Apheresis practice variation during the COVID-19 pandemic: Results of a survey.

BACKGROUND: The COVID-19 pandemic affected healthcare delivery across all specialties including apheresis. To describe the changes in apheresis service practices that occurred during the pandemic, the American Society for Apheresis (ASFA) Apheresis Medicine Attending Physician Subcommittee conducted a survey study. STUDY DESIGN AND METHODS: A 32-question survey was designed and distributed to 400 ASFA physician members on September 7, 2022. Attending physicians responded to questions about whether and how apheresis service practices changed during the COVID-19 pandemic compared with the time period prior to the pandemic in terms of: (1) procedure types and volumes, (2) patient consultation workflow, and (3) the use of telemedicine. Descriptive analyses were reported as number and frequency of responses. RESULTS: The survey response rate was 13.8% (55/400). Of these respondents, 96.4% (53/55) were attending physicians. The majority of respondents (42/53, 79.2%) indicated that the types of procedures performed during COVID-19 compared to pre-pandemic did not change. Most frequently for apheresis procedure volume, respondents reported: no change in their monthly inpatient volume (21/47, 44.7%) and a decrease in their monthly outpatient volume (28/46, 60.9%). Prior to COVID-19, 75.0% (30/40) of respondents performed consultations at bedside for inpatients and 67.4% (29/43) performed consultations at bedside for outpatients. Bedside consultations decreased in both settings during the pandemic but were still most frequently performed by attending physicians. At the same time, the use of telemedicine increased for 15.4% of survey respondents during COVID-19. CONCLUSION: Some, but not all, respondents observed or made changes to their apheresis service during the COVID-19 pandemic. A subset of changes, such as increased utilization of telemedicine, may persist.

Apheresis medicine education during the early phase of the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic introduced challenges and disruption across healthcare, including apheresis medicine (AM). In this study, we report findings from a survey conducted among American Society for Apheresis Physician Committee (ASFA-PC) members to describe the impact of the COVID-19 pandemic on AM education practices. STUDY DESIGN AND METHODS: A voluntary, anonymous, 24-question, institutional review board-approved survey regarding AM teaching during the pandemic was distributed to ASFA-PC members in the United States between December 1, 2020, and December 15, 2020. Descriptive analyses were reported as number and frequency of respondents for each question. Free text responses were summarized. RESULTS: Responses were received from 14/31 (45%) of ASFA-PC members, of whom 12 practiced at academic institutions. Among these, 11/12 (92%) transitioned to virtual platform for AM trainee conferences during the pandemic. A variety of resources were employed to support independent AM learning. While 7/12 (58%) respondents did not change the informed consent process for AM procedures, others delegated this process or introduced remote alternatives. The most common method respondents used to conduct AM patient rounding was a hybrid in-person/virtual model. CONCLUSION: This survey describes the adaptations and changes AM practitioners made to trainee education in response to the early phase of the COVID-19 pandemic. The transition to virtual and/or hybrid trainee learning and AM rounds underscores the importance of digital AM resources. Further study of the effects of the pandemic and its impact on AM trainee education, as well as patient care is warranted.

How did we reform our out of control massive transfusion protocol program?

BACKGROUND: The massive transfusion protocol (MTP) is designed to quickly provide blood products at a fixed ratio for the exsanguinating patient. At our academic medical center, the frequency of MTP activation increased over 10-fold between 2008 and 2015, putting inordinate stress on our transfusion service. STUDY DESIGN AND METHODS: Gathering a large number of relevant stakeholders, we performed a multidisciplinary root cause analysis (RCA) in response to the acute clinical need to reform our MTP. RESULTS: Through the RCA, we identified four principal opportunities for improvement (OFI) associated with our MTP: education, stewardship, process improvement, and communication. Through the deployment of new approaches to each of these OFI, we reduced MTP activations, blood product waste, and transfusion service technologist stress. CONCLUSION: The MTP is amenable to improvement, and, although time intensive, the RCA process yields significant favorable effects: improving communication with colleagues, reducing stress within the transfusion service, and improving resource utilization. Activation of the MTP at our institution is now more aligned with its primary purpose: rapidly providing large quantities of blood products to exsanguinating patients.

Apheresis physician well-being during the COVID-19 pandemic: Results of a survey.

BACKGROUND: The COVID-19 pandemic has placed additional stressors on physician lives. In this study, we report findings from a survey conducted among attending physician (AP) members of the American Society for Apheresis (ASFA) to elucidate the status of their well-being during the COVID-19 pandemic as well as resources provided or actions taken by their institutions and themselves personally to maintain or improve their well-being. STUDY DESIGN AND METHODS: A 17-question, voluntary, IRB-approved survey regarding well-being was distributed to the ASFA AP members between August 26, 2020 and September 16, 2020. The descriptive analyses were reported as number and frequency of respondents for each question. Non-parametric chi-square tests, ANOVA, and paired t-tests were performed to determine differences in categorical variables, changes in well-being scores, and compare time points, respectively. RESULTS: Based on the responses of 70 attending level physicians representing the United States (U.S., 53, 75.7%) and outside the U.S. (17, 24.3%), the following were observed: (1) COVID-19 negatively affects the well-being of a sub-population of APs, (2) neither institutional nor individual measures to improve well-being completely resolved the problem of decreased AP well-being during the pandemic, and (3) personal actions may be superior to institutional resources. CONCLUSION: There is a widespread decline in AP well-being during the COVID-19 pandemic that was not adequately improved by institutional or personal resources/actions taken. Institutions and physicians must work together to implement strategies including resources and actions that could further improve AP physician well-being during a public health crisis.

Evaluation and improvement of blood donor educational materials: results from a multicenter randomized controlled trial.

BACKGROUND: Blood collection centers are charged with creating donor educational materials (DnEM) that are easily understood across all prospective donor populations, while addressing mandates and recommendations from regulatory agencies and professional standard setting organizations. Donors must have sufficient information to understand the donation process with its risks and benefits, time to consider options before deciding, and opportunity to choose whether to proceed with or decline donating. The goal of this multisite randomized controlled trial was to evaluate knowledge acquired using standardized DnEM. America's Blood Centers' Working Group (WG) for Donor Education and Communication was formed to evaluate and suggest modifications of these documents. Based on pilot work, a randomized clinical trial was designed to test donor knowledge across a variety of populations. The WG identified several shortcomings in the current DnEM and proposed new DnEM. The new DnEM were tested against the same, current DnEM being used at all three sites (Blood Donor Educational Material, 2016 version 2.0, published in conjunction with the AABB uniform donor history questionnaire). METHODS AND MATERIALS: One-hundred sixty-five first time and returning donors were randomized in a 2x2 model to review either new DnEM or current DnEM. Every participant completed a pre- and post-quiz that tested their understanding of the DnEM. RESULTS: Returning donors had greater baseline knowledge compared to new donors, but new donors improved more versus returning donors. Donors using the new DnEM showed greater improvement in knowledge than those using current DnEM. CONCLUSION: Comprehension of DnEM can be improved. With this sample size the results suggest that the findings are independent of demographic characteristics, but a larger study would be necessary to confirm this.

The effect of entrustable professional activities on pathology resident confidence in blood banking/transfusion medicine.

BACKGROUND: The Accreditation Council for Graduate Medical Education requires milestone reporting of the Six General Core Competencies. Additionally, Graduate Medical Education (GME) is transitioning to adopt competency-based education methodologies including entrustable professional activities (EPAs) for objective, observable, and measurable milestone progression. The College of American Pathologists published 19 EPAs, including one for transfusion-related adverse events. This survey study includes developing EPAs for transfusion reaction evaluation and assessing residents before and after implementing these EPAs. STUDY DESIGN AND METHODS: Three transfusion reaction EPAs were developed and implemented in July 2018 for the Postgraduate Year (PGY) 2 pathology residents. An online, anonymous survey was sent to all 21 pathology trainees before and one year after EPA implementation. In July 2018 and August 2019, each survey included the same six multiple-choice, single-response, confidence questions, with a rating scale of extremely, very, slightly, or not at all confident. This study was approved by the hospital's Institutional Review Board for Health Sciences Research and GME Committee. RESULTS: Analysis was performed on PGY2-4 residents. In 2018, 13 of 20 participants were analyzed. In 2019, 15 of 19 participants were analyzed. Number and percentage of responses were reported. The results showed an increase in trainee confidence, with the greatest improvement among the first class to use the EPAs. CONCLUSION: EPAs provide an effective framework for objective and measurable progression of trainees. One year after the implementation of transfusion reaction EPAs at our site, the trainees showed enhanced confidence levels in handling Blood Bank and Transfusion Medicine Services coverage.

Vascular access practices for therapeutic apheresis: Results of a survey.

INTRODUCTION: Obtaining vascular access (VA) is a critical part of the therapeutic apheresis (TA) treatment plan. Currently, there are no guidelines for VA decision-making and maintenance related to TA procedures. MATERIALS AND METHODS: A 28-question survey to gather qualitative information regarding VA practices was distributed to the American Society for Apheresis (ASFA) 2018 Annual Meeting attendees and all ASFA members for voluntary participation. The descriptive analyses were reported as the number and frequency of responses for each question. RESULTS: Total participation was 206 with 147 (71.4%) answering some or all 16 VA focused questions. The majority of respondents were nurses or physicians (89.0%) at sites providing ≥100 procedures. The most common TA procedures were plasma exchange, red cell exchange, and leukocytapheresis. The VA evaluation was predominantly performed by the TA service (80.3%, 118/147). The majority of TA physicians and/or providers do not insert (91.7%, 132/144) or remove (81.2%, 117/143) VA catheters. When an emergent TA procedure is needed, the majority of respondents felt <2 hours was an acceptable turnaround time for VA placement (64.3%, 92/143). The most common anticoagulant for locking catheters and/or ports was heparin. The majority of TA services (54.3%, 76/140) collect data on aborted procedures due to catheter/line/port problems unrelated to infection, but only 41.4% (58/140) collect data on infections. CONCLUSION: VA contributes significantly to the overall risks associated with and the safety of TA. Our survey shows that there is substantial variation but common themes in TA VA practices. Several areas for future research may be identified.

Anti-D from alloimmunization versus RhIG: detective work in the blood bank and transfusion medicine services.

BACKGROUND: The blood bank and transfusion medicine services (BBTMS) engages with electronic health records (EHRs), clinicians, and outside hospitals (OHs) to obtain comprehensive patient history to optimize care. Detection of anti-D in a pregnant patient underscores this work. Differentiating passive anti-D due to RhIG administration versus alloanti-D affects clinical decision making. The objectives of this study were to identify the required steps, barriers, and outcomes of anti-D investigations in obstetric patients. STUDY DESIGN AND METHODS: This retrospective case series reviewed nine pregnant patients over 24 months, for whom anti-D was identified with no reported RhIG history. Six steps were performed to ascertain anti-D history: 1) review the on-site EHR; 2) contact the on-site obstetrician, 3) review history from the automatic health information exchange (HIE) with OHs using the same EHR platform, 4) request information from OHs with a shared EHR platform and without automatic HIE, 5) contact the OH BBTMS, and 6) communicate with the outside ambulatory practice (OAP). RESULTS: The investigations revealed that eight of nine patients received RhIG before their presentation. Five patients received RhIG at an OH's emergency department and three at an OAP. One patient's history remained unknown after initial investigations; however, a subsequent sample unveiled a confounding alloantibody. CONCLUSION: In the absence of a national HIE, continuity of care suffers through omission of critical information. Strategies to avoid confusing passive anti-D and alloanti-D include expanding HIE capabilities and use of patient identification cards with critical BBTMS information to include RhIG administration dates.

Apheresis Medicine education in the United States of America: State of the discipline.

Apheresis Medicine is a medical discipline that involves a variety of procedures (based on the targeted component to be removed or collected), indications (therapeutic vs. donation), and personnel (operators, management, and medical oversight). Apheresis services are accredited and/or regulated by a number of agencies and organizations. Given the complexity and the heterogeneity of apheresis services, it has been particularly challenging to formulate educational goals and define curriculums that easily cover all aspects of Apheresis Medicine. This review summarizes the current state of the discipline in the United States of America, and some of the challenges, strategies, and resources that Apheresis Medicine educators have used to ensure that Apheresis Medicine educational programs meet the health care needs of the relevant population within regulatory and accrediting entity frameworks.

A needs assessment and instrument comparison for a therapeutic apheresis medicine service.

This article outlines a needs assessment process for developing or updating a therapeutic apheresis medicine (TAM) service. The TAM service brings together administrative, medical, laboratory, and pharmacy services. As these services jointly respond to needs assessment questions, the TAM service evolves. Discussions identifying patient populations impact the types of procedures to be offered and subsequent instrument choices. This article will also review and compare current TAM devices using centrifugation-based or column-based methods for treatments. The TAM service is unique in regard to both the multiservice involvement and spectrum of patients served.

Blood banking and transfusion medicine for the apheresis medicine practitioner.

This article provides a concise overview of blood banking and transfusion medicine (BBTM) for the therapeutic apheresis medicine practitioner. It addresses the complete pathway from blood donor qualification to blood collection, to processing and storing blood components, to patient testing, to ordering blood components for therapeutic apheresis (TA) procedures, to preparing the component for transfusion, and finally to transfusion. The nurses, technologists, and physicians orchestrate these activities in concert to best serve patients undergoing TA procedures. Enhancing knowledge of these processes may improve the quality of patient care and the utilization of blood products.

Blood banking and transfusion medicine for the nephrologist.

Therapeutic Apheresis Medicine Services work closely with Blood Banking and Transfusion Medicine Services (BBTMS). The BBTMS performs patient testing and provides blood components for patients undergoing therapeutic apheresis procedures. This article will provide an overview of blood component descriptions, patient testing, and blood component options and preparations for therapeutic apheresis procedures.

Therapeutic apheresis instrumentation.

This article provides a concise overview of therapeutic apheresis medicine instrumentation. Three instrument modalities are discussed: (1) centrifugation-based instruments, (2) extracorporeal photopheresis instruments (a subset of centrifugation-based instruments), and (3) column-based instruments.

The nuts and bolts of curriculum and assessment.

A curriculum is a planned educational experience. This broad definition includes everything from a single didactic lecture to a rotation or clerkship to an entire training program such as an internship, residency or fellowship. This guide is a six-step approach for creating any of these curricula. Steps 1 through 6 include: (1) identify the problem, (2) perform a needs assessment, (3) create goals and objectives, (4) develop the program, (5) implement the program, and (6) evaluate participants and the program. Use of these steps may at first seem laborious, yet results are user friendly and simplify subsequent curricula updating. Education accrediting agencies are increasing their expectations for detailed curricula and evaluations. This approach helps meet these standards.

Universal donor education and consent: what we know and where we should go.

Each day thousands of blood donors across the country are given educational materials and sign a consent form, thus fulfilling two blood collection accreditation requirements. Very few donors will experience a documented adverse event, although a disproportionate number of these events occur in the youngest donor cohort. The literature reflects this disproportion and suggests mitigation strategies. Studies describe subjective, undocumented donor reactions and decreased donor return rates after a documented or subjective reaction. Additionally, studies have shown donor consent form variability among blood collection facilities and that donor comprehension of the educational materials and consent is limited. There are few standardized donor education materials or consent documents. Current accreditation standards for educational materials are limited to aspects of transfusion-transmitted diseases and for donor consent process and documentation are vague and nonspecific. Recent experiences with young donors and current research compel our community to engage in creating standardized, expanded donor educational materials and standardized donor consent processes and documents.

An academic-based hospital donor site: do physicians donate blood?

The objectives of this prospective, cross-sectional study were to characterize blood donors in an academic-based hospital donor center, to determine whether physicians donate, and to elucidate the donation impetus. A confidential survey was issued to presenting, potential donors over 200 weekdays. Three questions were asked: their role at the institution, if and when they had previously donated blood, and what prompted the current donation. The majority of the 687 respondents were institution-affiliated (73.5%) and 79.3% had previously donated, with a median of 3 mo since the prior donation. Only 21 (3.1%) respondents were physicians. The predominant reasons for donor presentation were an appointment, knowing it had been 8 wk since the last donation, and contact by the blood center to donate. This study shows the dearth of physician blood donors and a strong cohort of institution-affiliated repeat donors. Physicians represent a potential, stable, and sustainable donor pool; further studies are needed to establish physician recruitment programs.

Instituting a thawed plasma procedure: it just makes sense and saves cents.

BACKGROUND: The objectives of this time-series study were to elucidate the impact of a thawed plasma standard operating procedure (TP SOP) on plasma wastage and on cost savings. STUDY DESIGN AND METHODS: This study compared plasma wastage for 1 year before versus 1 year after implementation of a TP SOP. RESULTS: The plasma wastage and discard declined 79.7 and 64.9%, respectively, with a cost savings of $15,654.79 during the 1 year after implementation of the TP SOP. The risk that a unit of plasma would be wasted decreased 86.2% from Year 1 to Year 2 and the risk that a unit of plasma would be discarded decreased 76.3% from Year 1 to Year 2. CONCLUSION: Our study showed the positive, sustained, impact of implementing a TP SOP. Twelve months after introducing the SOP our Blood Bank and Transfusion Medicine Services' plasma wastage and discard were dramatically reduced, saving thousands of dollars. Initiating a TP SOP just makes sense; it is easy to implement, conserves plasma, and saves cents.

Estimating blood needs for very-low-birth-weight infants.

BACKGROUND: Red blood cell (RBC) transfusions are crucial for the care of very-low-birth-weight (VLBW) infants. These infants frequently require multiple, small-volume RBC transfusions, with potential exposure to multiple donors. Optimal protocols provide dedicated RBC units to reduce exposures and avoid RBC wastage. STUDY DESIGN AND METHODS: This study was a retrospective, single-institution review of RBC transfusions in VLBW infants. The RBC volume transfused during the entire hospitalization (VTH) and that transfused at 35 days were determined for all infants, 401 to 1250 g at birth, admitted to a Level III neonatal intensive care unit from January 1, 2000, through December 31, 2002. Multivariable models identified perinatal factors associated with volume transfused. RESULTS: The 640-infant cohort had a median birth weight (BW) of 818 g and gestational age (GA) of 26 weeks. Most infants (546 or 85%) required at least one RBC transfusion. Median number of RBC transfusions was 3 (range, 0-30) and median volume transfused was 82 mL (range, 9-737 mL). Of 328 infants who received all transfusions within a 35-day period, only 5 (1.5%) required at least 200 mL. VTH was inversely related to BW and GA. Multivariable models identified BW, GA, age at first transfusion, and use of inotropes as variables associated with higher volume transfused. CONCLUSION: Few VLBW infants use an entire RBC unit. One dedicated unit shared by two or more infants should meet their transfusion needs. GA, BW, and markers of illness severity predict increased RBC volume requirements.

Update on therapeutic apheresis.

The start of this century has brought medical advances that allow earlier disease detection and better, faster, and more-specific treatments. Advances in therapeutic apheresis are creating another set of medical options. Technological advances and better disease understanding allow treatment of a broader disease spectrum with more specific removal of disease mediators. New systems are currently under investigation around the globe. This review presents recent advances and updates in the field of therapeutic apheresis, including rheopheresis, granulocyte and monocyte adsorption, endotoxin adsorption, autoantibody adsorption, and plasma exchange protocols for incompatible renal transplants.