Category: Blood Bank IT

Includes all areas: Donor, patient, marker testing, component preparation

Patient D-Typing Algorithm Using Ortho Monoclonal Cocktail Reagents

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Principle:

We must select D-negative RBC units for transfusion if the patient is truly D-negative or if he/she is a partial D since transfusion of a partial D positive unit may induce antibodies against any part of the D molecule.  Thus, for patients, we will consider patients with partial D as D-negative.  Note that this is NOT the usual practice in the USA;  however, AABB Standards do allow that we do NOT test patients for weak D and give D-negative RBCs instead.

Background:

Ortho Diagnostics Reagents use two different monoclonal antibody cocktails that react variably with the antigen D (Rh1)—these are found on the card:  Anti-A/B/A,B/D/D/Ctrl:

Anti-D/Anti-RH1—IgM monoclonal antibody clone D7B8 can detect most examples of weak and partial D including weak D types 1, 2, 3, 4.0, and D categories II, III, IV, V, VII, DBT, and R0Har.  It does NOT detect category VI.  Retest positive reactions of 2+ or less by an alternate method.

Anti-D/Anti-RH1—IgM monoclonal antibody RUM1 can detect most examples of weak and partial D including weak D types 1, 2, 3, 4.0, and D categories II, III, IV, V, VII, DBT, and R0Har.  It does NOT detect category VI.  Retest positive reactions of 2+ or less by an alternate method.

Policy:

  1. Follow the manufacturer’s instruction for storage, handling, and usage of all reagents.
  2. If the D-control is positive, the reactions are indeterminate, repeat by another method.
  3. Run both anti-D reagents listed—do not use the donor typing algorithm or reagents.
  4. Use the following table for interpretation and further actions if needed:
Pattern #Anti-D/D7B8Anti-D RUM1D-Interpretation
1PositivePositiveD-positive
2PositiveNegativeDo additional testing
3NegativePositiveDo additional testing
4NegativeNegativeD-negative  

If the reaction is 2+ or less with either the Ortho anti-D/D7B8 reagent or anti-D/RUM1 or if the patterns 2 or 3 above, repeat by another manufacturer’s reagents.  In the meantime, consider the patient as D-negative.

Medinfo-Ortho interface settings for Patient Testing:

Anti-D/D7B8Anti-D RUM1D-Interpretation
3, 43, 4D-positive
3, 40~
03, 4~
00D-negative
~~~

Note all of the following:

  1. If the result is D-indeterminate, use D-negative RBCs.
  2. No reagents may be able to detect all D variants.
  3. ~ means any other value for that reagent (1+, 2+, mf, hemolyzed)
  4. Note that this new algorithm makes a 2+ reactivity as indeterminate with Anti-D/D7B8 or Anti-D/RUM1.

References:

  1. Publication e631300291, Product Insert, Anti-A/B/A,B/D/CDE/Control Card, 2010, Ortho Clinical Diagnostics, High Wycombe, Buckinghamshire/UK
  2. Standards for Blood Banks and Transfusion Services, Current Edition, AABB, Bethesda, MD, USA

Opinion: Handling Incorrect Physician Orders

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Most of the non-transfusion-medicine physicians with whom I have worked have had only limited training in placing component or hospital blood bank orders.  In previous posts I have discussed this and suggested that all physicians who may possibly order blood bank tests or blood components should have a training and documented competence on a periodic basis.  Only a very few physicians, mainly hematologists and some organ transplant physicians, have placed reliable orders.

Before we had a blood bank computer system, we received orders on a manual paper requisition.  If there were errors, my technical staff and I corrected the order.  Any changes were made by me in my capacity as the blood bank medical director.  The ordering physicians and I had good relations and they had no problem with this—in fact, many were afraid of the blood bank and felt happy to be relieved of the responsibility.

In the current software era, what happens depends on how the order is placed.  Can the technical staff and I correct the order directly or must we each and every time contact the physician to revise his/her order?  Do my staff have to cancel each erroneous order and wait for the corrected order?  This could slow down the work process and prevent release of blood components in a timely manner.

Should the non-blood bank physician be allowed to order our complicated esoteric transfusion tests directly—e.g. ordering extended antigen typings or antibody identifications or elutions?   What if they order something unnecessary or inappropriate?

At a recent hospital position as Division Head of Transfusion Medicine, I discovered that the Hospital Information System HIS was very slow for all blood bank orders.  The physicians complained, I would allow them to bypass the HIS and use the manual backup system in critical situations.  If we had been forced to cancel the order and have the physician reorder, this would have greatly disrupted the work process.

We did not use the HIS at all in Transfusion Medicine.  We had patient and donor modules in the dedicated blood bank system Medinfo.  We had a limited ordering interface from the HIS to Medinfo for blood components and some basic testing (e.g. ABO/D typing, DAT, type and screen/group and save, cord blood testing, and transfusion reaction workups).  All work was done in the dedicated blood bank system.

All components were leukodepleted to < 1E6, all platelet and plasma were Mirasol pathogen-inactivated, all platelets were in platelet additive solution PAS.

The doctors did not order the specific blood component, rather they indicated a preference, e.g.

  • Packed RBCs
  • Platelets (adult dose of 2.4 E11)
  • Plasma
  • Cryoprecipitate

The following appeared as an order comment in the blood bank system:

  • The specific number or amount of the each component type
  • Preferences for pooled vs. apheresis platelets, washed RBCs, irradiated RBCs.

The blood bank staff could review the doctor’s request and order in Medinfo as per our internal protocols under my responsibility.  In effect, I was modifying the orders when needed just as I had done under our manual system.  This included type, modification, and quantity.  Yet now, I did not have to change any orders since the doctors had only indicated preferences.

For blood bank testing orders, we had our own internal algorithms for the workups.  The doctors could not order antibody identifications, elutions, or any antigen typings other than ABO/D.  They latter were triggered by the screening test results.

This system allowed us to avoid cancellations due to physician errors.  I was very comfortable taking the responsibility to alter the orders for best patient care.  If a physician did not agree with our algorithms, they could discuss the issue with one of the transfusion physicians, or ultimately appeal to me.  I was fortunate that there were no legal issues with this approach where I practiced.

In summary, my recommendations are:

  1. Have the doctors order a preference for the type of blood component.  They still order the quantity and can request modifications such as washing or irradiating or apheresis-derived or buffy coat pool platelets.  The actual allocation is made by blood bank staff under my direction.
  2. Offer algorithmic based testing.  Doctors only order basic testing which triggers reflex algorithms.  Most of the test menu is not orderable directly by the physicians (example:  an antibody identification is triggered by a non-negative antibody screen.

9/12/20

Off-Line Donor Medinfo Transactions

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Principle:

When you cannot establish a direct link to the live Medinfo program, you must arrange for the local Medinfo engineers to create a local server that will have the current Medinfo donor database for use at outside campaigns where the internet connection cannot be used.  This can also be used if for some reason the Blood Donor Center link is down in order to register donors and check the donor deferral database.

Policy:

  1. For each outside campaign, there should be a pre-campaign visit to verify the availability of internet to connect to Medinfo.
    1. If the internet connection is working, use Medinfo using the 4G access points.  Otherwise:
    2. If none, inform the Medinfo engineers to prepare a local server on one of the laptops at least ONE DAY in advance of the campaign.
      1. Give Medinfo engineers the laptop to download the database and software.  This will be the offline server for the campaign.
      2. Link the offline server to the other portable computers for the campaign (see the corresponding Medinfo job aid).
      3. Use the local network (offline server and other portable computers) for registering donors.
      4. Upon return to the Blood Donor Center, upload the data.
      5. Continue the regular processes after uploading.

Note:  When the offline data is uploaded into Medinfo main database, it will be checked against the latest donor deferral database.  The latter will be applied for the donation.

Liver Transplant Processes for the Transfusion Service

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Principle:

Liver transplantation requires coordination of the Transfusion Service TS, Liver Transplant LTS , and the Blood Donor Center BDC to prepare blood components for this massive transfusion setting.

Policy:

  1. Whoever receives notification of a possible liver transplant should ensure that ALL of the following senior staff are also informed:
    1. Head, Transfusion Medicine
    2. Coordinator, Donor Recruitment
    3. Supervisor, Transfusion Service
  2. Transfusion Service Supervisor will arrange transfusion service staffing as needed to cover the surgery period and immediate post-operative period.
  3. The current, up-to-date inventory must be calculated.  The following minimum stock must be reserved:
    1. Twenty (20) packed RBCs
    2. Twenty (20) FFPs—-leukodepleted and pathogen-inactivated
    3. Three (3) platelet pools or apheresis doses (each ≥ 2E11 absolute number of platelets)—leukodepleted and pathogen-inactivated.
    4. The Medinfo Liver Transplant Protocol automatically orders all the above.
  4. Complex needs:
    1. If the patient has clinically significant antibodies, confirm the availability of the requested number of antigen-negative/compatible units.
    2. The Head, Transfusion Medicine, or the covering transfusion medicine consultant on-call will contact the liver transplant team to discuss the feasibility of proceeding after assessing the inventory of antigen-negative units.
    3. Only the transfusion medicine consultant can approve the use of antigen-incompatible RBCs in conjunction with the liver transplant team.
  5. Donor Center should increase recruitment/production to meet the anticipated usage as needed.
  6. When the procedure is confirmed:
    1. Crossmatch the RBCs by the appropriate technique according to our algorithms (i.e. computer/electronic, immediate-spin, or full AHG).
    2. Thaw the FFP:  the FFP is valid for FIVE days after thawing for use for the transplant patient or other patients with coagulopathy.
    3. If more than the above number of units is needed, HGH Transfusion Service must inform the Donor Center senior staff (Head, Donor Center; Administrative/Technical Director, and Coordinator, Donor Recruitment) to arrange for additional donations.

Example of Dealing with HIS Interface Issues to Dedicated Blood Bank Software

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The following is an actual working document for interactions between the Medinfo HIIG system and a monolithic hospital information system covering nursing, laboratory, ADT, etc.  For the purpose of this post, I shall name it B*.

In a previous position, I was in charge of the Laboratory Information Systems and worked both with Medinfo for donor and patient hospital blood bank processes AND B* for the general laboratory.  It was my decision NOT to use B* for the hospital blood bank because there would be no integration between the donor module in Medinfo and patient blood bank module in B*.  Also, B* had limited handling of complex immunology algorithms and fewer safeguards than Medinfo.

B* could not directly read ISBT product labels from the ISBT dictionary and required hard-coding the links for each and every type of blood component and modification.  It was also slow to order blood components so in emergency situations, I allowed physicians to bypass B* and order directly if they felt in their clinical judgment that the delay in using B* might harm the patient.

The non-transfusion physicians had to directly order blood components in B* except for emergencies as stated above.  They were only allowed to order a limited number of basic tests such as ABO/D type, direct antiglobulin test DAT, or antibody screen.  Based on those tests, we would use algorithms in Medinfo’s patient module.  Example:  an outside doctor could not order a Jka typing—that could only be done according to our internal Medinfo algorithms.  Doctors could only order antibody screens, not antibody identifications, elutions, or titrations.

Sadly, most physicians had no specific training in blood component or blood component therapy so they made many mistakes in ordering manually before the computer system.  I had requested offering training sessions for the doctors but this had never been approved by the medical administration.

Thus, my decision was to place the responsibility for the correct ordering of blood components and testing directly by Transfusion Medicine.  The non-transfusion doctors were only ordering preferences for components—the actual selection was made in Medinfo by my blood bank staff under my order.  We decided whether to irradiate.  All platelet and plasma components were pathogen-inactivated.  All components were leukodepleted to < 1E6 according to CE Standards.

In Medinfo we could thus modify or even cancel requests without having to deal with the B* system.  B* would accept Medinfo cancellations directly.

During the frequent B* downtimes, all processes would be limited to using Medinfo.  There was no way to initiate orders in Medinfo and send them back to B*.  Thus during downtimes, the only way to retrieve results was to use Medinfo.

The following is the process for the interface as was used during my tenure at that institution:

Medinfo-B* Interface Process

Principle:

Limited ordering of components and basic transfusion testing may be initiated on the B* side.  All component orders and all test results will pass into B*, including those which can only be ordered by blood bank staff.  All blood bank processes will continue to be performed within Medinfo.  Transfusion Medicine is not responsible for training physicians and nurses on how to use the B* interface.

Abbreviations:

NTMP:  Non-Transfusion Medicine physicians

TM:  Transfusion Medicine

B*:  A hospital information system including laboratory module (not used by Transfusion Medicine for either patient blood bank or donor issues)—NOT MEDINFO!!

THE FOLLOWING POLICY SUPERCEDES ANY AND ALL PROCESSES CURRENTLY DOCUMENTED IN TRANSFUSION MEDICINE.  The processes are currently being updated to reflect the Medinfo-B* interface issues.

Policy:

  1. For our hospitals, B* ordering must be used unless B* is non-functional or there is a life-threatening clinical emergency that cannot be met expeditiously by ordering in B* e.g. MTP)
  2. NTMP must place all component orders (RBC, plasma, and platelet) and the limited test menu (type and screen, transfusion reaction, ABO/D type, direct antiglobulin test, cord blood) in B*.
    1. The ordering physician must DIRECTLY enter the order, not list the transfusion as a nursing task in the B* system.
  3. NTMP may indicate a preference to the type of component and number/amount requested, but the actual selection and release will be based on internal TM algorithms under the order of the Division Head, Transfusion Medicine.
  4. Tests not listed in the B* menu cannot be directly ordered by the NTMP.
  5. It is the responsibility of TM staff to periodically check the interface from Medinfo to import requests.
  6. Transfusion service/hospital blood bank staff will integrate those order requests which are currently needed for patient care.
    1. Other requests will be kept in the B*-Medinfo queue until they are needed and will be automatically cancelled after 3 days.
  7. Internal Hospital Transfusion Service/Blood Bank Processes:
    1. All Transfusion Medicine work processes will be performed within Medinfo, nothing within B*.
    2. B* Functioning (non-MTP):
    3. Transfusion Medicine staff will accept signed specimens without requisition.
      1. The specimen bar code will provide the two unique identifiers for patient identification.
        1. We will accept even if name is truncated on the B*-generated label, relying on the full name and HC number visible on the screen
      2. Internal processes and algorithms in Medinfo are to be used for selection and reservation of components, component modification, and all testing.
    4. Documentation of work:
      1. Routine specimens (type and screen, ABO/D typings, DAT, negative cord bloods) will be paperless.
      2. Non-routine specimens require paper documentation.  These include:
        1. Abnormal Results that needs supervisor /TRM physician review
        2. If the analyzer is not interfaced to Medinfo
        3. If a manual tube technique is performed
        4. Requests received from any site not ordering through the Medinfo-B* interface
    5. Massive transfusion protocols:
      1. The ordering physician will decide whether to order in B*:  if he decides that ordering in B* will adversely affect the patient outcome, he may revert to the old system (e.g. call the blood bank hotline and request blood and then send paper requisitions and samples to blood bank as conditions permit)
      2. Physicians who use the B* interface must order each wave of the MTP separately (e.g. MTP1, MTP2, MTP3) and adjust the quantities accordingly.
        1. The B*-Medinfo interface does not include ordering for non-blood-bank items (e.g. medications) in the massive transfusion protocol.
  8. B* Results and Statuses:
    1. All results and statuses of tests and components will be available in B* for those sites using the Medinfo-B* interface.
      1. This includes non-B* orderables for components and tests.
    2. Formatting of tests and other requests are limited to the B* build’s capabilities:
      1. NTMP may see test results in the Medinfo Viewer if they prefer.
    3. During B* downtime, TM will revert to Medinfo-only processes including ordering, test-requesting, resulting, and release of components.
      1. There will be NO recovery post-down-time in B*:   test results will be viewable in the Medinfo Viewer only.  There will be no component information in the Medinfo Viewer.
  9. Downtimes and recovery:
    1. B* Downtimes:
      1. Revert to 100% Medinfo processes.
      2. Manual requisitions and specimens will be sent:  complete concordance between specimen tube and requisition is required for the specimen to be used for the purpose of selecting components.
      3. Medinfo accession numbers will be used.
      4. There will be no B* ordering recovery.
      5. Test results will be viewable in Medinfo Viewer only.
      6. No statuses will be available.
    2. Medinfo Downtimes (B* available):
      1. Paper downtime procedures will be in effect.
      2. After restoration:
        1. Retrieve orders from B* interface and proceed OR:
        2. Others use paper requisitions and order/process in Medinfo only.
  10. Training of Clinical Staff:
    1. Training of physicians and nurses to use the B* interface is the responsibility of the Hospital Information System HIS staff, NOT TRANSFUSION MEDICINE!!
    2. All questions for clinical usage should be referred to the hospital’s HIS Help Desk.
    3. Transfusion Medicine will NOT provide B* support!!!

References:

  1. Medinfo interface documentation for B* Integration, January, 2019
  2. Standards for Blood Banks and Transfusion Services, Current Edition, AABB, Bethesda, MD, USA

Opinion: Software for Massive Transfusion Protocols–Pools

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Massive transfusion protocols may contain large numbers of different blood components all to be released simultaneously as quickly as possible:

  • Packed RBCs
  • Low-titer group O whole blood
  • Platelets
  • Plasma
  • Cryoprecipitate

For an adult, it might include 6 RBCs, 1 adult platelet dose, 6 plasma, and 10 cryoprecipitate—23 components at one time.

For liver transplant, I had a protocol with 20 RBCs, 3 adult platelet doses, and 20 plasma units—43 components in all.

Even if the blood bank software prints all of these release forms, it requires considerable time to check the identity and serial number of each unit.  This is the rate-limiting step for their release to the critically ill patient.

Our clinicians wanted release within 5 minutes of ordering;  however, it was physically impossible to sign out so many components within this time limit.

Medinfo has facilitated the release by offering pools of one component type (platelets, cryoprecipitate, or plasma).  A pool number is generated to cover the components and this ONE number is used for release.

I would like to see the pooling concept expanded to allow multiple component types to be included in the pool.  Then, at release from the blood bank, only ONE number can be used to sign out the components.

Additionally, the individual units in this mixed pool should be treated the same way as if the units had been released individually including:

  • Apply all protocols for the components.
  • Return individual units back into stock or discard.
  • Use the mixed pool number to view the contents of the pool.
  • Query using the mixed-pool number for its contents.
  • Query the individual unit(s) (e.g. for look-back).
  • Quarantine the unit(s) as needed.

29/11/20

Processes and Software Building 56: Multi-Site Patient and Donor Considerations

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As our hospital network expanded, there were many patients who moved between locations.  They might first start in an emergency room and then be transferred to a specialty hospital.  These locations might be served from different hospital blood banks/transfusion services.  What happens if work is progress from one site when the new site receives the patient.  Must the previous workup be repeated or could it be used for transfusion at the next site?

For example, the ABO typing could be performed at one site and the antibody screen at a second site, and the antibody identification at still another site.  Could the results be used across the entire system?

I had multiple hospital blood banks and blood donor centers.  The general and specialty laboratories had multiple sites.  The hospital information system was set up so that the various tests could only be performed at specific designated sites.  This posed problems as patients were moved around or if some site(s) became inoperative since the specimens then had to transported at great distances for testing.  Only a few basic STAT tests were available at all sites.

It was my decision to allow all test categories at all sites, e.g. a DAT request from any site, any methodology, could be used to satisfy the order.  Similarly, all donor processes were available at all donor centers (the processes could be completed at one or more sites).  Different hospital blood banks had different equipment but all the test categories were the same across site—the methodologies might differ.  We had at least four different DATs across our system.

The interface between the blood bank and hospital system worked as follows:  In the hospital information system HIS, test orders pointed to a category of testing and any methodology for that category at any site could be used in the blood bank system for testing and reporting back to the HIS.  Any test in a category from any site could be used to satisfy the test request.  Blood bank staff would choose the particular test methodology to use.  It was NOT specified by the HIS!

In summary, for blood banks and donor centers within our system, the work could be flexibly moved between sites.  There was no need to repeat testing when a patient transferred to a new site.  The only type the work was repeated if testing was done at an institution outside our system.

Sample Validation Change Protocol: Donor Hgb Levels

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Changes to donor criteria can occur at any time.  This example is the change in donor criteria for males to 13.0 g/dl based on AABB Bulletin #16-05.

I made a validation protocol, which was subsequently performed by a Donor Center Medinfo Super-User.   The data was then sent to me for review and then accepted.

Note that females were included in the testing for regression purposes.  Females were only permitted to donate RBCs—all other components were discarded in production. Contraindication information appears in RED.

Physician Review and Data Entry of Transfusion Reactions

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Physicians must enter their interpretations and recommendations for each transfusion reaction review.  In addition, they may enter comments against any of the data.  This post shows the process used in Medinfo Hematos IIG.

By highlighting Interpretation (left side), they then click on the Result Field (right side) and select their interpretation from the drop-down menu.  They can also select other and then enter a comment.

References:

  1. Standards for Blood Banks and Transfusion Services, Current Edition, AABB, Bethesda, MD, USA
  2. Guidelines to the Preparation, Use, and Quality Assurance of Blood Components, European Committee (Partial Agreement) on Blood Transfusion (CD-P-TS), Current Edition

External Disaster Plan, Simplified

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Principle:

Maintaining an adequate blood supply and expedited compatibility testing are critical in disaster planning.  Medinfo Hematos IIG allows us to get dynamic updates of our blood supply and dynamically reallocate blood components as needed.

Policy:

  1. Determinate total available blood supply across all locations by using the Cumulative Stock Display program in Medinfo Hematos IIG.
    1. Recheck stock at least every hour during the disaster.
  2. At each transfusion service site, in conjunction with a Transfusion Medicine Consultant:
    1. Cancel reservations for elective surgical and non-emergency medical cases of affected ABO/D types.
    2. Retain reservations for antigen-matched, oncology, NICU, and high-risk obstetrical cases.
  3. Inform Donor Recruitment/Logistics to send SMS, radio, and television messages for blood donors—all types.
  4. Contact ALL staff and have them report to duty.
    1. At the Blood Donor Center, the Head Nurse, Recruitment, Supervisor, Component Processing, and Supervisor, Marker Testing will contact staff.
    2. At hospital transfusion services, the site supervisor will contact all staff.
  5. Process blood components using automated component technology (Reveos).
  6. Perform all donor marker testing including single-well NAT.
    1. Abbreviation of donor marker testing is only at the discretion of the Division Head, Transfusion Medicine.
  7. Transfusion Services:
    1. Release blood component according to the various protocols as needed:
      1. Massive Transfusion Protocols
      2. Emergency release
      3. STAT
      4. Priority
      5. Routine
  8. Compatibility testing will be electronic, immediate-spin, or full AHG as per our protocols.

References:

  1. Standards for Blood Banks and Transfusion Services, Current Edition, AABB, Bethesda, MD, USA
  2. Guidelines to the Preparation, Use, and Quality Assurance of Blood Components, European Committee (Partial Agreement) on Blood Transfusion (CD-P-TS), Current Edition