Electronic remote blood issue supports efficient and timely supply of blood and cost reduction: evidence from five hospitals at different stages of implementation.

BACKGROUND: This multicenter international study evaluated electronic remote blood issue (ERBI) for blood unit collection in hospitals. STUDY DESIGN AND METHODS: Retrospective data were collected from the ERBI software databases and blood bank information systems. Prospective "time-and-motion" data collection methods simulated the delivery of red blood cell units to determine the staff time for each step. RESULTS: The main benefit of ERBI was found in two hospitals where the blood unit was issued and collected at refrigerators remote from the blood bank (closer to the clinical area) compared with the standard process of blood bank issue (BBI) and blood unit collection in the blood bank. There was a reduction in the time for blood to reach patients (2.02 min compared to 8.43 min at one site [p ≤ 0.0001], 1.57 min compared to 6.54 min at the other [p ≤ 0.0001]). However, there was no reduction in time where ERBI was conducted in the blood bank or where a blood unit issued by the standard BBI was collected at remote refrigerators. In the three hospitals where ERBI was conducted at remote refrigerators, there was an improved issue:transfusion ratio (range of 1.02-1.09 for ERBI compared to 1.48-1.58 for BBI) and a reduction in staff time and costs of between $5,000 and $10,000/year. CONCLUSION: This multicenter international study builds on findings from studies in single hospitals that ERBI at remote refrigerators improves the efficiency of transfusion by reducing the time taken for blood units to reach patients, staff time, and costs.

Effect of incubation with crystalloid solutions or medications on packed red blood cells.

BACKGROUND: American Association of Blood Banks (AABB) guidelines suggest that packed red blood cells (PRBCs) be administered through a dedicated intravenous (IV) catheter. Literature supporting this broad-scope declaration are scarce. Obtaining additional IV access is painful, costly, and an infectious risk. We evaluated the effect of co-incubating PRBCs with crystalloids and medications on PRBC hemolysis, membrane deformability, and aggregation, as well as medication concentration. METHODS: PRBCs were co-incubated 5 minutes with plasma, normal saline (NS), 5% dextrose in water (D5W), Plasmalyte, epinephrine (epi), norepinephrine (norepi), dopamine (dopa), or Propofol (prop). Samples were then assessed for hemolysis (free hemoglobin, serum potassium), membrane deformability (elongation index [EI]), aggregation (smear, critical shear stress [mPa]) and drug concentration (High Performance Liquid Chromatography/Tandem Mass Spectrometry [LCMS-MS]). Significance (p ≤ 0.05) was determined by Wilcoxon-paired comparisons or Wilcoxon/Kruskall Willis with post-hoc Dunn's test. RESULTS: Compared to co-incubation with plasma: 1) co-incubation resulted in significantly increased hemolysis only when D5W as used (free hemoglobin, increased potassium); 2) EI trended lower when co-incubated with D5W and trended toward higher when co-incubated with prop; 3) aggregation was significantly lower when PRBCs co-incubated with NS, D5W, or Plasmalyte, and trended lower when co-incubated with epi, norepi, or dopa. Medication concentrations were between those predicted by distribution only in plasma and distribution through the entire intra- and extracellular space. CONCLUSION: Our data suggest that 5 minutes of PRBC incubation with isotonic crystalloids or catecholamines does not deleteriously alter PRBC hemolysis, membrane deformability, or aggregation. Co-incubation with D5W likely increases hemolysis. Propofol may promote hemolysis.

The epidemiology of bacterial culture-positive and septic transfusion reactions at a large tertiary academic center: 2009 to 2016.

BACKGROUND: Bacterial contamination and associated septic transfusion reactions (STRs) remain the leading infectious risk to the blood supply. We sought to characterize the risk and clinical presentation of blood culture-positive transfusion reactions (BCPTRs) and STRs at our institution. STUDY DESIGN AND METHODS: A retrospective analysis was conducted of all suspected transfusion reactions reported to the transfusion service at a 1000-bed tertiary academic medical center from January 2009 to September 2016. Routine investigation included review of the clinical presentation, Gram stain, and bacterial culture of residual blood from the transfused product or associated blood bag. BCPTRs were defined by the presence of a positive bacterial culture in the blood product and/or recipient. STRs met definitive Centers for Disease Control and Prevention hemovigilance criteria for transfusion-transmitted infection, with definite imputability and concordant bacterial culture of the blood product and recipient. RESULTS: A total of 688,514 blood products were transfused during the study period, 3170 transfusion reactions were reported, and 18 (0.57%) were BCPTRs of which seven (0.22%) were STRs. Fifteen of 18 (83.3%) BCPTRs and six of seven (85.7%) were associated with transfusion of apheresis platelets. Major symptoms and signs of BCPTRs included chills (67%), fever (61%), and nausea and vomiting (50%). Four of seven (57.1%) STRs were classified as severe or life-threatening. CONCLUSION: BCPTRs are rare yet potentially serious. The signs and symptoms of BCPTRs, and associated STRs, are not specific, posing risk of misclassification. Challenges surrounding reporting and case ascertainment underscore the need for laboratory measures to address residual risk of contamination.

Implementation of secondary bacterial culture testing of platelets to mitigate residual risk of septic transfusion reactions.

BACKGROUND: Bacterial contamination of platelets remains a major transfusion-associated risk despite long-standing safety measures in the United States. We evaluated an approach using secondary bacterial culture (SBC) to contend with residual risk of bacterial contamination. STUDY DESIGN AND METHODS: Phased implementation of SBC was initiated in October 2016 for platelets (all apheresis collected) received at our institution from the blood donor center (Day 3 post collection). Platelet products were sampled aseptically (5 mL inoculated into an aerobic bottle [BacT/ALERT BPA, BioMerieux, Inc.]) by the blood bank staff upon receipt, using a sterile connection device and sampling kit. The platelet sample was inoculated into an aerobic blood culture bottle and incubated at 35°C for 3 days. The cost of SBC was calculated on the basis of consumables and labor costs at time of implementation. RESULTS: In the 13 months following implementation (October 6, 2016, to November 30, 2017), 23,044/24,653 (93.47%) platelet products underwent SBC. A total of eight positive cultures were detected (incidence 1 in 2881 platelet products), seven of which were positive within 24 hours of SBC. Coagulase negative Staphyloccus spp. were identified in four cases. Five of the eight cases were probable true positive (repeat reactive) and interdicted (cost per averted case was US$77,935). The remaining three cases were indeterminate. No septic transfusion reactions were reported during the observation period. CONCLUSION: We demonstrate the feasibility of SBC of apheresis platelets to mitigate bacterial risk. SBC is lower cost than alternative measures (e.g., pathogen reduction and point-of-release testing) and can be integrated into workflow at hospital transfusion services.

Prenatal ABO/RHD Genotyping: A New Paradigm to Allow for Fresh Whole Blood for Cardiopulmonary Bypass in the Immediate Newborn Period.

Compared to standard component therapy, fresh whole blood (FWB) offers potential benefits to neonates undergoing cardiopulmonary bypass (CPB) in the context of open cardiac surgery: decreased blood loss and subsequent risk of volume overload, improved coagulation status, higher platelet counts during and following CPB, circumvention of limited vascular access, and significantly reduced donor exposures. Obtaining FWB, however, entails 2-5 days of preparation, which often precludes its availability for neonates requiring CPB in the immediate newborn period. Using a multidisciplinary approach and molecular ABO/RHD genotyping on amniotic fluid, we developed a protocol to allow procurement of FWB for timed delivery followed by open cardiac surgery. Eligible subjects include patients undergoing genetic amniocentesis following the diagnosis of a fetal cardiac anomaly likely to require open surgical repair in the initial days after birth. This protocol has been successfully implemented following prenatal diagnosis of severe fetal cardiac anomalies. Taking advantage of the prenatal time period and the ability to perform fetal blood typing prenatally using molecular genotyping makes possible a new paradigm for the availability of FWB for CPB to improve perioperative, short-term, and long-term outcomes in a population comprised of some of the smallest and sickest patients who will undergo CPB.

Drone transportation of blood products.

BACKGROUND: Small civilian unmanned aerial vehicles (drones) are a novel way to transport small goods. To the best of our knowledge there are no studies examining the impact of drone transport on blood products, describing approaches to maintaining temperature control, or component physical characteristics during drone transport. STUDY DESIGN AND METHODS: Six leukoreduced red blood cell (RBC) and six apheresis platelet (PLT) units were split using sterile techniques. The larger parent RBC and PLT units, as well as six unthawed plasma units frozen within 24 hours of collection (FP24), were placed in a cooler, attached to the drone, and flown for up to 26.5 minutes with temperature logging. Ambient temperatures during the experimental window ranged between -1 and 18°C across 2 days. The difference between the ambient and unit temperatures was approximately 20°C for PLT and FP24 units. After flight, the RBC parent units were centrifuged and visually checked for hemolysis; the PLTs were checked for changes in mean PLT volumes (MPVs), pH, and PLT count; and the frozen air bubbles on the back of the FP24 units were examined for any changes in size or shape, as evidence of thawing. RESULTS: There was no evidence of RBC hemolysis; no significant changes in PLT count, pH, or MPVs; and no changes in the FP24 bubbles. The temperature of all units was maintained during transport and flight. CONCLUSION: There was no adverse impact of drone transport on RBC, PLT, or FP24 units. These findings suggest that drone transportation systems are a viable option for the transportation of blood products.

The evolution of perioperative transfusion testing and blood ordering.

The evolution of modern anesthesia and surgical practices has been accompanied by enhanced supportive procedures in blood banking and transfusion medicine. There is increased focus on the preparation and the use of blood components including, but not limited to, preventing unnecessary type and screen/crossmatch orders, decreasing the time required to provide compatible red blood cells (RBCs), and reducing the waste of limited blood and personnel resources. The aim of this review is to help the anesthesiologist and surgical staff identify patients at highest risk for surgical bleeding. In addition, this review examines how anesthesia and transfusion medicine can efficiently and safely allocate blood components for surgical patients who require transfusions. The following databases were searched: PubMed, EMBASE, Google Scholar, and the Cochrane Library from January 1970 through March 2014. Subsequent reference searches of retrieved articles were also assessed. Several innovations have drastically changed the procedures by which blood is ordered, inventoried, and the speed in which blood is delivered for patient care. Before entering an operating room, patient blood management provides guidance to clinicians about when and how to treat preoperative anemia and intra- and postoperative strategies to limit the patient's exposure to blood components. Timely updates of the recommendations for blood orders (maximum surgical blood ordering schedule) have enhanced preoperative decision making regarding the appropriateness of the type and screen versus the type and crossmatch order. The updated maximum surgical blood ordering schedule reflects modern practices, such as laparoscopy, improved surgical techniques, and use of hemostatic agents resulting in a more streamlined process for ordering and obtaining RBCs. The electronic (computer) crossmatch and electronic remote blood issue have also dramatically reduced the amount of time required to obtain crossmatch-compatible RBCs when compared with the more traditional serologic crossmatch methods. These changes in blood banking methods have resulted in more efficient delivery of blood to surgical patients.

Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative Blood Component Administration.

BACKGROUND: Confirmation of match between patient and blood product remains a manual process in most operating rooms (ORs), and documentation of dual-signature verification remains paper based in most medical institutions. A sentinel event at Johns Hopkins Hospital in which a seriously ill patient undergoing an emergent surgical procedure was transfused with a unit of incompatible red blood cells that had been intended for another patient in an adjacent OR led the hospital to conduct a quality improvement project to improve the safety of intraoperative blood component transfusions. METHODS: A multidisciplinary quality improvement project team led a four-phase implementation of bedside bar code transfusion verification (BBTV) for intraoperative blood product administration. Manual random sample audits of blood component transfusions were used to examine accuracy of documentation from July 2014 through June 2016. After the transition to the Epic anesthesia information management system (AIMS) in July 2016, automated Epic reports were generated to provide population-level audits. RESULTS: After initiation of BBTV and the addition of Epic AIMS, compliance with obtaining three metrics on documentation of patient identification (two electronic signatures, start and stop times of transfusion, and blood volume transfused) was improved during a one-year period to > 96%. Pre-Epic audits had shown a mean compliance of only 86%, mainly reflecting a lack of paper blood component requisitions. CONCLUSION: By implementing BBTV and using a novel intraoperative documentation process within the Epic AIMS, a safer process of blood transfusion in the ORs was initiated and documentation improved.

Physician treatment of osteoporosis in response to heel ultrasound bone mineral density reports.

Optimal information that should be included in ultrasound (US) heel bone mineral density (BMD) reports is not known. If additional information about further evaluation of patients with low heel BMD were included in reports, would responses for treatment improve? We screened people at health fairs using the Sahara heel US machine. For those with a T-score of

High-risk HIV minorities in the United States: who gets tested and where?

OBJECTIVES: To assess characteristics of high-risk populations tested for HIV at particular testing sites. METHODS: BRFSS data (N=20,633) was used to quantify rates of HIV testing and identify specific racial/ethnic testing locations. RESULTS: Analysis determined associations existing among high-risk individuals based on demographics. Testing differences were identified in racial/ ethnic groups among those at high-risk in the United States. HIV testing was more likely among high-risk African Americans (OR=1.62), other races (OR=1.42), and multiracial participants (OR=1.89) than whites. CONCLUSIONS: Minorities were more likely to be tested at locations such as hospitals and clinics supporting the need for alternative testing locations.