My Opinion: Separate Transfusion Medicine from the Laboratory and Clinical Departments

This is an update of a previous post.

Transfusion Medicine includes laboratory and non-laboratory functions.  The non-laboratory and purely clinical functions are unique and have no analogy within the general laboratory.  Likewise, from a clinical department perspective, transfusion medicine is not just a clinical service, but also a laboratory and a drug manufacturing center.

The transfusion service/hospital blood bank laboratory is the closest to a laboratory operation, but there is also component modification and complex manual testing, especially for reference immunohematology testing.  The staff must make detailed manual decisions, the errors for which could be life-threatening for the patient.

The blood donor center manufactures a pharmaceutical, i.e. blood components with collection, donor qualification, donor abnormal results review, infectious disease marker testing, component production, and donor immunohematology testing—all subject to Good Manufacturing Practices.  Never forget:  Blood is a drug!!  There is no other part of the clinical services or laboratory that manufactures drugs.

Transfusion Medicine is directly responsible for treatment of critically ill patients.  Therapeutic apheresis is essential for organ and stem-cell transplants, nephrology, neurology, etc.  No other laboratory section is directly responsible for treatment of critically ill patients.  Transfusion Medicine physicians are functioning as intensivists.  There is no hiding in the blood bank from clinical medicine.

It may also be an industrial manufacturing plant to extract various blood derivatives (e.g. factor concentrates, albumin, Rh immune globulin, etc.)  This is pharmaceutical manufacturing on a large-scale basis.  There is medical, technical, and special administrative expertise.

Many functions may operate 24/7. 

The unique blend of clinical skills is unlike anything else in the laboratory.  Thus, those outside the blood bank may not be familiar enough to decide the best course of action for transfusion medicine or for its operations.

The transfusion medicine physician must make acute, life-threatening decisions unlike anyone else in the laboratory 24/7 at all times.  The transfusion medicine physician may be on-call for donor issues and review of complex immunohematology problems to acutely decide which blood component (and phenotype) should be given as well as review all adverse reactions to transfusion.  The blood bank technologist is at the cutting edge of the battle with his testing and interpretations.  No other area of the laboratory is at such risk for injuring or even killing the patient.  There is high stress and burn-out.

I have talked with many blood bankers and many seem to share the exasperation that the laboratory or clinical departments do not understand or appreciate us.  Often, the laboratory looks at blood bank testing like that coming off a hematology or chemistry analyzer—although patients rarely would have severe morbidity or mortality like the blood bank from errors in those analyzers.

No laboratory pathologist has the pressure of the blood bank physician on-call.  It really is 24/7 and requires a broad, clinical background to make the right decisions.  It is very stressful and does not permit a good night’s sleep.

Thus, I make my case to separate us from the laboratory.  We can form our own more effective administrative organization and optimize our own planning.  Regretfully, I have never experienced or worked in such an administrative structure.  I also am a realist that cost-containment nowadays makes it much less likely high administration would permit this change.  This will probably never happen during my career.

Finally, Transfusion Medicine is an essential service.  Blood components are essential drugs.  The operations and staff must be free of political influences.  This is a service for the entire region or country like the fire department, civil defense, etc.  You are playing with fire when you disturb the blood bank.