greater in this field of clinical laboratory practice than in other fields because of the awareness of the Public of the medical consequences from the transfusion of incompatible blood. In Pennsylvania there has been widespread cooperation in implementing inspection and accreditation of individual hospital blood banks on the part of pathologists and hospital administrators. Some of the deficiencies encountered on inspection are listed. It is possible that this voluntary program in blood banking may be extended to other areas of laboratory medicine.     

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.     

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.     

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.     

The clinician's approach to the management of risk

Although risk has always been accepted as an integral part of any medical or surgical therapy, it is only in recent years that quantitation of this risk in transfusion medicine is being assessed in a detailed and practical manner. Balancing of the risk/benefit equation in relation to blood component therapy has only become a day-to-day issue in clinical medicine since the recognition that HIV could be transmitted by blood transfusion. Blood transfusion has never been as safe a procedure as most patients and clinicians have thought, with numerous potential complications and new ones being recognized. As medical teaching in blood component therapy has not had a high profile in most undergraduate and postgraduate medical curricula, there has been an inappropriately low level of awareness for the indications for the risks and benefits of blood component therapy. Since the appearance of transfusion-transmitted HIV, clinicians and patients alike have rapidly become aware of the potential risks associated with transfusion medicine. This paper addresses the issues of how the clinician can minimize the risks of blood component therapy and to effectively present the risks and benefits to clinical users and potential recipients of blood component therapy. Paradoxically, in developed countries, transfusion therapy is probably safer than it has ever been in the past, but the perception of the community is the opposite. Why is this so?, and what can be done to improve that patient's perception and associated fear? The ultimate answer rests with improving assessment of risks versus benefits, effective education and communication with the patient (and relatives) in order to achieve meaningful informed consent.     

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.     

Hemolysis during percutaneous mechanical thrombectomy can mimic a hemolytic transfusion reaction

BACKGROUND: Interventional radiologists have developed percutaneous mechanical thrombectomy (PMT) devices to remove intravascular thrombi. Hemolysis, secondary to thrombus destruction from these devices, has been described in radiology journals, but similar reports appear to be lacking in the transfusion medicine literature. Two cases of hemolysis after PMT are described that involved the transfusion service, one of which was reported as a hemolytic transfusion reaction. CASE REPORTS: The first patient received 4 units of red cells (RBCs) during a thrombectomy and subsequent placement of a transjugular intrahepatic portosystemic shunt. The patient developed hemoglobinuria, and it was reported to the blood bank as a possible hemolytic transfusion reaction. After RBC mismatch and bacterial contamination were excluded, the hemolysis was attributed to thrombectomy-related mechanical hemolysis. In the second case, a hemolyzed sample was sent to the blood bank for a type and cross-match. Upon requesting that the sample be redrawn, it was learned that the sample was obtained after PMT. CONCLUSION: Patients who have undergone PMT can have clinical and laboratory findings suggestive of hemolytic transfusion reactions. Although interventional radiologists are familiar with these side effects, the blood bank profession needs to be aware that these procedures cause nonimmune hemolysis and must consider this possibility when evaluating transfusion reactions in these patients.     

A multidisciplinary "think tank": the top 10 clinical trial opportunities in transfusion medicine from the National Heart, Lung, and Blood Institute-sponsored 2009 state-of-the-science symposium

BACKGROUND: In September 2009, the National Heart, Lung, and Blood Institute convened the State‐of‐the‐Science Symposium in Transfusion Medicine to identify Phase II and/or III clinical trials that would provide important information to advance transfusion medicine. STUDY DESIGN AND METHODS: Seven multidisciplinary subcommittees developed proposals in the following areas: 1) platelet (PLT) product use, 2) neonatal and/or pediatric transfusion practice, 3) surgical transfusion practice, 4) intensive care unit and/or in trauma transfusion practice, 5) plasma and/or cryoprecipitate product use and therapeutic apheresis practice, 6) red blood cell (RBC) product use and/or blood conservation management, and 7) medical transfusion practice or blood donor studies. The committees consisted of transfusion medicine specialists, hematologists, cardiovascular surgeons, anesthesiologists, neonatologists, critical care physicians, and clinical trial methodologists. Proposals were presented and an external panel evaluated and prioritized each concept for scientific merit, clinical importance, and feasibility. RESULTS: Twenty‐four concepts were presented by the subcommittees. Ten concepts addressed four areas deemed most important: 1) PLT transfusion strategies to prevent and/or mitigate bleeding in neonates and patients with hematologic malignancies, 2) RBC transfusion trigger strategies to improve overall outcomes in different patient populations, 3) evaluation of optimal plasma:PLT:RBC ratios in trauma resuscitation, and 4) pathogen inactivation of PLTs to improve PLT transfusion safety. CONCLUSIONS: The proposal themes not only represent inquiries about the indications for transfusion, but also epitomize the lack of consensus when clinical practice lacks a strong evidence base. Ultimately, the purpose of this publication is to provide a “blueprint” of ideas for further development rather than endorse any one specific clinical trial design.     

Qualitative research in transfusion medicine

Transfusion medicine research has traditionally employed quantitative methods to answer clinical research questions. Increasingly, qualitative research methods are being used in the field to address a wide variety of research questions in areas such as blood donation, transfusion practices and policy development. This article describes the key characteristics, methodologies and methods of qualitative research and draws on examples to show how qualitative research approaches have been applied in the field of transfusion medicine. It is hoped that this overview will inform and encourage the application of qualitative research in the field of transfusion medicine.     

Assessment of physicians knowledge in transfusion medicine, Iran, 2007

Knowledge of physicians has an important role in optimal use of blood products. This study was carried out to assess Iranian physicians' knowledge in transfusion medicine. In this cross-sectional study, 1242 physicians were selected through multistage sampling method in March 2007. Physicians' knowledge was assessed by the questionnaire comprising of 50 questions addressing basic knowledge, clinical aspects of blood use and transfusion reactions. One point was awarded for each correct answer. Approximately 22%, 37%, and 40% of the questions referring to basic knowledge, clinical aspects of blood use and transfusion reactions, respectively, were replied correctly. Thirty three percent came out to be the average figure for the questions receiving correct answers. Knowledge score of the specialists who were more frequently involved in blood use was not significantly different from other specialists (radiologists or psychiatrics) and general practitioners. Knowledge score decreased with increasing years in practice ( P < 0.001). Ninety nine percent of physicians under the study believed that they required special education to raise their transfusion medicine knowledge. Knowledge of physicians was about one-third lower than the expected level. Therefore, educational materials concerning transfusion medicine should be provided for medical students, residents and fellows. For practicing physicians, continuous medical education programmes should be offered so that the level of transfusion medicine knowledge can be improved.     

Problems with a walking donor transfusion program

A walking donor transfusion program is outlined in detail. A total of 205 transfusions from 72 walking donors were given to 57 newborns in a Newborn Intensive Care Unit over a nine-month period. The average recipient weighed 1,762 g and the average transfusion was 15 ml of blood. Because a suitable walking donor was not always available when a transfusion was needed, 19 units of regular adult blood were also used to support the program. No immediate or delayed transfusion reactions were noted, but one fatal incident of serum hepatitis transmission occurred. Our experience suggests that a walking donor program carries an inherent significant risk of transmission of hepatitis and alternative methods with strict blood bank control are needed to assure maximum safety in neonatal transfusion.     

Hospital Medicine Providers’ Transfusion Knowledge: A Survey Study

Blood transfusion is one of the most common procedures performed in the inpatient setting. Although ordering a transfusion is a component of routine practice for most hospitalists, prior literature has shown that non-transfusion medicine physicians have poor to intermediate transfusion medicine knowledge (TMK). No recent study has evaluated TMK among hospitalists, including both attending hospitalists and advanced practice providers (APPs). Using a validated exam and a truncated version of a validated survey, we obtained an initial impression of attitudes, perceived and actual TMK. A total of 183 hospital medicine providers nation-wide completed the 12-question online survey and 20 question exam, including 155 attending hospitalists and 28 APPs. The overall mean score was 52% (range 20%-85%). Forty-one percent of participants reported less than 1 hour of training in transfusion medicine. Five of the seven questions with the worst performance (<25% correct) were on transfusion reactions. Almost all respondents reported consenting a patient for blood transfusion and 60% believed that TMK was very or extremely important in order to provide appropriate care for patients. More than 80% believed that having additional transfusion medicine education would be at least moderately helpful. Although routinely consenting patients for transfusion, hospital medicine providers may have insufficient TMK particularly as it pertains to transfusion reactions. The majority of hospitalists rated TMK important to clinical practice and had an interest in additional training, thus continuing medical education has the potential to improve TMK and patient care.