Improving documentation of blood product administration using a standardized electronic health record-based system: a single-institution experience

OBJECTIVES

To improve documentation of blood product administration by assessing the completion status of blood transfusions. In this way, we can ensure compliance with the Association for the Advancement of Blood & Biotherapies standards and facilitate investigation of potential blood transfusion reactions.

METHODS

This before-and-after study includes the implementation of an electronic health record (EHR)-based, standardized protocol for documenting the completion of blood product administration. Twenty-four months of retrospective data (January-December 2021) and prospective data (January-December 2022) were collected. Meetings were held before the intervention. Ongoing daily, weekly, and monthly reports were prepared, and targeted education to deficient areas as well as spot in-person audits by the blood bank residents were conducted.

RESULTS

During 2022, 8,342 blood products were transfused, of which 6,358 blood product administrations were documented. The overall percentage of completed transfusion order documentation improved from 35.54% (units/units) in 2021 to 76.22% (units/units) in 2022.

CONCLUSIONS

Interdisciplinary collaborative efforts helped produce quality audits to improve the documentation of blood product transfusion through a standardized and customized EHR-based blood product administration module.

Transfusion-Transmitted Disorders 2023 with Special Attention to Bone Marrow Transplant Patients

Transfusion medicine is traditionally a strong/fundamental part of clinical practice, saving hundreds of millions of lives. However, blood-borne or transmitted infections are a well-known and feared possibility, a risk we relentlessly mitigate. Pathogens are continuously and rather quickly changing, so during the last decade, many, sometimes exotic, new pathogens and diseases were recorded and analyzed, and some of them were proved to be transmitted with transfusions. Blood or blood component transfusions are carried out after cautious preparative screening and inactivation maneuvers, but in some instances, newly recognized agents might escape from standard screening and inactivation procedures. Here, we try to focus on some of these proven or potentially pathogenic transfusion-transmitted agents, especially in immunocompromised patients or bone marrow transplantation settings. These pathogens are sometimes new challenges for preparative procedures, and there is a need for more recent, occasionally advanced, screening and inactivation methods to recognize and eliminate the threat a new or well-known pathogen can pose. Pathogen transmission is probably even more critical in hemophiliacs or bone marrow transplant recipients, who receive plasma-derived factor preparations or blood component transfusions regularly and in large quantities, sometimes in severely immunosuppressed conditions. Moreover, it may not be emphasized enough that transfusions and plasma-derived product administrations are essential to medical care. Therefore, blood-borne transmission needs continued alertness and efforts to attain optimal benefits with minimized hazards.

Sickle cell trait results in a high leukoreduction quality control failure rate for whole blood donations

Background

Prior studies have shown that sickle cell trait (SCT) is the most common reason attributed to leukoreduction (LR) filter failure due to physical blockage. However, current Food and Drug Administration (FDA) guidelines do not require blood collectors to take a specific action to mitigate inadequate LR that may occur among donors with SCT. We sought to determine the scope of inadequate LR among whole blood (WB) donations collected from individuals with SCT and processed under standard manufacturing conditions.

Study Design and Methods

Between 8/2021 and 2/2022, a total of 40 red blood cells units (RBCs) manufactured from WB donations collected from donors historically positive for SCT had residual leukocyte testing performed. All 40 of the units had appeared to successfully complete leukofiltration.

Results

Out of the 40 units tested, 22 failed routine residual leukocyte quality control testing (55% failure rate, 95% confidence interval 40%–70%). Nine out of the 22 failures resulted in more than 100 residual leukocytes per microliter of product.

Conclusion

Even when leukofiltration appears to have been completed successfully, WB units collected from donors with SCT have a high (55% in aggregate) rate of inadequate leukoreduction. Correlating this result with previous studies showing that of up to 50% of WB units collected from donors with SCT fail to pass through the leukoreduction filter, we estimate that only 25% of WB donations collected from individuals with SCT will result in a leukoreduced RBC unit that meets all FDA requirements. Blood centers should encourage individuals with SCT to donate platelets or plasma, rather than WB.

See editorial on page 1683–1687, in this issue

CMV screening of group-specific orders-good stewardship of the blood supply

BACKGROUND

In addition to antigen-negative red blood cells (RBC), Immunohematology Reference Laboratories (IRL) must provide RBCs that are cytomegalovirus (CMV) seronegative. Due to high percentage of CMV seropositive individuals, it is challenging to find CMV and antigen-negative RBC. The IRL selects predominantly group O donors tested for CMV, and these RBC are sometimes needed to fill orders for nongroup O patients. This study evaluated units sent that were out of group to fulfill CMV-seronegative requests.

STUDY DESIGN AND METHODS

Requests for CMV-seronegative and antigen-negative RBCs were divided into Period 1 (January 1, 2019-February 29, 2020) before intervention and Period 2 (March 1, 2020-May 31, 2020) post intervention. ABO Rh units requested were compared to ABO Rh units provided.

RESULTS

Period 1: 537 CMV-seronegative RBC units were provided. 99/188(52.66%) B-positive requests were fulfilled using O RBCs. 58/504 (11.51%) of D-negative units were sent to D-positive patients. Period 2: 119 CMV-seronegative RBC units were provided. 18/51 (35.29%) B positive requests were fulfilled using O RBCs. Only 7/113 (6.19%) D-negative units were sent to D-positive patients.

DISCUSSION

For 239/656 (36.43%) CMV-seronegative antigen orders requested for B-positive patients, more than half of these orders were filled with O RBCs. To decrease group O usage for nongroup O patients, the IRL practice has changed to increase CMV testing for group B donors. Since the change in algorithm, there was a 17.37% decrease group O usage for group B patients.

Optimizing the recovery of peripheral blood mononuclear cells trapped in leukoreduction filters - A comparison study

Introduction

The isolation of captured peripheral blood mononuclear cells (PBMNCs) from leukoreduction filters (LRFs) can be of great importance in terms of bringing the lost cells back into use.

Objective

The aim of this study was to evaluate various methods based on their potential to recover the peripheral blood cells from LRFs with a focus on mononuclear cells (MNCs).

Method

For cell isolation from LRFs, three distinct methods (back-flushing, direct and vacuum pump) were compared through the calculation of the yield of isolated MNCs. The viability of extracted cells was determined by the flow cytometry technique. Moreover, the recovered MNCs were characterized regarding the presence of blood stem cell purification. The cell culture, microscopic observation, and immunophenotyping were employed to characterize the blood stem cells (hematopoietic, mesenchymal and progenitor endothelial stem cells).

Results

The yield of isolation obtained in the back-flushing, direct and vacuum pump methods were 17.7 ± 1.28, 17.3 ± 0.96 and 21.2 ± 0.90 percent, respectively. Although the highest potential for total blood cell recovery belonged to the vacuum pump method, the lowest cell viability (85.73 ± 4.84%) was observed in this method. However, the isolation process of the back-flushing and direct methods had less effect on cell viability. The characterization of the isolated MNCs displayed that the dominant positive phenotype was for CD34/CD45, indicating hematopoietic stem cells. In addition, the endothelial stem/progenitor cells were significantly detected as CD31/CD133 positive cells.

Conclusion

According to our results and considering the safety and efficiency potential of each of the applied methods, the back-flushing in comparison with the other methods can be considered a suitable procedure for MNC isolation from LRFs.

Reducing infectious complications after allogeneic stem cell transplant

INTRODUCTION

Infections remain a significant problem, in patients undergoing an allogeneic hematopoietic stem-cell transplant (HSCT) and efforts have been made over the years, to reduce the incidence, morbidity and mortality of infectious complications.

AREAS COVERED

This manuscript is focused on the epidemiology, risk factors and prevention of infections after allogeneic HSCT. A systematic literature review was performed using the PubMed database, between November 2019 and January 2020, with the following MeSH terms: stem-cell transplantation, infection, fungal, bacterial, viral, prophylaxis, vaccines, prevention. The authors reviewed all the publications, and following a common revision, a summary report was made and results were divided in three sections: bacterial, fungal and viral infections.

EXPERT OPINION

Different infections occur in the early, intermediate and late post-transplant period, due to distinct risk factors. Improved diagnostic techniques, pre-emtive therapy and better prophylaxis of immunologic complications, have reduced the morbidity and mortality of infections. The role of the gut microbiota is under careful scrutiny and may further help us to identify high-risk patients.

A national survey of hospital-based transfusion services on their approaches to platelet bacterial risk mitigation in response to the FDA final guidance for industry

BACKGROUND

Bacterial contamination of platelets is the leading infectious risk to the United States (US) blood supply. On 30 September 2019, the US Food and Drug Administration (FDA) published a Final Guidance for Industry to reduce the risk of transfusing platelets contaminated by bacteria. A national survey was undertaken to assess readiness, attitudes, and the potential impact on hospital-based transfusion services.

STUDY DESIGN AND METHODS

A survey was distributed to transfusion services in all 50 US states. Summary statistics were performed along with review and categorization of email feedback and free text comments.

RESULTS

Eighty-three transfusion services from 48 states participated in this survey study. Currently, the most common approach is primary culture performed at manufacturing (n = 49/83, 59%). Of the bacterial risk mitigation strategies provided by the FDA, the most frequently preferred are (a) pathogen reduced platelets (PRP) for up to 5-day storage (n = 36/77, 47%), (b) large volume delayed sampling (LVDS) ≥48 hours for up to 7-day storage (n = 16/77, 21%), and (c) primary culture ≥24 hours + secondary rapid testing for up to 7-day storage (n = 7/77, 9%). The main motivating factors for the survey participants' selected strategies to comply with FDA final guidance were product availability from supplier, reducing the risk of septic transfusion reactions (STR), and complexity of implementing and performing a new or additional test.

CONCLUSION

While having platelets to transfuse and preventing STR are of the utmost importance, nationwide, the majority of transfusion services do not want to take on performing new or additional testing in their laboratories.

How do you… decide which platelet bacterial risk mitigation strategy to select for your hospital-based transfusion service?

The United States Food and Drug Administration Final Guidance for Industry titled, "Bacterial Risk Control Strategies for Blood Collection Establishments and Transfusion Services to Enhance the Safety and Availability of Platelets for Transfusion" provides nine strategies for platelet bacterial risk mitigation. Even if it is assumed all strategies are comparable in terms of safety and efficacy, the decision of which to implement remains challenging. Some additional factors that warrant evaluation before selecting a strategy include the financial impact, process for implementation, logistics upon implementation, institutional acceptance by blood bank staff, administration and clinicians, and effect on platelet availability. To assist with this difficult choice, a panel of transfusion service physicians who have expertise on the topic and have already selected strategies for their transfusion services were recruited to provide varied perspectives. In addition, the use of a decision-making tool that objectively evaluates defined criteria for assessment of the nine strategies is described.

Transfusion-transmitted cytomegalovirus: behaviour of cell-free virus during blood component processing. A study on the safety of labile blood components in Switzerland

BACKGROUND

Nowadays, most blood products are leukocyte-reduced. After this procedure, the residual risk for transfusion transmitted cytomegalovirus (TT-CMV) is mostly attributed to cell-free viruses in the plasma of blood donors following primary infection or viral reactivation. Here, objectives are: 1) to study the behaviour of cell-free CMV through the blood component processing; 2) to determine the anti-CMV seroprevalence, the level of viremia, the window-period in blood donor population; and 3) to identify cases of TT-CMV in bone marrow transplant (BMT) recipients.

MATERIALS AND METHODS

Cell-free CMV was injected into blood bags originating from regular donors. Blood components were processed according to either the CompoSelect^® or the CompoFlow^® (Fresenius Kabi AG) techniques. Samples were analysed at each step for presence of virus DNA using quantitative polymerase chain reaction (PCR). The anti-CMV seroprevalence in our donor population was taken from our donor data system. The viremia was assessed in pooled plasmas samples from routine donations by quantitative PCR. Medical charts of 165 BMT anti-CMV seronegative recipients/anti-CMV seronegative donors who received CMV-unscreened blood products were reviewed.

RESULTS

Cell-free CMV passes without any decrease in viral load through all stages of blood processing. The anti-CMV seroprevalence was 46.13%. Four DNA positive samples out of 42,240 individual blood donations were identified (0.009%); all had low levels of viremia (range 11-255 IU/mL). No window-period donation was identified. No TT-CMV was found.

DISCUSSION

Cell-free CMV remains a concern with current blood component processing as it passes through all the processes. However, since low levels of CMV DNA were identified in the donations tested, and no BMT recipients had TT-CMV, the residual threat of TT-CMV after leukocyte reduction appears to be very low.

Risk of cytomegalovirus transmission by blood products after solid organ transplantation

Cytomegalovirus (CMV) infection and CMV disease are significant contributors to increased morbidity, mortality, and cost for immunocompromised solid organ transplant recipients. Although the most significant risk for CMV transmission is the CMV serological status of the transplant donor and recipient, exposure to blood products is another potential risk factor. Before the era of leukocyte reduction, CMV seronegative products were issued to reduce the risk of CMV transmission, thus rendering the products CMV safe. This approach requires maintenance of two inventories of blood products and continuous donor testing. Leukocyte-reduced cellular transfusion products are also considered CMV safe and are essentially universally available. To minimize the risk of CMV infection in transplant recipients, strategies include use of seronegative blood products or prestorage leukocyte reduction. However, no recent randomized prospective controlled trial directly compares the two CMV safety approaches for transplant recipients. Hence, current policy relies on historic trials and more recent observational studies. As a consequence, though generally considered equivalent approaches, preferred practice varies between centers. This review provides guidance to inform an acceptable practice approach.

Guidelines for the management of cytomegalovirus infection in patients with haematological malignancies and after stem cell transplantation from the 2017 European Conference on Infections in Leukaemia (ECIL 7)

Cytomegalovirus is one of the most important infections to occur after allogeneic haematopoietic stem cell transplantation (HSCT), and an increasing number of reports indicate that cytomegalovirus is also a potentially important pathogen in patients treated with recently introduced drugs for hematological malignancies. Expert recommendations have been produced by the 2017 European Conference on Infections in Leukaemia (ECIL 7) after a review of the literature on the diagnosis and management of cytomegalovirus in patients after HSCT and in patients receiving other types of therapy for haematological malignancies. These recommendations cover diagnosis, preventive strategies such as prophylaxis and pre-emptive therapy, and management of cytomegalovirus disease. Antiviral drugs including maribavir and letermovir are in development and prospective clinical trials have recently been completed. However, management of patients with resistant or refractory cytomegalovirus infection or cytomegalovirus disease is a challenge. In this Review we summarise the reviewed literature and the recommendations of the ECIL 7 for management of cytomegalovirus in patients with haematological malignancies.

The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation

Despite recent advances, cytomegalovirus (CMV) infections remain one of the most common complications affecting solid organ transplant recipients, conveying higher risks of complications, graft loss, morbidity, and mortality. Research in the field and development of prior consensus guidelines supported by The Transplantation Society has allowed a more standardized approach to CMV management. An international multidisciplinary panel of experts was convened to expand and revise evidence and expert opinion-based consensus guidelines on CMV management including prevention, treatment, diagnostics, immunology, drug resistance, and pediatric issues. Highlights include advances in molecular and immunologic diagnostics, improved understanding of diagnostic thresholds, optimized methods of prevention, advances in the use of novel antiviral therapies and certain immunosuppressive agents, and more savvy approaches to treatment resistant/refractory disease. The following report summarizes the updated recommendations.

Transfusion-Transmitted Infections: an Update on Product Screening, Diagnostic Techniques, and the Path Ahead

The mandated testing of blood components for infectious diseases, to prevent transfusion-transmitted infections (TTIs), began in the 1950s. Since then, changes in predonation questionnaires and advances in testing techniques have afforded more sensitive and specific tests for pathogens, in addition to allowing earlier detection. Given that these approaches have very low but detectable failure rates, the recent development and implementation of proactive pathogen reduction approaches is the new forefront of TTI prevention strategies. With globalization and the ability of pathogens to evolve rapidly, continuous redefining of testing standards and laboratory techniques is paramount for maintaining a safe blood supply.

Cost-utility and budget impact of methylene blue-treated plasma compared to quarantine plasma

BACKGROUND

Methylene blue and visible light treatment and quarantine are two methods used to reduce adverse events, mostly infections, associated with the transfusion of fresh-frozen plasma. The objective of this study was to estimate and compare the budget impact and cost-utility of these two methods from a payer's perspective.

MATERIALS AND METHODS

A budget impact and cost-utility model simulating the risks of hepatitis B virus, hepatitis C virus, cytomegalovirus, a West Nile virus-like infection, allergic reactions and febrile non-haemolytic transfusion reactions achieved using plasma treated with methylene blue and visible light (MBP) and quarantine plasma (QP) was constructed for Spain. QP costs were estimated using data from one blood centre in Spain and published literature. The costs of producing fresh-frozen plasma from whole blood, apheresis plasma, and multicomponent apheresis, and separately for passive and active methods of donor recall for QP were included. Costs and outcomes over a 5-year and lifetime time horizon were estimated.

RESULTS

Compared to passive QP, MBP led to a net increase of € 850,352, and compared to active QP, MBP led to a net saving of € 5,890,425 over a 5-year period. Compared to passive QP, MBP increased the cost of fresh-frozen plasma per patient by € 7.21 and had an incremental cost-utility ratio of € 705,126 per quality-adjusted life-year. Compared to active QP, MBP reduced cost by € 50.46 per patient and was more effective.

DISCUSSION

Plasma collection method and quarantine approach had the strongest influence on the budget impact and cost-utility of MBP. If QP relies on plasma from whole blood collection and passive quarantine, it is less costly than MBP. However, MPB was estimated to be more effective than QP in all analyses.