Trend towards reduction of transfusion reactions using prestorage leukocyte-reduced and pooled whole blood-derived platelets and cost savings compared with poststorage whole blood-derived random platelets as evidenced by real-time hemovigilance.

BACKGROUND: Due to chemotherapy-induced neutropenia or hematologic malignancies, immunocompromised cancer patients may have higher incidence of febrile nonhemolytic transfusion reactions compared with the general population and frequently require platelet transfusions. This quality improvement project compared the safety of transfusion using prestorage leukocyte-reduced and pooled whole blood-derived platelets (Acrodose/WBD) with conventionally produced poststorage WBD platelets (RDP) using an active hemovigilance system. METHODS: Every patient receiving a blood product at the hospital was virtually monitored in real time by trained nurses from a remote hemovigilance unit. These nurses monitor a digital dashboard, which populates a watch list of patients from the time blood product administration is initiated until 12 hours posttransfusion. Over the course of 6 months, 371 patients receiving 792 RDP transfusions and 423 patients receiving 780 Acrodose/WBD platelets transfusions were monitored for transfusion reactions. RESULTS: We identified 26 transfusion reactions in RDP but only 12 transfusion reactions in the Acrodose/WBD platelet group. CONCLUSION: Acrodose platelet transfusion was associated with fewer transfusion reactions, which resulted in significant cost savings.

Digitally enabled hemovigilance allows real time response to transfusion reactions.

BACKGROUND: Transfusion carries a risk of transfusion reaction that is often underdiagnosed due to reliance on passive reporting. The study investigated the utility of digital methods to identify potential transfusion reactions, thus allowing real-time intervention for affected patients. METHOD: The hemovigilance unit monitored 3856 patients receiving 43,515 transfusions under the hemovigilance program. Retrospective comparison data included 298,498 transfusions. Transfusion medicine physicians designed and validated algorithms in the electronic health record that analyze discrete data, such as vital sign changes, to assign a risk score during each transfusion. Dedicated hemovigilance nurses remotely monitor all patients and perform real-time chart reviews prioritized by risk score. When a reaction is suspected, a hemovigilance trained licensed clinician responds to manage the patient and ensure data collection. Board-certified transfusion medicine physicians reviewed data and classified transfusion reactions under various categories according to the Centers for Disease Control hemovigilance definitions. RESULTS: Transfusion medicine physicians diagnosed 564 transfusion reactions (1.3% of transfusions)-a 524% increase compared to the previous passive reporting. The rapid response provider reached the bedside on average at 12.4 min demonstrating logistic feasibility. While febrile reactions were most diagnosed, recognition of transfusion-associated circulatory overload demonstrated the greatest relative increase. Auditing and education programs further enhanced transfusion reaction awareness. DISCUSSION: The model of digitally-enabled expert real-time review of clinical data that prompts rapid response improved recognition of transfusion reactions. This approach could be applied to other patient deterioration events such as early identification of sepsis.

Oncology Patients Who Develop Transfusion-Associated Circulatory Overload: An Observational Study.

BACKGROUND: Transfusion-associated circulatory overload (TACO) is a largely preventable transfusion complication that results in significant morbidity and mortality. Cancers, related treatments, and comorbidities are among the factors that can predispose patients to TACO, but currently there are limited data on this topic in the literature. METHODS: We collected data retrospectively from the electronic health records of 93 adult patients with cancer who met Centers for Disease Control and Prevention (CDC) criteria for TACO from July 1, 2019, through October 31, 2020. The parameters we studied included demographics, comorbidities, treatment modalities, transfusion practices, and outcomes. We summarized data by means and ranges for continuous variables, and proportions for categorical variables. RESULTS: During the study period, the incidence of TACO among oncology patients was 0.84 per 1000 transfusions (95% CI, 0.68-1.02), representing 6.6% of all reactions. This percentage is high, compared with 1%-6% among other populations. Unique characteristics such as hematology malignancy (75.3%), receipt of cardiotoxic chemotherapy (87.1%), pneumonia (57.0%), preexisting oxygen use (59.1%), dyspnea (62.4%), hypertension (55.9%), renal insufficiency (46.2%), daily use of corticosteroids (43.0%), daily use of diuretics (40.9%), daily use of beta-blockers (36.6%), and elevated NT-proBNP (33.3%) were frequently observed in these group of oncology patients. CONCLUSIONS: Our study indicates that oncology patients have unique factors that may lead to diagnosis of TACO. Developing appropriate guidelines that apply to oncology patients, in addition to those set forth by the CDC, should be considered. Implementation by ordering healthcare providers of a tools that can predict TACO can help in early recognition and mitigation of TACO.

A Quality Approach to Reducing the Occurrence of Occluded Leukocyte Reduction Filters During Platelet Transfusion.

BACKGROUND: In 2019, an increase in clotted platelet filter occurrences was noted with the implementation of new leukocyte reduction filters through a volumetric pump. LOCAL PROBLEM: Occluded platelet filters contribute to delays in platelet transfusions, additional nursing workflows, and potential wastage of platelets, leading to staff and patient dissatisfaction. METHODS: Direct observation of nursing practice with priming platelet filters identified opportunities for improvement. Education was designed incorporating manufacturer recommendations with results of the observations. Nursing education was disseminated through small group sessions, one-to-one teaching, tip sheets, and an e-learning video. RESULTS: Nursing education interventions resulted in a 170% reduction in the reported monthly filter occlusion rate. CONCLUSION: Engagement of nurses in quality improvement processes and collaboration across departments led to a sustained decrease in the clotted platelet filters.

Integration of Lean Visual Management Tools Into Quality Improvement Practices in the Hospital Setting.

BACKGROUND: Lean management tools have proven effective in achieving high reliability in health care. LOCAL PROBLEM: Unstructured leader rounds, decentralized prevention bundle repositories, and unfavorable patient experience outcomes prompted leaders on a thoracic and cardiovascular surgery unit to find other methods to address these issues and positively impact outcomes. METHODS: Nurse sensitive indicator prevention bundles, root cause analysis tools, and best practices were used to develop Kamishibai Cards (K-Cards) for each measure targeted. INTERVENTIONS: K-Cards were implemented to standardize processes, engage patients in their care, and promote staff identification of barriers and solutions. RESULTS: Nurse-sensitive indicators and patient experience metrics were positively impacted by Kamishibai Rounding. K-Cards promote a state of continuous improvement, which supports sustainability of evidence-based practice and best practices that were implemented. CONCLUSIONS: K-Cards use high-reliability principles to standardize nursing practice to promote quality outcomes.

Perceptions of Missed Care Across Oncology Nursing Specialty Units.

BACKGROUND: An opportunity was identified to compare perceptions of the occurrence and types of missed care at a comprehensive cancer center. PURPOSE: The purpose was to evaluate the difference in perceived occurrence and types of missed care between medical, surgical, and hematologic oncology units in the context of a newly implemented patient care delivery system, Primary Team Nursing (PTN). METHODS: A descriptive, repeated-measures design was used. The MISSCARE survey was distributed electronically to 580 staff members across 6 inpatient units. RESULTS: Frequently perceived elements of missed nursing care were ambulation, turning every 2 hours, and care conference attendance. At the time of study implementation, surgical units reported 0.24 higher scores than medical units (P = .017); hematology units reported 0.26 lower scores than surgical units (P = .005). PTN status did not affect MISSCARE scores (P = .525). CONCLUSIONS: Study findings suggest that perceived missed care in a comprehensive cancer center is similar to that in other hospital settings.

Clinical Nurse Leader: Evolution of the Role in Oncology Care.

The clinical nurse leader (CNL) role has evolved since the American Association of Colleges of Nursing published a white paper on the role in 2007. Since then, various publications have evaluated the role of CNLs in enhancing quality outcomes for patients. The introduction of the CNL role in the oncology setting, although occurring with variability across the United States, provides a unique opportunity to explore the benefits of this role in cancer care outcomes.