Identification and management of preoperative anaemia in adults: A British Society for Haematology Guideline update.

This updated British Society for Haematology guideline provides an up-to-date literature review and recommendations regarding the identification and management of preoperative anaemia. This includes guidance on thresholds for the diagnosis of anaemia and the diagnosis and management of iron deficiency in the preoperative context. Guidance on the appropriate use of erythropoiesis-stimulating agents and preoperative transfusion is also provided.

Haemovigilance resources available for everyone: A report from the International Haemovigilance Tools Collaborative Project.

BACKGROUND AND OBJECTIVES: Haemovigilance systems are intended to collect and analyse data, and report findings relating to transfusion complications, such as blood product safety, procedural incidents, and adverse reactions in donors and patients. A common problem among developing haemovigilance programs is the lack of resources and tools available to countries striving to establish or enhance their haemovigilance system. MATERIALS AND METHODS: World Health Organization, in collaboration with International Society for Blood Transfusion (ISBT), International Haemovigilance Network and other haemovigilance experts embarked on a Haemovigilance Tools Project to collect and provide materials and resources to assist with the stepwise implementation of haemovigilance. RESULTS AND CONCLUSIONS: Resources are housed as a virtual compendium on the ISBT website under the Haemovigilance Working Party. These are managed by a subcommittee of the Working Party and are freely available and downloadable to all without requiring ISBT membership.

Construction of a decision model for donor testing in cases of suspected antibody-mediated transfusion-related-acute-lung-injury.

OBJECTIVE: To propose a rational basis for donor testing in cases of suspected antibody-mediated transfusion-related lung injury (AMT). BACKGROUND: Anti-leukocyte antibodies in donated blood are established causes of transfusion-related lung injury (TRALI). However, the question of whether to test donors for antibodies is not identical to whether the case meets definition criteria for TRALI. There is a balance between the potential benefits of testing and the costs of donor deferral and investigation. We propose that a decision-making process based on optimising the balance between risk and benefit requires a subjective choice of the relative value of different outcomes of testing. METHODS: We have developed a formal decision model to illustrate how these choices affect testing decisions. RESULTS: Using a Bayesian probability model, we show that the diagnostic benefit and TRALI prevention benefit of testing donors have a complex interrelationship with the number of implicated donors and clinical suspicion of antibody-mediated TRALI (AMT) and that rational testing choices vary according to value assigned to outcomes. CONCLUSIONS: The challenges to the use of a formal decision model for clinical testing are discussed and conclude that a formal model is a useful consensus-building tool for improving consistency and openness in decision making.

Standardized reporting of pulmonary transfusion complications: Development of a model reporting form and flowchart.

BACKGROUND: Pulmonary complications of blood transfusion, including transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), and transfusion-associated dyspnea, are generally underdiagnosed and under-reported. The international TRALI and TACO definitions have recently been updated. Currently, no standardized pulmonary transfusion reaction reporting form exists and most of the hemovigilance forms have not yet incorporated the updated definitions. We developed a harmonized reporting form, aimed at improved data collection on pulmonary transfusion reactions for hemovigilance and research purposes by developing a standardized model reporting form and flowchart. MATERIALS AND METHODS: Using a modified Delphi method among an international, multidisciplinary panel of 24 hemovigilance experts, detailed recommendations were developed for a standardized model reporting form for pulmonary complications of blood transfusion. Two Delphi rounds, including scoring systems, took place and several subsequent meetings were held to discuss issues and obtain consensus. Additionally, a flowchart was developed incorporating recently published redefinitions of pulmonary transfusion reactions. RESULTS: In total, 17 participants completed the first questionnaire (70.8% response rate) and 14 participants completed the second questionnaire (58.3% response rate). According to the results from the questionnaires, the standardized model reporting form was divided into various subcategories: general information, patient history and transfusion characteristics, reaction details, investigations, treatment and supportive care, narrative, and transfused product. CONCLUSION: In this article, we present the recommendations from a global group of experts in the hemovigilance field. The standardized model reporting form and flowchart provide an initiative that may improve data collected to address pulmonary transfusion reactions.

SHOT UK Collaborative Reviewing and Reforming IT Processes in Transfusion (SCRIPT) survey: Laboratory information management systems: Are we ready for digital transformation?

OBJECTIVES: To understand the use, functionality and interoperability of laboratory information management systems (LIMS) in UK transfusion laboratories. BACKGROUND: LIMS are widely used to support safe transfusion practice. LIMS have the potential to reduce the risk of laboratory error using algorithms, flags and alerts that support compliance with best practice guidelines and regulatory standards. Reporting to Serious Hazards of Transfusion (SHOT), the United Kingdom (UK) haemovigilance scheme, has identified cases where the LIMS could have prevented errors but did not. Shared care of patients across different organisations and the development of pathology networks has raised challenges relating to interoperability of IT systems both within, and between, organisations. METHODS AND MATERIALS: A survey was distributed to all SHOT-reporting organisations to understand the current state of LIMS in the UK, prevalence of expertise in transfusion IT, and barriers to progress. Survey questions covered LIMS interoperability with other IT systems used in the healthcare setting. RESULTS: A variety of LIMS and version numbers are in use in transfusion laboratories, LIMS are not always updated due to resource constraints. Respondents identified interoperability and improved functionality as the main requirements for transfusion safety. CONCLUSION: A nationally agreed set of minimum standards for transfusion LIMS is required for safe practice. Adequate resources, training and expertise should be provided to support the effective use and timely updates of LIMS. A single LIMS solution should be in place for transfusion laboratories working within a network and interoperability with other systems should be explored to further improve practice.

Incorporating the entity of under-transfusion into hemovigilance monitoring: Documenting cases due to lack of inventory.

BACKGROUND: Under-transfusion is an underreported entity within most hospitals and hemovigilance systems. While critical blood shortages are being reported more frequently, without incident codes to document instances of under-transfusion due to lack of inventory, estimating its impact on patient care as it relates to hemotherapy (HT) has hampered our ability to assess and inform strategic initiatives to combat inventory issues as well as prepare for future blood supply threats. STUDY DESIGN AND METHOD: An 11-member working group of the AABB (Association for the Advancement of Blood and Biotherapies) Hemovigilance Committee was formed in October 2020 to study the topic of under-transfusion including its potential causes and clinical expressions. The group was also charged with proposing simple definition/incident codes to be used by hemovigilance systems to document such instances. RESULTS: The working group proposed four simple incident codes under the new process code-No Blood (NB)-that can be used by hemovigilance systems to appropriately document instances of under-transfusion due to lack of inventory. The codes were described as: (1) NB 01-Inventory less than usual level due to supplier shortage; (2) NB 02-Demand for blood product exceeding usual inventory levels; (3) NB 03-Substitution with incompatible/inappropriate units; and (4) NB 04-Suboptimal dose/no transfusion given. CONCLUSION: The adoption of these codes within hemovigilance systems globally would assist in recognition and reporting instances of under-transfusion due to inventory, thus supporting development of better collection strategies, inventory management techniques as well as effective policies to improve blood safety and availability.

Safe handovers: Safe patients-why good quality structured handovers in the transfusion laboratory are important.

BACKGROUND: Effective transfer of information relating to patient care is vital in healthcare. In the UK formal handover is an established and well reported process in the clinical setting but less so in transfusion laboratories. Blood transfusions occur within many hospital specialities and across clinical and laboratory staff shifts, making robust handover critical for safe practice. Failure to adequately transfer information relating to pending or ongoing provision of blood components during shift handover in the laboratory can have an adverse impact on patient care. AIMS: To identify transfusion errors where laboratory handover was considered a contributory factor. MATERIALS AND METHODS: Serious adverse events and reactions reported to the UK haemovigilance scheme, Serious Hazards of Transfusion (SHOT), involving handover in the transfusion laboratory were reviewed for a 6-year period. RESULTS: Laboratory incidents involving handover were mainly associated with incorrect blood component transfused-specific requirements not met (IBCT-SRNM) and delays in provision of blood components transfusion, with 16.6% of these cases involving major haemorrhage situations. Handover was found to be insufficient in most cases, no handover was completed in 29.5% of cases, inadequate written handover accounted for 14.8% cases, and inadequate verbal for 5.7% of cases. DISCUSSION: Poor handover can lead to laboratory errors, particularly delays in provision of blood components. Embedding effective handover processes in the laboratory and including handover time within the shift working pattern, may help reduce errors and ensure continuity of care. CONCLUSION: Handover should be considered a task that is built into laboratory routine practices, ensuring effective transfer of information and appropriate follow up actions are taken. SHOT have created a handover template which can be adopted in laboratories to formalise this process.

Missed irradiation of cellular blood components for vulnerable patients: Insights from 10 years of SHOT data.

BACKGROUND: Irradiation of cellular blood components is recommended for patients at risk of transfusion-associated graft-vs-host disease (TA-GvHD). Prestorage leucodepletion (LD) of blood components is standard in the UK since 1999. STUDY DESIGN AND METHODS: Analysis of 10 years' reports from UK national hemovigilance scheme, Serious Hazards of Transfusion (2010-2019), where patients failed to receive irradiated components when indicated according to British Society for Haematology guidelines (2011). RESULTS: There were 956 incidents of failure to receive irradiated components all due to errors. One hundred and seventy two incidents were excluded from analysis, 125 of 172 (72.7%) because of missing essential information. No cases of TA-GvHD were reported in this cohort. The 784 patients received 2809 components (number unknown for 67 incidents). Most failures occurred in patients treated with purine analogues (365) or alemtuzumab (69), or with a history of Hodgkin lymphoma (HL) (192). Together these make up 626 of 784 (79.9%). Poor communication is an important cause of errors. CONCLUSION: Leucodepletion appears to reduce the risk for TA-GvHD. None of 12 cases of TA-GvHD reported to SHOT prior to introduction of LD occurred in patients with conditions recommended for irradiated components by current guidelines. Irradiation indefinitely for all stages of HL is not based on good evidence and is a difficult guideline to follow. Further research on long-term immune function in HL is required. Variation between different national guidelines reflects the very limited evidence.

How we forecast tomorrow's haemovigilance.

The field of haemovigilance continues to develop, building on more than forty years of international experience. This review considers the current scope and activities of haemovigilance around the world and explores aspects of preparation for the advent of new blood products and alternative therapies to transfusion; new tools for data acquisition (including patient- and donor-reported outcomes, and data from 'wearables') and the analysis and communication of haemovigilance results.