Category: Transfusion Medicine

Includes patient, donor, apheresis and related IT topics

Opinion: Outside Accreditation and Quality Consultants

drzeyd

Sometimes, you may not have adequate resources for a project so you will consider hiring an outside consultant.  During my career, I have used several outside consultants for projects ranging from installing a new general laboratory computer system to assisting in getting international accreditations.

For a complex accreditation process such as AABB, I have used such consultants to audit operations in the donor center including processing and testing, hospital blood banks, and stem cell laboratory.  They are high-level technical specialists with highest blood bank qualifications (e.g. SBB(ASCP) or equivalent) and have considerable experience in practice of blood banking and quality systems.  They have been AABB Assessors so they can give you a dry-run accreditation assessment.

Depending on the project, you may need one or a group of consultants.  I have worked with both individual consultants and groups.  A group can complete the tasks quicker but this is not always necessary.  Organizations such as AABB have many different consultants with different types of expertise so you can select the most appropriate individuals to form a team for your needs.

These specialists can audit your operations and propose a model and if you want, actually help you to implement the processes.  They can help you with the accreditation formalities, especially if you do not have any staff with experience in the process.  It all depends how much you can spend.

In the Middle East, to bring in such consultants may mean expensive air fares, hotels, meals, plus the actual costs of doing the consulting.  This is a major investment for your organization but it is well worth it to expedite the process.  There are local consultants available as well and using them may greatly help with the expenses.

Although it is expensive upfront, it can be cheaper in the long run by establishing the appropriate framework in the first place.  You can engage the consultants to actually do much of the work themselves, but it is better for them to offer a train the trainer experience, i.e. engage your own technical staff to learn new skills and then have them cross-train the rest of the staff. 

Based on the findings, your local staff can implement the changes.  You can then consider rehiring the consultants to verify that the work has been done properly.

I have used both individual consultants and groups through AABB Consulting.  My staff and I have learned much from such interactions, and I highly recommend their use when local expertise is not available.

Process: Donor Medical Questionnaire

drzeyd

This is one of a series of posts comparing policies and processes in the blood bank.

PROCESS:  5.2.1 DONOR QUESTIONNAIRE

Process:

  1. The donor is positively identified by a designated picture ID and Medinfo Hematos donor consent form with specimen/encounter number and barcode.
  2. Donor is taken to a private area for the interview.
  3. Donor is asked ALL questions by Donor Center staff using the Hematos IIG questionnaire.
  4. Hematos IIG determines if any contraindications apply.
  5. Questionnaire will be referred to transfusion medicine physician for any questions requiring physician review.
  6. Donors without contraindication are sent for donor physical examination.

References:

  1. HMC 1001 Setting Specification, Version 1.5, Hematos IIG, Medinfo
  2. Standards for Blood Banks and Transfusion Services, Current Edition, AABB, Bethesda, Maryland, USA

Policy: Donor Medical Questionnaire

drzeyd

This is one of a series of posts on blood bank operations, comparing the process and policy documents.

5.2 POLICY:  DONOR MEDICAL QUESTIONNAIRE

Policy:

  1. All policies, processes, and procedures must comply with Qatari, HMC, and applicable accreditation standards (i.e. AABB, CAP, and JCI).
  2. All donors will be positively identified with a picture ID and by their Medinfo Hematos identifiers (donor ID and session registration/specimen number).
  3. Donors will be assessed confidentially in a private area.
  4. Donors will be asked questions based on the latest Uniform Donor Questionnaire with additional localization questions for Qatar using Medinfo Hematos IIG software.
  5. Donor must understand either English or Arabic.
    1. Otherwise, they cannot be accepted for donation.
  6. Donors passing the donor questionnaire will be processed for the donor physical examination.

References:

  1. HMC 1001 Setting Specification, Version 1.5, Hematos IIG, Medinfo
  2. Standards for Blood Banks and Transfusion Services, Latest Edition, AABB, Bethesda, Maryland, USA

Case Study: Importance of Enzyme Panels in RBC Antibody Workups

drzeyd

I am a strong believer in performing both AHG and enzyme panels together in routine antibody workups.  I especially feel this is important when the patient is R1R1 since I always want to rule out anti-c.  Sometimes, anti-c is only identified in the enzyme phase.

This is a case from my files of an R1R1 patient with the following results:

Antibody Screen:

AHG Panel:

Enzyme Panel (Ficin):

This anti-S is enzyme-labile but anti-c is revealed, only reacting at enzyme phase.  The patient was Kell-negative so I selected S-negative, R1R1 K-negative RBCs for transfusion.  Anti-c can be a dangerous antibody causing severe hemolytic disease of the fetus/newborn and sever hemolytic transfusion reaction.  If only the AHG panel had been performed, the anti-c would have been missed.

Hypotonic Saline to Phenotype Multiply Transfused Sickle Cell Patient

drzeyd

Nowadays, if we have a multiply transfused patient with a complex antibody pattern, we might resort to RBC genotyping to help us resolve the antibody issues.  Fortunately, there is one situation where we can quickly phenotype the patient by using hypotonic saline to lyse the transfused RBCs since the sickle cells are resistant.

The results can be quite clean and easy to interpret as in the following example using 0.4% saline:

It is a lot cheaper to make dilute saline than an RBC genotype—and much quicker!

Management of Acute Transfusion Reactions

drzeyd

This was a teaching document for medical students and residents I made for NGHA Riyadh. I have updated it for leukodepleted components and platelet additive solution.

Immediate Steps for All Reactions:

  1. Stop Transfusion.
  2. Keep IV Open with 0.9% NaCl.
  3. Verify correct unit was given to correct patient.
  4. Notify attending physician and blood bank

After Transfusion is Terminated (except mild allergic, see below):

  1. Send report of reaction, freshly collected blood, and urine samples with blood unit and administration set to blood bank.
Reaction TypeSigns and SymptomsEtiologyClinical Action
Allergic (mild)Pruritus, urticaria (hives)Antibodies to plasma proteinsSteps 1-3 above; administer antihistamines (PO, IM, or IV); resume transfusion if improved; if no improvement in 30 minutes treat as below.
Allergic (moderate to severe)Hives, dyspnea, abdominal pain, hypotension, nausea, anaphylaxisAntibodies to plasma proteins, including IgA (patient has anti-IgA antibodies)Steps 1-5 above; administer antihistamines, epinephrine, vasopressors, and corticosteroids as needed; avoid future reactions by premedication and consider use of washed red cells if refractory.
Febrile (mild to moderate)Fever, chills, rigors, anxiety, mild dyspneaAntibodies to leukocyte antigens, (mostly HLA): cytokinesSteps 1-5 above; mild—administer antipyretics as needed; avoid future reactions by premedication and use of leukodepleted red cells and platelets
Acute lung injuryFever, chills, dyspnea, respiratory failureAntibodies form donor plasma to recipient WBCs; less commonly recipient antibodies to donor WBCsSupportive therapy for respiratory failure, oxygen, mechanical ventilation, leukodepleted blood components, consider use of solvent detergent plasma, minimize plasma transfusions (use platelets in additive solution and leukodepleted RBCs in additive solution).
Acute hemolyticAnxiety, chest pain, flank pain, dyspnea, chills, fever, shock, unexplained bleeding, hemoglobinemia/ hemoglobinuria, cardiac arrestHemolytic transfusion reaction; usually due to ABO incompatibilitySteps 1-5 above; treat shock with vasopressors, IV fluids, corticosteroids as needed; maintain airway; increase renal blood flow (IV fluids; furosemide); maintain a brisk diuresis; monitor renal status for acute renal failure. Monitor coagulation status for DIC; administer blood components as needed after etiology is clear.
Septic / toxicChills, fever, hypotensionBacteria in contaminated bloodSteps 1-5 above; treat shock with vasopressors, IV fluids, culture patient and blood bag,antibiotics.

Process Donor Medical Questionnaire

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5.2.1 PROCESS:  DONOR QUESTIONNAIRE

Process:

  1. Donor passes donor deferral database screening.
  2. Donor is taken to a private area for the interview.
  3. The donor is positively identified by a designated picture ID and Hematos donor consent form with specimen/encounter number and barcode.
  4. Donor is asked ALL questions by trained Donor Center staff using the Medinfo Hematos IIG questionnaire.
  5. Hematos IIG determines if any contraindications apply.
  6. Donor responses are reviewed by the transfusion medicine physician as indicated in the questionnaire.
  7. Donors without contraindication are sent for donor physical examination.
  8. Donors passing transfusion medicine physician review are sent for donor physicial examination.

References:

  1. HMC 1001 Setting Specification, Version 1.5, Hematos IIG, Medinfo, Nice, France
  2. Standards for Blood Banks and Transfusion Services, Current Edition, AABB, Bethesda, Maryland, USA