Migration of di(2-ethylhexyl) phthalate, diisononylcyclohexane-1,2-dicarboxylate and di(2-ethylhexyl) terephthalate from transfusion medical devices in labile blood products: A comparative study.

BACKGROUND AND OBJECTIVES: Polyvinyl chloride (PVC) plasticized with di(2-ethylhexyl) phthalate (DEHP) is a widely used material for medical transfusion devices. Not covalently bound to PVC, DEHP can migrate into blood products during storage. Recognized as an endocrine disruptor and raising concerns about its potential carcinogenicity and reprotoxicity, DEHP is gradually being withdrawn from the medical device market. Therefore, the use of alternative plasticizers, such as diisononylcyclohexane-1,2-dicarboxylate (DINCH) and di(2-ethylhexyl) terephthalate (DEHT), as potential candidates for the replacement of DEHP in medical transfusion devices has been investigated. The purpose of this study was to evaluate the quantity of PVC-plasticizers in the blood components according to their preparation, storage conditions and in function of the plasticizer. MATERIALS AND METHODS: Whole blood was collected, and labile blood products (LBPs) were prepared by the buffy-coat method with a PVC blood bag plasticized either with DEHP, DINCH or DEHT. DINCH and DEHT equivalent concentrations were quantified in LBPs by liquid chromatography-tandem mass spectrometry or coupled with UV and compared to DEHP equivalent concentrations. RESULTS: The plasticizer equivalent concentration to which a patient is exposed during a transfusion depends on the preparation of LBPs as well as their storage conditions, that is, temperature and storage time. At day 1, for all LBPs, the migration of DEHP is 5.0 and 8.5 times greater than DINCH and DEHT, respectively. At the end of the 49 days storage period, the DEHP equivalent concentration in red blood cells concentrate is statistically higher when compared to DINCH and DEHT, with maximal values of 1.85, 1.13 and 0.86 µg/dm2 /mL, respectively. CONCLUSION: In addition to lower toxicity, transfused patients using PVC-DEHT or PVC-DINCH blood bags are less exposed to plasticizers than using PVC-DEHP bags with a ranging exposure reduction from 38.9% to 87.3%, due to lower leachability into blood components.

How do we forecast tomorrows' transfusion: Non-transfusional hemotherapy.

Hemotherapy is the treatment of diseases by the use of blood or blood products from blood donation (by others of for oneself). It is clear that blood components transfusion represents the most important part of the activities of the professionals (doctors, nurses, technicians…) working in hemotherapy. But there are others forms of hemotherapy that are steadily growing, that we will discuss: plasma exchange, mononuclear cells collections for cellular therapies, extracorporeal photoapheresis, ABO antigen specific immunoadsorption and autologous platelet lysate.

Puesta al día sobre transfusión masiva / Massive transfusion update / Atualização sobre transfusão maciça

La transfusión masiva plantea desafíos clínicos, organizacionales y logísticos para el personal de la salud en general y los servicios de Medicina Transfusional en particular. No existe una definición universalmente aceptada de transfusión masiva, las definiciones más comúnmente utilizadas se basan en el número de unidades de sangre administradas dentro de un cierto período de tiempo. La mayoría de los eventos de transfusión masiva ocurren en el contexto de hemorragias graves en pacientes quirúrgicos, politraumatizados, con hemorragia gastrointestinal u obstétrica. La reanimación de control de daños y los protocolos de transfusión masiva son las estrategias más utilizadas actualmente para el tratamiento inicial, seguidas de un tratamiento personalizado, dirigido por objetivos, mediante la monitorización de la coagulación en tiempo real mediante estudios viscoelásticos. Existen una serie de controversias alrededor del tratamiento óptimo, incluyendo el uso de sangre total, la relación de hemocomponentes a utilizar, el uso de concentrados de factores de la coagulación, y la indicación óptima del ácido tranexámico. El estudio de los productos ideales para el tratamiento de los pacientes con sangrado masivo se ha convertido en un área de gran interés de la investigación científica. El contexto clínico en el que ocurrió el evento hemorrágico, el número de hemocomponentes transfundidos, la edad del paciente y las comorbilidades son los predictores más importantes de la sobrevida a corto y largo plazo. Esta revisión narrativa explora el estado actual del conocimiento sobre la transfusión masiva, así como los avances que podemos esperar en el futuro cercano.

Massive transfusion poses clinical, organizational and logistic challenges for the health staff in general, and the Transfusion Medicine Services in particular. There is no universally accepted definition for massive transfusion, the most widely used being based on the number of blood units administered in a certain period of time. Most massive transfusion events occur in the context of severe hemorrhage on surgical or multiple-trauma patients or patients with gastrointestinal or obstetric bleeding. Today, damage control resuscitation and massive transfusion protocols are the most common strategies for initial treatment, followed by personalized therapy, goal-directed, my means of monitoring coagulation in real time with viscoelastic studies. There are disputes as to the best surgical treatment, including using whole blood, the relation of blood components to be used, the use of coagulation factor concentrates and the optimal indication of tranexamic acid. The study of ideal products to treat patients with massive hemorrhage has become an area of great interest for scientific research. The clinical context of the hemorrhagic event, the number of blood components transfused, patient's age and comorbilities are the most important predictors for survival in the short and long term. This narrative review explores the current state of affairs on knowledge about massive transfusion, as well as progress to be expected in the near future.

A transfusão maciça apresenta desafios clínicos, organizacionais e logísticos para o pessoal de saúde em geral e para os serviços de Medicina Transfusional em particular. Não existe uma definição universalmente aceita de transfusão maciça; as definições mais comumente usadas são baseadas no número de unidades de sangue administradas em um determinado período de tempo. A maioria dos eventos de transfusão maciça ocorre no contexto de sangramento maior em pacientes cirúrgicos, politraumatizados, com sangramento gastrointestinal ou obstétrico. Atualmente, a ressuscitação para controle de danos e os protocolos de transfusão maciça são as estratégias mais usadas para o tratamento inicial, seguidos por tratamento personalizado e orientado por objetivos usando monitoramento de coagulação em tempo real usando testes viscoelásticos. Há uma série de controvérsias em torno do tratamento ideal, incluindo o uso de sangue total, a proporção de componentes sanguíneos a serem usados, o uso de concentrados de fator de coagulação e a indicação ideal de ácido tranexâmico. O estudo dos produtos ideais para o tratamento de pacientes com sangramento maciço tornou-se uma área de grande interesse na pesquisa científica. O contexto clínico em que ocorreu o evento hemorrágico, o número de hemocomponentes transfundidos, a idade do paciente e as comorbidades são os preditores mais importantes de sobrevida a curto e longo prazo. Esta revisão narrativa explora o estado atual do conhecimento sobre transfusão maciça, bem como os avanços que podemos esperar no futuro próximo.

Transfusioonravi juhend (I osa): Äge verejooks ja transfusioonravi; operatsioonile eelnev patsiendi ambulatoorne ja perioperatiivne käsitlus / Guidelines for transfusion therapy (Part I): acute bleeding and transfusion therapy; outpatient and perioperative management of the patient before surgery

The need to prepare a treatment manual In 2005, "Medicinal preparations made from human blood" was published in Estonia the Estonian guide to the use" (1), the purpose of which was to provide the first a more comprehensive overview in Estonian of the state-of-the-art in the use of blood preparations principles. This guide has helped create a theoretical foundation for all patients to ensure a consistent quality of transfusion therapy, but as the guideline authors point out, the point of departure for this guide is the remedy, not the condition. Bearing in mind that in other parts of the world, the patient's blood has started to be followed more and more there is a need to prepare the concept of patient blood management a new treatment guide introducing the use of transfusion therapy from the patient and based on his medical conditions. The concept of the patient's blood is based on the evidence of modern transfusiology a multidisciplinary concept that seeks to optimize the need for blood transfusion patient treatment. When making a treatment decision, the patient, whose conserving one's own blood is paramount, and a clinical outcome is sought without unnecessary transfusion of blood components. To date, the patient's blood perception program implemented in many countries, e.g. Australia, Great Britain, in the United States, Germany, etc. The guideline aims to emphasize the importance of preoperative assessment and performing analyzes and, if necessary, correcting the patient's treatment so that reduce the number of patients receiving blood transfusions. Anemia, acute bleeding and blood transfusion are three independent risk factors affecting the patient treatment outcome unfavorably. The mortality rate of patients receiving blood transfusions is higher and morbidity (including occurrence of cardiac, renal, respiratory and wound complications) more frequent, the duration of hospitalization is longer, and the need for intensive care and treatment costs are higher higher than in patients who did not receive a blood transfusion in the same condition. The updated treatment manual provides an opportunity to evaluate the practice of transfusion therapy on the same basis throughout the country, analyze it, correct it if necessary and to lead. Together with the guide, it is published in cooperation with SA Põhja-Eesti Regionalhaigla Updated additional material on blood components prepared by the Blood Center specifications and additional materials prepared by the Estonian Society of Anesthesiologists 10 on the treatment of antithrombotic drugs in scheduled surgery and emergencies in situations. Treatment area and target group of the treatment manual The treatment guide describes a patient with anemia and/or bleeding risk pre-operative diagnostics and outpatient treatment and diagnostics and treatment of patients with acute bleeding, including massive transfusion. Also emergency transfusion treatment related to obstetric care and the need to check all patients who have undergone acute blood loss in the future improvement. The treatment manual is mainly intended for emergency use

Ravijuhendi koostamise vajadus Eestis on ilmunud 2005. aastal "Inimverest valmistatud ravimpreparaatide kasutamise Eesti juhend" (1), mille koostamise eesmärk oli anda esimene põhjalikum eestikeelne ülevaade verepreparaatide kasutamise nüüdisaegsetest põhimõtetest. See juhend on aidanud luua teoreetilist alust kõigile patsientidele ühtlase kvaliteediga transfusioonravi tagamiseks, kuid nagu juhendi koostajad esile toovad, on selle juhendi lähtepunkt ravivahend, mitte haigusseisund. Pidades silmas, et mujal maailmas on hakatud järjest enam järgima patsiendi vere käsituse kontseptsiooni (ingl patient blood management), on vajadus koostada uus ravijuhend, milles tutvustatakse transfusioonravi kasutamist patsiendist ja tema haigusseisunditest lähtuvalt. Patsiendi vere käsitus on nüüdisaegse transfusioloogia tõenduspõhine multidistsiplinaarne kontseptsioon, mis püüab optimeerida vereülekannet vajava patsiendi ravi. Raviotsuse tegemisel asetatakse kesksele kohale patsient, kelle enda vere säästmine on kõige olulisem, ja kliinilist tulemust püütakse saavutada ilma verekomponentide ebavajaliku ülekandeta. Praeguseks on patsiendi vere käsituse programmi juurutatud paljudes riikides, nt Austraalias, Suurbritannias, Ameerika Ühendriikides, Saksamaal jne. Juhendiga soovitakse rõhutada, kui oluline on preoperatiivne hindamine ja analüüside tegemine ning vajaduse korral patsiendi ravi korrigeerimine, et vähendada vereülekannet saavate patsientide arvu. Aneemia, äge verejooks ja vereülekanne on kolm sõltumatut riskifaktorit, mis mõjutavad patsiendi ravitulemust ebasoodsalt. Vereülekannet saanud patsientide suremus on suurem ja haigestumus (sh kardiaalne, renaalne, respiratoorne ja haava tüsistuste esinemine) sagedasem, haiglaravi aeg on pikem ning intensiivravivajadus ja ravikulud on suuremad, kui samas seisundis vereülekannet mittesaanud patsientidel. Kaasajastatud ravijuhend annab võimaluse hinnata transfusioonravi praktikat samadel alustel kogu riigis, seda analüüsida, vajaduse korral korrigeerida ja juhtida. Juhendiga koos avaldatakse koostöös SA Põhja-Eesti Regionaalhaigla Verekeskusega valminud ajakohastatud lisamaterjal verekomponentide spetsifikatsioonide kohta ja Eesti Anestesioloogide Seltsi koostatud lisamaterjalid antitrombootiliste ravimite käsitlusest plaanilises kirurgias ja erakorralistes situatsioonides. Ravijuhendi käsitlusala ja sihtrühm Ravijuhendis kirjeldatakse aneemiaga ja/või veritsusriskiga patsiendi operatsioonile eelnevat diagnostikat ja ambulatoorset ravi ning ägeda verejooksuga patsientide diagnostikat ja ravi, sh massiivset transfusiooni. Samuti käsitletakse juhendis sünnitusabiga seonduvat erakorralist transfusioonravi ja vajadust kontrollida edaspidi kõikide ägeda verekaotuse läbi teinud patsientide paranemist. Ravijuhend on peamiselt mõeldud kasutamiseks erakorralise

Economic Evaluation of National Patient Blood Management Clinical Guidelines in Cardiac Surgery.

OBJECTIVES: To the best of our knowledge, no published clinical guidelines have ever undergone an economic evaluation to determine whether their implementation represented an efficient allocation of resources. Here, we perform an economic evaluation of national clinical guidelines designed to reduce unnecessary blood transfusions before, during, and after surgery published in 2012 by Australia's sole public blood provider, the National Blood Authority (NBA). METHODS: We performed a cost analysis from the government perspective, comparing the NBA's cost of implementing their perioperative patient blood management guidelines with the estimated resource savings in the years after publication. The impact on blood products, patient outcomes, and medication use were estimated for cardiac surgeries only using a large national registry. We adopted conservative counterfactual positions over a base-case 3-year time horizon with outcomes predicted from an interrupted time-series model controlling for differences in patient characteristics and hospitals. RESULTS: The estimated indexed cost of implementing the guidelines of A$1.5 million (2018-2019 financial year prices) was outweighed by the predicted blood products resource saving alone of A$5.1 million (95% confidence interval A$1.4 million-A$8.8 million) including savings of A$2.4 million, A$1.6 million, and A$1.2 million from reduced red blood cell, platelet, and fresh frozen plasma use, respectively. Estimated differences in patient outcomes were highly uncertain and estimated differences in medication were financially insignificant. CONCLUSIONS: Insofar as they led to a reduction in red blood cell, platelet, and fresh frozen plasma use during cardiac surgery, implementing the perioperative patient blood management guidelines represented an efficient use of the NBA's resources.

Effectiveness of Enhanced Performance Feedback on Appropriate Use of Blood Transfusions: A Comparison of 2 Cluster Randomized Trials.

Importance: Auditing and feedback are frequently used to improve patient care. However, it remains unclear how to optimize feedback effectiveness for the appropriate use of treatments such as blood transfusion, a common but costly procedure that is more often overused than underused. Objective: To evaluate 2 theoretically informed feedback interventions to improve the appropriate use of blood transfusions. Design, Setting, and Participants: Two sequential, linked 2 × 2 cluster randomized trials were performed in hospitals in the UK participating in national audits of transfusion for perioperative anemia and management of hematological disorders. Data were collected for a surgical trial from October 1, 2014, to October 31, 2016, with follow-up completed on October 31, 2016. Data were collected for a hematological trial through follow-up from July 1, 2015, to June 30, 2017. Trial data were analyzed from November 1, 2016, to June 1, 2019. Interventions: Hospitals were randomized to standard content or enhanced content to improve feedback clarity and usability and to standard support or enhanced support for staff to act on feedback. Main Outcomes and Measures: The primary end point was appropriateness of transfusions audited at 12 months. Secondary end points included volume of transfusions (aiming for reductions at patient and cluster levels) and transfusion-related adverse events and reactions. Results: One hundred thirty-five of 152 eligible clusters participated in the surgical audit (2714 patients; mean [SD] age, 74.9 [14.0] years; 1809 women [66.7%]), and 134 of 141 participated in the hematological audit (4439 patients; median age, 72.0 [IQR, 64.0-80.0] years; 2641 men [59.5%]). Fifty-seven of 69 clusters (82.6%) in the surgical audit randomized to enhanced content downloaded reports compared with 52 of 66 clusters (78.8%) randomized to standard reports. Fifty-nine of 68 clusters (86.8%) randomized to enhanced support logged onto the toolkit. The proportion of patients with appropriate transfusions was 0.184 for standard content and 0.176 for enhanced content (adjusted odds ratio [OR], 0.91 [97.5% CI, 0.61-1.36]) and 0.181 for standard support and 0.180 for enhanced support (adjusted OR, 1.05 [97.5% CI, 0.68-1.61]). For the hematological audit, 53 of 66 clusters (80.3%) randomized to enhanced content downloaded the reports compared with 53 of 68 clusters (77.9%) randomized to standard content. Forty-nine of 67 clusters sites (73.1%) assigned to enhanced support logged into the toolkit at least once. The proportion of patients with appropriate transfusions was 0.744 for standard content and 0.714 for enhanced content (adjusted OR, 0.81 [97.5% CI, 0.56-1.12]), and 0.739 for standard support and 0.721 for enhanced support (adjusted OR, 0.96 [97.5% CI, 0.67-1.38]). Conclusions and Relevance: This comparison of cluster randomized trials found that interventions to improve feedback usability and guide local action were no more effective than standard feedback in increasing the appropriate use of blood transfusions. Auditing and feedback delivered at scale is a complex and costly program; therefore, effective responses may depend on developing robust local quality improvement arrangements, which can be evaluated using rigorous experimental designs embedded within national programs. Trial Registration: isrctn.org Identifier: ISRCTN15490813.

Pro-Con Debate: Viscoelastic Hemostatic Assays Should Replace Fixed Ratio Massive Transfusion Protocols in Trauma.

Major trauma patients at risk of traumatic coagulopathy are commonly treated with early clotting factor replacement to maintain hemostasis and prevent microvascular bleeding. In the United States, trauma transfusions are often dosed by empiric, low-ratio massive transfusion protocols, which pair plasma and platelets in some ratio relative to the red cells, such as the "1:1:1" combination of 1 units of red cells, 1 unit of plasma, and 1 donor's worth of pooled platelets. Empiric transfusion increases the rate of overtransfusion when unnecessary blood products are administered based on a formula and not on at patient's hemostatic profile. Viscoelastic hemostatic assays (VHAs) are point-of-care hemostatic assays that provided detailed information about abnormal clotting pathways. VHAs are used at many centers to better target hemostatic therapies in trauma. This Pro/Con section will address whether VHA guidance should replace empiric fixed ratio protocols in major trauma.

Risk of transfusion-transmitted hepatitis E virus infection from pool-tested platelets and plasma.

BACKGROUND AND AIMS: Immunocompromised patients are at risk of chronic hepatitis E which can be acquired by blood transfusions. Currently, screening of blood donors (BDs) for HEV RNA with a limit of detection (LOD) of 2,000 IU/ml is required in Germany. However, this may result in up to 440,000 IU of HEV RNA in blood products depending on their plasma volume. We studied the residual risk of transfusion-transmitted (tt) HEV infection when an LOD of 2,000 IU/ml is applied. METHODS: Highly sensitive individual donor testing for HEV RNA on the Grifols Procleix Panther system (LOD 7.89 IU/ml) was performed. HEV loads were quantified by real-time PCR. RESULTS: Of 16,236 donors, 31 (0.19%) were HEV RNA positive. Three BDs had viral loads between 710 and 2,000 IU/ml, which pose a significant risk of tt hepatitis E with any type of blood product. Eight BDs had viral loads of >32 to 710 IU/ml, which pose a risk of tt hepatitis E with platelet or plasma transfusions because of their higher plasma volume compared to red blood cell concentrates. Eight of these 11 potentially infectious BDs were seronegative for HEV, indicating a recent infection. Only 8 of 31 donors had viral loads >2,000 IU/ml that would also have been detected by the required screening procedure and 12 had very low HEV loads (<32 IU/ml). CONCLUSIONS: Screening of BDs with an LOD of 2,000 IU/ml reduced the risk of tt HEV infection by about 73% for red blood cell concentrates but by just 42% for platelet and fresh frozen plasma transfusions. Single donor screening (LOD <32 IU/ml) should lead to an almost 100% risk reduction. LAY SUMMARY: Immunocompromised patients, such as solid organ or hematopoietic stem cell recipients, are at risk of chronic hepatitis E, which can be acquired via blood transfusions. The risk of transfusion-transmitted hepatitis E in these patients may not be sufficiently controlled by (mini-)pool hepatitis E virus RNA screening of blood donors. Single donor screening should be considered to improve the safety of blood products.

Transfusion 2024: A 5-year plan for clinical and laboratory transfusion in England.

The Transfusion 2024 plan outlines key priorities for clinical and laboratory transfusion practice for safe patient care across the NHS for the next 5 years. It is based on the outcomes of a multi-professional symposium held in March 2019, organised by the National Blood Transfusion Committee (NBTC) and NHS Blood and Transplant (NHSBT), attended and supported by Professor Keith Willet and Dame Sue Hill on behalf of NHS England and Improvement. This best practice guidance contained within this publication will facilitate the necessary change in pathway design to meet the transfusion challenges and pressures for the restoration of a cohesive, and functional, healthcare system across the NHS following the COVID-19 pandemic.

[Residual risk for transfusion-transmitted hepatitis B virus infection due to occult hepatitis B virus infection in donors living in Yaoundé, Cameroon]. / Risque résiduel de la transmission par transfusion de l´infection du virus de l´hépatite B dû aux donneurs porteurs de l´infection du virus de l´hépatite B occulte à Yaoundé, Cameroun.

INTRODUCTION: viral infection caused by hepatitis B virus is the most frequent transfusion-transmitted viral infection. Although the search for hepatitis B surface antigen (HBsAg) in blood banks has significantly reduced the risk for transfusion-transmitted virus infection, there is still a residual transfusion risk of transmission from donors with occult hepatitis B. Blood bags containing aHBc with or without aHBs and viral DNA can cause infections and represent a threat to transfusion safety when aHBc levels are undetectable. The purpose of this study is to determine the residual risk for transfusion-transmitted hepatitis B virus at the Central Hospital of Yaoundé (CHY) as well as at the St Martin de Porres's Catholic Hospital (SMPCH) in Yaoundé, Cameroon. METHODS: we conducted a cross-sectional study among blood donors at the Central Hospital of Yaoundé (CHY) and the St Martin de Porres's Catholic Hospital. In these subjects the search for aHBc and/or the aHBs was conducted by immunochromatography. HBV DNA test was performed on blood samples tested positive for aHBc and/or aHBs by Polymerase Chain Reaction (PCR) technique using specific primers. RESULTS: out of a total of 193 blood donors negative for HIV, HBV (HBsAg), HCV serological markers and treponema infections, the overall seroprevalence of aHBc and/or aHBs was 9,84% (19/193). Out of a total of 19 potentially infected donors, HBV DNA was detected in 03 individuals, including 02 aHBc carriers and 01 carrier of both aHBc and aHBs, reflecting a prevalence of occult hepatitis B of 15,79% (3/19) [IC 95% =3,38%-39,58%] and a residual risk for transfusion-transmitted hepatitis B virus of 1,55% (3/193) [IC 95% =0,32%-4,48%]. CONCLUSION: this study shows that the residual risk for transfusion-transmitted hepatitis B virus is low. However, it is recommended to screan blood donors for aHBc and/or aHBs.

Therapeutic approach to pediatric patients with acute chest syndrome: national multicenter survey of non invasive ventilation (NIV) and transfusion.

BACKGROUND: Intensive care units (ICUs) have seen a spike in the use of noninvasive ventilation (NIV) for many medical conditions. We sought to investigate the attitudes and clinical practice regarding the management of acute chest syndrome (ACS) with a focus on NIV in pediatric ICUs. METHOD: Members of the French Group for Pediatric Intensive Care Emergencies (GFRUP) were asked to complete an online survey on physicians' attitudes toward children with ACS admitted to the PICU during 2015. RESULTS: The survey was answered by teams from 17 PICUs (240 beds). In total, 15 centers (88%) had a local transfusion unit and 14 (82%) worked in connection with a sickle cell disease (SCD) reference center. During 2015, 360 patients with SCD were managed (median: 7 per center; 21) of whom 137 (38%) for an ACS (median: 4 ACS per center; 8). The median length of PICU stay for ACS was 5 days (3.1). Among the 137 patients who presented with ACS, 73 (53%) received simple blood transfusion and 16 (12%) received exchange transfusion. For patients who required noninvasive ventilatory support, NIV with bilevel pressure (BiPAP) was the most frequent method (n = 68, 50%), followed by continuous positive airway pressure (CPAP) (n = 23, 17%) and high-flow oxygen (n = 21, 15%). The proportion of patients on BiPAP was up to 71% in the centers most frequently managing ACS patients. CONCLUSION: BiPAP is commonly used in PICUs for SCD patients with ACS, especially in trained centers. Future physiological studies and randomized controlled trials might help to choose the best ventilatory support for ACS.

Evidence-Based Competency Training Program for Blood Product Administration.

BACKGROUND: Health care in deployed military environments requires robust clinical nursing skills to care for patients with traumatic injuries. Blood product administration is a critical skill in which nurses should be competent. However, in non-deployed environments, blood transfusions are performed less frequently, resulting in skill competency loss. AIMS: Our clinical inquiry focused on maintaining competency for infrequently performed nursing skills, specifically blood product administration. METHODS: A literature review and critical appraisal were executed, followed by an evidence-based practice change. A knowledge test, objective and subjective assessment, and training satisfaction evaluation were performed to measure the practice change outcomes. Both inpatient and outpatient nurses were included. RESULTS: Sixteen articles were identified and appraised. The evidence recommended a blended education approach, that is, lecture plus hands-on practice. Thus, a classroom lecture and simulation scenario were put into practice with an existing computer-based training for blood administration. The nurses met knowledge test standards (≥ 90%) before and after implementation, while skill performance improved by 13% and improved self-competence scores by 7%. Nurses in outpatient settings improved performance scores by 18.4% compared to inpatient nurses, whose scores improved by 9.4%. The simulation scenario completion time decreased by 8.3 minutes post-implementation, and the training program earned a 90% satisfactory rating. LINKING EVIDENCE TO ACTION: A blended education program improves clinical skill performance and enhances confidence in performing critical interventions. Blended education provides a safe learning environment for nurses to be prepared for the management of low-volume patient care emergencies.

Transfusion Safety Officers in the United States: Survey of characteristics and approaches to implementation.

BACKGROUND: Transfusion safety officers (TSO) function as liaisons between the blood bank and clinical staff, utilizing audits, quality improvement, reviews, communication, education, and general vigilance to enhance transfusion safety. While hospitals in Europe and Canada have long employed TSOs, a majority of institutions in the United States (US) have yet to implement this resource, despite the mounting evidence to support their effectiveness. STUDY DESIGN AND METHODS: An anonymous 20-question survey was administered to 104 hospitals with valid email contact information. Survey questions addressed the presence of a TSO, characteristics, backgrounds, and education of TSOs, the reporting and funding structure of the position, and role responsibilities. RESULTS: 53 responses were received, with 52 surveys completed (51 % response rate). The majority of responding institutions have a patient blood management (PBM) program (n = 40, 77 %) and 33 (63 %) have at least 1 TSO. 61 % of TSOs report an educational background in nursing, with 11 additional unique training backgrounds identified. TSO responsibilities are varied and include quality improvement, education, transfusion safety event analysis, and participation in PBM initiatives. Barriers to implementing a TSO position include lack of resources, financial impediments, and a lack of understanding of the position and its value by administrators and clinicians. DISCUSSION: The results of this survey highlight how TSOs contribute to transfusion safety and PBM and may provide guidance to hospitals interested in implementing a TSO position. It also elucidates the range of TSO responsibilities and approaches that institutions utilize to advocate for, and implement, this position in the US.

Blood Conservation and Hemostasis in Cardiac Surgery: A Survey of Practice Variation and Adoption of Evidence-Based Guidelines.

BACKGROUND: Blood conservation and hemostasis are integral parts of reducing avoidable blood transfusions and the associated morbidity and mortality. Despite the publication of blood conservation guidelines for cardiac surgery, evidence suggests persistent variability in practice patterns. Members of the Society of Cardiovascular Anesthesiologists (SCA) created a survey to audit conformance to existing guidelines and use the results to help narrow the evidence-to-practice gap. METHODS: Members of the SCA and its Continuous Practice Improvement (CPI)- Blood Conservation Work Group developed a 48-item Blood Conservation and Hemostasis in Cardiac Surgery (BCHCS) survey. The questionnaire included the components of the Anesthesia Quality Institute's (AQI) composite measure AQI49. The survey was distributed to the entire SCA membership by e-mail via the Research Electronic Data Capture (REDCap) Consortium between the fall of 2017 and early 2018. RESULTS: Of 3152 SCA members, 536 returned surveys for a response rate of 17%. Most responders worked at academic institutions. The median transfusion trigger after cardiopulmonary bypass was hemoglobin (Hgb) 7.0 to 8.0 g/dL. There are 4 components to AQI49, and the composite conformance to all of them was low due to 1 specific component: the use of transfusion algorithms supplemented with point-of-care (POC) testing. There was good conformance to the other 3 components of AQI49: use of antifibrinolytics, minimization of hemodilution and use of red cell salvage. Overall, practices with a multidisciplinary patient blood management (PBM) team were the most successful in meeting all 4 AQI49 criteria. CONCLUSIONS: The survey demonstrated widespread adoption of several best practices, including the tolerance of lower hemoglobin transfusion triggers, use of antifibrinolytics, minimization of hemodilution, and use of red cell salvage. The survey also confirms that gaps remain in preoperative anemia management and the use of transfusion algorithms supplemented with POC hemostasis testing. Serial use of this survey can be used to identify barriers to implementation and audit the effectiveness of interventions described in this article. This instrument could also help harmonize local, regional, and national efforts and become an essential component of an implementation strategy for PBM in cardiac surgery.