How do I … implement diagnostic management teams in transfusion medicine?

Impact of diagnostic management team on patient time to diagnosis and percent of accurate and clinically actionable diagnoses

OBJECTIVES

Diagnostic management teams (DMT) are groups of experts with specialized knowledge to guide test selection and interpretation of results. They have been active in institutions over the past 20 years. To date, there are limited data on whether the presence of experts to advise healthcare providers on appropriate laboratory test selection and interpretation of complex test results positively impacts patient care.

METHODS

A retrospective study at a regional healthcare system with 257,000 patient encounters between 2011 and 2022 reviewing test interpretations provided by clinical laboratory experts on a diagnostic management team.

RESULTS

Cases reviewed by the coagulation DMT were 6 times more likely to have an established, scientifically based diagnosis compared to those without a DMT. Patients who have a coagulation DMT review were twice as likely to receive a diagnosis vs. having no diagnosis.

CONCLUSIONS

This study demonstrates that for several objective clinical outcomes, specifically diagnostic conclusions and length of stay, a DMT of coagulation experts assessing patients' test results has had a major impact on outcomes and delivery of care.

Interprofessional diagnostic management teams: a scoping review protocol

BACKGROUND

Diagnostic errors are a major problem in healthcare. In 2015, the report "Improving Diagnosis in Health Care" by the National Academies of Sciences, Engineering, and Medicine (NASEM) stated that it is likely that most people will experience at least one diagnostic error in their lifetime. The report suggests implementing diagnostic management teams, including patients and their relatives, diagnosticians, and healthcare professionals who support the diagnostic process, to limit diagnostic error and improve patient safety. Implementing interprofessional diagnostic management teams (IDMT), however, is not an easy task due to the complexity of the diagnostic processes and the traditional organization of healthcare with divided departments and healthcare professional who operate in different geographic locations. As this topic is still emerging, a scoping review is ideal to determine the scope of the body of literature on IDMT, indicate the volume of literature and studies available and identify any gaps in knowledge. In a long-term perspective, this scoping review will contribute to prevent diagnostic errors and improve patient safety, for adults and children with physical health issues.

METHODS

We will conduct this scoping review in accordance with the JBI methodology and report it based on the PRISMA-ScR. We will systematically search six databases (EMBASE, PubMed, CINAHL, Academic Search Premier, SCOPUS and Web of Science) for papers published between 1985 and 2023 that describe the use of interprofessional diagnostic management teams. The participants included will be adults and children seeking diagnostic care for physical health issues. The concept studied will be interprofessional diagnostic management teams, and the context will be the diagnostic process in the healthcare system. Studies examining the diagnostic process in psychiatry, odontology or complementary medicine will be excluded. Data extraction, including key study characteristics and findings, will be done by two reviewers independently. Any disagreement will be resolved by discussion and eventually by including the two remainder reviewers.

DISCUSSION

To our knowledge, this will be the first scoping review regarding IDMT and the derived effects on diagnostic safety and can therefore be a very important contribution to improve patient safety significantly during the diagnostic process.

PROTOCOL REGISTRATION

The project is registered at Open Science Framework (OSF) with ID: osf.io/kv2n6.

Three patients highlighting potential pitfalls in platelet refractory testing

BACKGROUND

Platelet-transfusion refractory (PR) patients do not achieve expected post-transfusion platelet counts. We investigate suspected PR patients with post-transfusion platelet counts, indirect platelet antibody screens (ind-PAS), Class I HLA antibody tests (HLA-Scr), and physical platelet crossmatch (PXM) studies.

STUDY DESIGN AND METHODS

The three following cases describe possible pitfalls of laboratory tests used in PR workup and management.

RESULTS

Case #1: Antibody testing detected antibodies to only HLA-B13, corresponding to a 4% calculated panel reactive antibodies (CPRA; 96% predicted donor compatibility). However, PXM showed the patient compatible with 11/14 (79%) donors; two of the PXM-incompatible units were ABO-incompatible. Case #2: PXM revealed compatibility with 1/14 screened donors; however, the patient did not respond to the product from the compatible donor. The patient did respond to HLA-matched product. Dilution studies provided evidence of the prozone effect, which caused negative PXM despite clinically relevant antibodies. Case #3: There was a discrepancy between the ind-PAS and HLA-Scr. Ind-PAS was negative for HLA antibodies, while HLA-Scr was positive and specificity testing corresponded to 38% CPRA. Per the package insert, the sensitivity of ind-PAS is ~85% compared to HLA-Scr.

DISCUSSION

These cases highlight the importance of investigating incongruent results. Cases #1 and #2 demonstrate PXM pitfalls: ABO incompatibility can result in positive PXM and false-negative PXM can occur in the setting of the prozone effect. Case #3 reveals the importance of knowing a test's sensitivity. Centers that only perform ind-PAS may fail to detect HLA antibodies.

Loss of heterozygosity leading to incorrect HLA typing for platelet-transfusion refractory patient

BACKGROUND

Management of platelet-transfusion refractory (PR) patients due to anti-HLA antibodies includes the provision of HLA-matched (HLAm) platelets (PLT) or PLTs that are negative for HLA antigens corresponding to the recipient antibodies. Obtaining HLAm PLTs is predicated on accurate HLA antigen typing of the recipient and donor. Here, we present the clinical implications of a case involving loss of heterozygosity (LOH) in a patient presented for PR workup.

STUDY DESIGN AND METHODS

HLA typing was performed by three methods: (1) Real-time PCR; (2) Sequence-specific oligonucleotide (SSO) typing test; and (3) Next-Generation Sequencing (NGS). Cytogenomic SNP microarray was utilized to assess LOH.

RESULTS

A 30-year-old female with newly diagnosed acute myelogenous leukemia was found to be PR secondary to HLA sensitization. A peripheral blood (PB) sample, containing 93% myeloid blast cells, was sent for HLA typing for the provision of HLAm PLTs. HLA typing revealed homozygosity at the HLA-A locus but was heterozygous at the -B and -C loci. After chemotherapy, HLA typing on a new PB sample, devoid of blast cells, identified HLA-A locus heterozygosity, which was subsequently confirmed by real-time PCR and NGS. Cytogenomic SNP microarray analysis demonstrated LOH of the HLA-A locus on chromosome 6p in the pretreatment sample but not in the posttreatment sample.

CONCLUSION

In hematologic patients with high tumor burden, HLA homozygosity should be viewed with suspicion for potential LOH. Therefore, HLA testing should be repeated, preferably with a non-hematological source (e.g., buccal swab) or following successful reduction of the tumor burden.