Category: Blood Bank IT

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

COVID-19 Convalescent Plasma CCP Donor Registration

drzeyd

I designed a completely quarantined process for collection, processing, and release of CCP at HMC Doha.  This document shows the Medinfo process for donor registration as a separate donor center code.

Check donor history and donor deferral database.  If there is no previous encounter, generate a new donor file:

At the completion of this action, the Blood Donation Record with the donor unit number (in this example 2200000099) and consent form in English and Arabic is generated.

CCP could only be collected at this special site and only the apheresis bag could be used for collection.  Regular donation options were not available at this CCP site nor was CCP collection an option at the regular donation sites.

8/1/21

Further Thoughts on Inter-Depot Transfer, Blood Delivery, Type and Antigen Matching

drzeyd

In my recent post, I provided sample flows and parameter mapping for delivery of blood components.  The final components from the component preparation center may be sent to various depots (freestanding location and/or hospital blood banks.  There should be complete traceability for every step (from donor reception, collection, testing, and processing) transport between locations, and finally the exact storage site, which might include which refrigerator/freezer/incubator and even shelf/position number for each component is stored.  The end of that document showed rules for type/antigen matching.

For disaster planning, rapid inventory enumeration by type is very important.  This can be very time-consuming manually.  With our Medinfo Hematos blood bank system, we could quickly get total inventory across the Qatar or by hospital in less than one minute.  We could also quickly find antigen-matched units across the system and reserve it at any one site for another if necessary.

Smart blood bank dispensing refrigerators, as offered by Haemonetics and Angelatoni, may also serve as depots and take the place of a hospital blood bank for some dispensing.  These solutions can also capture vital information about the storage conditions of the components and prevent release if the storage criteria are not met.  They can also interface with blood bank computer systems and use the main system’s logic for the dispensation rules.  In Medinfo, they can be added as a hospital blood bank site.

Upon receipt at the hospitals from the blood processing center, the forward ABO and D typing must be confirmed.  We used D reagents which detected partial D so we would call such donor units as D-positive.  However, if a patient type reagent insensitive to partial D types is used, it is possible for a unit to be typed as D-negative whereas in the donor center it might be D-positive.  Sometimes, nothing types consistently as D-positive:  all you can say is that with a particular reagent and lot number, there is or isn’t reactivity.

The greatest complexity is for RBCs since potentially so many antigens exist.  Criteria for matching/ignoring certain antigens must be made.  Critically significant antibodies such as the Kell, Duffy, Kidd, and certain Rh (D and c) must be antigen matched.  A robust blood bank computer system can enforce these rules.

For other components, antigen/typing may be less important.  In fact, in most situations, any type of platelets can be given to anyone (except neonates).  Despite the potentially incompatible plasma, there is rarely significant hemolysis.  In fact, if pooling platelets without regard to blood types is done, a platelet transfusion is a common cause of a positive direct antiglobulin test DAT—something that is not clinically significant.  No one died of a positive DAT by itself for this reason.

Specific rules for compatible plasma types are important, but nowadays, low-titer group A plasma may be used like universal AB plasma.  The challenge is to be able to perform the ABO titration (specifically anti-B) quickly—titration can be a slow process, even with automated equipment.  A similar situation for low-titer, universal group O whole blood requires both anti-A and anti-B titration (I will return to this topic in a future post).  With Medinfo, I can define rules (e.g. IgM titer < 1:64) to accept these units as a universal type for all ABO groups.

Special rules can be built into the software so that production, transfer, storage, and release of COVID convalescent plasma CCP are only performed at special quarantine sites by designated personnel.  This means there can be dedicated transport pathways built into the inter-depot transfer process to keep this inventory separate at all times.

Logistics and Processes for a COVID-19 Convalescent Plasma Program

drzeyd

I prepared the following plan for a CCP program for HMC Qatar in March, 2020.  The workflow is divided into four (4) modules:

  1. Registration/Interview/Physical Examination/Apheresis Collection
  2. Donor Marker Testing and Immunohematology Testing
  3. Production/Aliquoting/Pathogen-Inactivation/Storage
  4. Product Thawing/Product Release

Module 1:

  1. Collection/registration/screening must be in a separate area from regular blood and apheresis donations.
  2. Donors must provide consent.
  3. ISBT specimen labels must be used on each tube collected.
  4. We need a minimum of two apheresis nurses, one for the registration/screening/post-donation observation and one for the actual apheresis procedure.
  5. If there will be multiple serial donors, then we need a waiting area (each donor at least 2 meters apart).
  6. Donor screening must be in sound-proof area so that other waiting donors cannot hear the interview/questionnaire process.
  7. Amount that can be collected depends on body weight:  500 ml for <80 kg and 600 ml for >= 80 kg, collection may occur twice per week
  8. Collection time includes 15 minutes for registration/interview/physical examination, 60-75 minutes and 15 minutes for cleanup/disinfection before the next case, approximately 2 hours per donation.
  9. A post-donation observation area (minimum 15 minutes after collection) with apheresis nurse nearby in case of reactions is needed if there will be multiple donors.
  10. Specimens will

Module 2:

  1. Donor testing and donor immunohematology will be done with other donor specimens in our regular location

Module 3:

  1. Apheresis collection must be processed and stored separately from regular blood/apheresis donations.
  2. Processing will occur only after the results are shown to meet all criteria.
  3. Pre-collection testing (test-only donation) would permit processing without waiting for results.
  4. Storage at minus 80C may be for a minimum of six (6) years but this may be extended if needed.
  5. All acceptable components will have a final ISBT label—no products without the ISBT label will be transfused.  The ISBT label indicates that the unit meets all donor criteria for convalescent plasma.

Module 4:

  1. Product modification (thawing) and release (sign out from blood bank) must be in a separate area(s) from the regular hospital blood bank.
  2. Release of convalescent plasma follows the same process as regular component release
  3. Transfusion of convalescent plasma at the patient’s bedside follows same process as regular component transfusion
  4. Nursing and other staff performing the transfusion must pass competency assessment.
  5. Plasma will be transfused as ABO-identical or compatible unless low ABO-titer group A is used.
  6. Plasma must be free of clinically significant antibodies

Workflow Considerations:

  1. Donors must be restricted to the waiting, collection, or post-donation observation areas.
  2. Donors must NOT pass through production, testing, or component release areas (just as they are currently restricted in the Blood Donor Center and HMC hospital blood banks/transfusion services).

Logistics:

  1. Throughput is a maximum of 4 donors (2000 to 2400 ml plasma) per eight-hour shift with one apheresis nurse and one donor apheresis (Trima) machine.
  2. The processes are scalable with additional staff and machines (e.g. with 3 machines and nurses, then 12 donors and 6000 to 7200 ml of plasma collected).
  3. Thawing of 1-2 units of plasma takes up to one hour.  Contact the quarantine blood bank at least one hour before the desired pick-up time.
  4. The four modules above can be in separate areas not adjacent to one another.  Modules 1, 3, and 4 must be quarantine areas where access is limited.  Module 2 can be performed with regular donor specimens using standard precautions.
  5. We can provide training for transfusion of blood components and competency assessment to any location transfusing this product.

Information Technology:

  1. All modules will be connected to the Medinfo Hematos IIG dedicated blood bank computer system.
  2. All records of collection/production/testing/storage/modification/release will be stored therein.
  3. All ordering of convalescent plasma components will be through Medinfo.
  4. External test results (e.g. future antibody titering) can be added to the component information.
  5. Links to the Hospital Information System (Cerner) may be considered after the Medinfo processes are fully functional.

COVID-19 Convalescent Plasma CCP Site Registration

drzeyd

I designed a completely quarantined process for collection, processing, and release of CCP at HMC Doha.  This document shows the Medinfo process for site registration as a separate donor center code.

CCP could only be collected at this special site and only the apheresis bag could be used for collection.  Regular donation options were not available at this CCP site nor was CCP collection an option at the regular donation sites.

4/1/21

Therapeutic Apheresis Policy

drzeyd

This has been revised to recommend the use of a continuously recording portable vital signs device such as Umana’s UT1M (GPI, Italia) which includes PAO2 and heart rhythm measurements.

Principle:

All therapeutic apheresis procedures are potentially life-threatening and must only occur by an order from a transfusion medicine physician with experience/competence in such procedures.

Definitions:

  • Referring Physician is the clinical physician requesting a therapeutic apheresis procedure.
  • Transfusion Medicine Physician is a physician in the Transfusion Medicine Section with medical privileges for therapeutic apheresis procedures.  This includes the Head, Transfusion Medicine, consultants in Transfusion Medicine, and designated specialist physicians in Transfusion Medicine.  The final decision to accept/reject the patient is made by the transfusion medicine physician.
  • Covering Physician is the clinical physician designated by the referring physician to be physically present and covering the patient in case of any adverse reactions during a therapeutic apheresis procedure.
  • Apheresis Nurses are nurses in Transfusion Medicine who are designated by this section for performing therapeutic apheresis procedures.
  • Medical Privileges are determined by Transfusion Medicine in conjunction with the medical privileging by the Medical Director.

Policy:

  1. The referral physician will discuss the request for a therapeutic apheresis with the designated transfusion medicine physician.  The referral physician must certify that the patient can tolerate the procedure based on his medical condition.
  2. The transfusion medicine physician will review the patient’s clinical and laboratory data, with special note of the history of allergies, medications, previous transfusion reactions, and current vital signs.
  3. Vascular access will be initially assessed by the apheresis nurse.  Any questionable situations will be reviewed by the transfusion medicine physician.
  4. The following laboratory values (less than 24 hours old) must be available before the procedure may begin:
    1. CBC including platelet count
    2. PT and APTT
    3. Fibrinogen
    4. Serum calcium
    5. Serum protein and albumin
    6. LDH for TTP cases
  5. A valid type and screen must have been done within the previous three days of the procedure.
  6. Upon review of # 2 through 5, the transfusion medicine physician will determine if the procedure is indicated and will communicate this to the referral physician, who will sign written order in the patient chart.  Appropriate replacement fluids will also be mutually agreed upon in advance of the procedure and ordered by the transfusion medicine physician.  The order specification must include:
    1. Name of procedure and specification (e.g. therapeutic plasma exchange, isovolemic)
    2. Replacement fluid type and volume (e.g. 3 liters 5% albumin, 2 liters, FFP, cryoprecipitate, normal saline)
    3. Blood component orders if indicated (e.g. RBC exchange) and timing (before, during, and/or after the procedure)
    4. Calcium replacement (e.g. 2 grams calcium gluconate IV in 100 ml normal saline to run during the procedure)
    5. Any special laboratory testing post-procedure
  7. The apheresis nurse will follow the orders of the necessary prescribed replacement fluids (FFP, albumin, PPF) in the quantities necessary for the exchange.
  8. The referring physician will obtain the signed, informed consent from the patient.
  9. If vascular access is unsatisfactory, the referring physician will obtain the proper access (central line, AV shunt, etc.).
  10. The referring physician will arrange for a physician member of his team to be present at the actual therapeutic procedure.  This physician designate will be responsible to treat any complications arising from the procedure.
  11. Vital signs and weight will be obtained before starting the procedure.
  12. If the procedure is outside an intensive care unit and the patient is critically ill, consider the use of a portable attached monitoring patch (such as the Umana UT1M device).  The device will give alarm if any measurement is outside the defined ranges.
    1. If any blood components are administered, keep the patch attached to detect TRALI/TACO and other adverse transfusion reactions.
  13. When approved by the Blood Bank Director or designate with proper venous access and informed consent, the apheresis may start the procedure in the presence of the patient’s covering physician.  The procedure will be performed in a designated hospital area.
  14. The procedure must be documented on the appropriate therapeutic apheresis order and procedure worksheets.

References:

  1. Standards for Blood Banks and Transfusion Services Current Edition, AABB, Bethesda, MD, USA
  2. CAP Standard TRM.42245 regarding therapeutic apheresis procedures

Revised 3/1/21

Medinfo COVID Convalescent Plasma Workflow Revisited

drzeyd

It now has been over eight 8 months since I prepared the CCP workflow in Medinfo.  It was built on the framework of the manual CCP process including donor prescreening with an abbreviated donor questionnaire.  It was really quite simple and used the donor and patient modules to create quarantine areas for donor screening, collection, processing, and hospital patient blood bank release.

Here are my current comments on the process:

Donor Qualification:

I would still exclude malaria and HTLV from the donor questionnaire and would update to UDQ 2.1.  Since these donors have recovered from a potentially life-threatening illness, I would keep the Hgb threshold at 11 g/dl.

Donor Collection:

In the future, I would consider using one of the soon-to-be-released portable devices that continuously monitor vital signs with pO2 and EKG lead to rule out asymptomatic pulmonary or cardiac problems.

I would also consider using low-ABO-titer, group A, universally to meet the demand for group B and AB patients.

Donor Testing:

There is still no need to segregate and separately test CCP donor specimens from regular blood donor specimens.  I would perform SARS-CoV-2 antibody testing and set a threshold for qualifying donors—that threshold will be based on the manufacturer’s recommendations.  However, if the treating physician wanted to use a low-titer unit, I would permit this.

Donor Processing:

There is no need to change this from the current processes.  Keep the CCP processing separate from the regular operations.

CCP Plasma Release:

I would keep the quarantine release and restrict it to the locations used for treating COVID-19 patients

Medinfo Software Modifications:

I would record the IgG and IgM titers for SARS-CoV-2 antibodies in each donation record.  This would include testing and entering the results on donations prior to this testing.  ISBT labels should include this antibody titer.

Hospital Information Software Modifications:

Set up restricted CCP ordering for the actual treating physicians only.  Also provide the ISBT code and shortened descriptors to it if necessary (certain HIS vendors still cannot read ISBT codes natively).

The original CCP workflow is attached for reference.

Manual Collection of COVID-19 Convalescent Plasma

drzeyd

This process was originally done in the first phase of CCP collection.  I have updated it to include SARS-CoV-2 antibody testing.

Principle:

Due to the pandemic, we will initially MANUALLY collect an experimental, investigational-use-only plasma product from apheresis donors and treat it with Mirasol.  THIS IS A EMERGENCY INTERIM PROCESS UNTIL THE MEDINFO HEMATOS IIG PROCESSES ARE PREPARED AND VALIDATED.

Policy:

  1. Good Manufacturing Practice applies:
    1. Manufacturers’ recommended processes for equipment and materials usage applies.
    1. All staff engaged in these processes must be competency assessed successfully.
  2. Pre-Screening:
    1. Clinical staff will use the prescreening document to select donors for pre-donation screening.
  3. Quarantine:
    1. All processes (day 0, day 1, day 2, and product modification and release) will be done in quarantine areas SEPARATE and DISTINCT from regular Transfusion Medicine activities.  This includes:
      1. Separate space and equipment must be provided.
        1. Equipment for this project may NOT be used for regular, non-quarantine processes
    2. Non-Transfusion Medicine staff will not be permitted in operational areas.
    3. Prospective donors will not be permitted in the processing, testing, storage, or blood bank work areas.
  4. Donation Process:
    1. Day 0:  Registration, check donor deferral database, questionnaire, physical exam including arm check, and specimen collection using ISBT specimen labels
    2. Use latest manual donor questionnaire.
    3. Day 1:  Donor marker and immunohematology testing, review of results, accept or reject donor for actual plasmapheresis
    4. Day 2:  Collect manufacturer’s recommended volume of plasma (500 ml if < 80 kg, 600 ml if >= 80 kg), aliquot, pathogen-inactivate (Mirasol), freeze at minus 80C
  5. Testing:
    1. Testing will be performed with regular blood donor specimens using ISBT specimen labels
    2. Testing must be done by donor-specific processes (not those for clinical patients)
      1. Exclude malaria and HTLV testing.
    3. Testing must be directly interfaced to Medinfo Hematos IIG donor module
    4. CCP COVID antibody testing:
      1. SARS-CoV-2 antibody testing to be performed to determine cut-off for donor eligibility for CCP collection.
      2. Use of donors with antibody levels below threshold is at the discretion of the treating clinician.
  6. Processing:
    1. Aliquoting, pathogen-inactivation, and labelling may proceed if the pre-donation screening results are acceptable.
  7. Storage:
    1. Long-term in minus 80C quarantine freezer
    2. Short-term at 1-6 C just after thawing in quarantine refrigerator
    3. Standard temperature monitoring and alarms apply
  8. Labelling:
    1. The backup manual labelling process applies
    2. The ISBT specimen label will the donor unit number
      1. Outdate will be 6 years if the product is stored at -65C, 1 year if stored at -18C
  9. Product Release:
    1. Orders must be on the PAPER requisition (old Blood Bank Order Form) with a patient prescription and signed by a physician designated to treat COVID patients.
      1. No orders in Cerner
    2. Thawing plasma at 37C upon receipt of order by Transfusion Medicine staff
    3. Signing out component to clinical unit by Transfusion Medicine Staff to locations treating COVID-19 patients.
  10. Information Technology:  Medinfo Hematos IIG customized software to be implemented as soon as possible for all processes
  11. Not covered:  Transfusion Medicine is NOT responsible for:
    1. Triage of request for convalescent plasma
    2. Pickup and transport of components

References:

  1. Level 1-4 documents for donation, testing, processing, and release of blood components
  2. COVID-19 Plasma Donor Prescreening Document, 8/4/20

Policy: Selection of Components for ABO-Incompatible Renal Transplants

drzeyd

Principle:

Kidneys have strong expression of ABO type and must be matched the same way as RBC components.  In the case of ABO-incompatible renal transplants, we must not give significant amounts of plasma incompatible to the ABO type of the donor kidney.  Plasma must also be compatible with the patient’s ABO type for RBC transfusions.  The amount of residual plasma in PRBCs is limited since we use an additive solution SAGM.  Likewise, platelet components are suspended in platelet additive solution with only minimal residual plasma.  Cryoprecipitate has only minimal plasma and is given without regard to the patient’s ABO type.

All of the following rules can be built into the blood bank computer system Medinfo without hard coding.

Policy:

  1. RBC components:  Use ABO-compatible RBCs in SAGM.  DO NOT USE WHOLE BLOOD!!
  2. Platelet components in platelet additive solution PAS (normally available component):  Any ABO type may be given
  3. Platelet components in plasma:  Only group AB platelets may be used.
  4. Plasma (any type FFP, FP24, solvent-detergent treated, or thawed):  Only group AB plasma may be used
  5. Cryoprecipitate:  Any ABO type including mixed types may be used, mixed types are preferable to neutralize the minimal ABO-incompatible plasma.

References:

  1. Standards for Blood Banks and Transfusion Services, AABB, Current Edition, Bethesda, MD USA
  2. Technical Manual, AABB, Current Edition, Bethesda, MD, USA

My Experience: Blood Bank Considerations for Setting Up ABO-Incompatible Renal Transplantation

drzeyd

Setting up ABO-incompatible renal transplants is a major undertaking and requires close coordination between Transfusion Medicine and the clinical team.  This post addresses my experience in setting up this program in 2019 at HMC in Qatar.

Like any process involving titration, it is best to automate it to minimize inter-technologist variability.  Unfortunately, doing both IgG and IgM titers takes up to 1 hour per machine and totally monopolizes the machine during that interval.  I did not have sufficient staff to even consider doing the titrations manually.  Performing automated titers disrupted my workflow so I encouraged the clinicians to send the specimens for off-peak processing.

Titration:

  1. Obtain the full clinical protocol and especially note the thresholds for transplantation.
  2. Determine the methodologies used at the reference site.  Can you do this at your local site or do you have to use an alternative method?
  3. Do you have equipment to automatically titer?  Doing both IgG and IgM may monopolize an immunohematology analyzer for one hour?  How will this affect your other testing?
  4. Regardless if it is the same method, you must still correlate your titers with the protocol site, both IgG and IgM.
  5. If you are using multiple analyzers for titration, you must do a comparison study between them.  How much does the titer vary?

Columns:

  1. Determine column inventory and order the A, B, and AB columns.  You must order enough to finish the course of treatment.  It may take weeks to get additional columns, depending on your supply chain.  Each column costs thousands of euros.
  2. Where are you going to store the columns?  Ours needed 2-8C storage.  Can you keep them away from quarantined products and patient specimens?
  3. Are your columns single-use? 
  4. If multi-use, who is going to restore them after use?  How do you ensure that it is dedicated for the right patient?

Apheresis Equipment:

  1. How are you going to attach the column to the apheresis equipment?
  2. Will you use your therapeutic apheresis equipment like Terumo Optia directly or will you use a second machine (e.g. Medicap)?
  3. Do you have all the clamps, tubing, and holder for the column?

Staffing:

  1. Do you have sufficient apheresis nurses to perform the procedures?  You may be running the apheresis for up to 8 hours.  How does this impact your other procedures or donor center operations?  Our pool of apheresis nurses was very limited.  They also covered routine blood donation.  How will doing this process impact your regular donation and other apheresis operations—donor and therapeutic?
  2. Do you have sufficient supplies of ACD-A anticoagulant and calcium gluconate?

Specimen Collection:

  1. Perform titrations expeditiously:  Can you finish titration testing before the next scheduled procedure?  In our institution, we collected specimens at 0400 and had them directly brought to the blood bank for testing.  Results were ready at 0600 so the clinicians could decide early if another procedure was needed.

Table of Permissible ABO Types:

  1. Define acceptable blood products by blood type—take into consideration pathogen inactivation and platelet additive solution if used.  At our institution, all RBCs were in additive solution and all platelets were pathogen-inactivated in platelet additive solution PAS so residual ABO antibodies were minimal in the final components.  Since the platelets contain only minimal plasma, we did not concern ourselves with matching their ABO type with the donor kidney.  Otherwise, platelet types with plasma compatible to the donor kidney must be selected.

Software:

  1. Prepare a truth table for acceptable ABO component types based on #16 above.
  2. Include the titer cutoff for IgG and IgM antibodies in the organ transplant module.

Selection of blood component for ABO-incompatible renal transplantation is discussed in a separate post that will follow.

25/12/20