CONTINUING EDUCATION
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LEARNING OBJECTIVES
Upon completion of this article, the reader will be able to:
- Identify common problems in providing pertinent transfusion medicine information to healthcare workers.
- Understand the impact the lack of information has on transfusion medicine practices.
- Identify signifi cant transfusion information that can be made available using the Quick View electronic page or a similar system.
- Describe the steps involved to develop and implement a similar software system.
- Compare traditional and newer testing methodologies in transfusion medicine in terms of effi ciency and safety.
- Discuss underlying reasons for improving efficiency and safety in transfusion medicine.
A common challenge faced by many healthcare organizations is the lack of access and availability of transfusion medicine information to clinicians. Information on sample availability, antibodies, and transfusion reactions may not be easily accessible. In many hospital information systems current patient information is easy to locate, but finding detailed historical information may require substantial investigation into previous records. The lack of accessibility can cause delays in transfusions, increased patient time in the operating room, increased transfusion service workload, increased patient risk, and poor customer service—all significant negatives for both clinicians and patients.
Patient scenarios
The following scenarios are typical of those seen in our tertiary care medical center:
- A patient with an anti-U identified five years ago, during a previous surgery, was admitted for a liver biopsy. The clinicians were not aware of the patient’s history of atypical antibodies until the morning of surgery, when an order for blood was placed and a sample was sent to the blood bank. A blood bank technologist then called the clinicians to inform them that the blood would not be immediately available for that patient if needed.
- Ten days before surgery, a patient presented to the pre-operative clinic and had an extended life sample drawn (sample drawn before surgical admission that may be held and used for surgery). The day before surgery, the clinician checked the computer but did not find a current sample because the date range of the viewable results in the computer system was set too narrowly. The clinician ordered and drew another sample to send to the blood bank.
- A trauma patient had been an inpatient for 27 days, and his last sample to the blood bank had been drawn 17 days ago. On the 28th day, the patient needed a dose of platelets before a procedure. The nurse received the dose of platelets but had to search back in the results section of the computer to find the last sample results to verify the patient’s blood type against the product she was about to transfuse.
Based on these cases and others like them, we identified a need to implement a solution that would improve our processes and those of the transfusing team by enhancing communication.
The challenges
The Virginia Commonwealth University Medical Center (VCUMC) blood bank typically receives approximately 20 phone calls in a one-hour period during the day shift, 85% of which are questions about whether a patient has a current sample or needs a type confirmation sample. Over the years we implemented several work-arounds in our LIS and HIS, both Cerner Millenium, to help mitigate some of these issues. Every morning, the blood bank received an operating room schedule. The blood bank technologists would take an average of 60 minutes to manually complete the schedule by adding information about sample availability and any antibodies the patient may have had in the past. The operating room staff did not appear to effectively utilize the schedule, so this still resulted in numerous phone calls to the lab. We built a rule on the blood ordering pathway in the hospital information system that would alert the clinician that there was no current sample in the blood bank. The system would “auto order” the blood bank tests, but the message to draw the sample rarely was passed from the clinicians to the nurses who drew the samples. The blood bank technologists added comments to various results upon verification to try and bridge the information gap. In general, these various work-arounds were labor-intensive and mostly ineffective in providing the needed information to the appropriate individuals in a timely enough fashion to enhance patient safety.
Getting started
Multiple inquiries were made to the Transfusion Medicine and Anesthesia departments, surgeons, and other clinical staff with the goal of creating an easily accessible location for blood bank patient information. The result of these inquiries led to a collaboration between the blood bank and Clinical Information Systems (CIS) to build an electronic “page” to quickly display all the required blood bank information. A technologist from the blood bank met with a CIS analyst to discuss how the page could be built, what information could be displayed, and how the information would be extracted from the LIS. VCUMC uses the new QuickView Cerner functionality. QuickView utilizes customizable widgets which can be built to display specific information on a single electronic page.
During the initial meeting between CIS and blood bank, the CIS analyst described the QuickView functionality and asked that the blood bank outline specific widgets to be built and identify where, in the LIS, the information would be pulled from to be used for those widgets. The blood bank structured the initial 10 widgets to be built, and a CIS analyst constructed the logic needed to pull the information from the system and display it in the appropriate widgets. The CIS analyst and blood bank technologist worked closely together to structure the widgets. This close working relationship was crucial to the successful building of the page because of the specific knowledge that both brought to the task. The CIS analyst had no previous knowledge of blood banking or its terminology, while the blood bank technologist did not have the knowledge to write the computer logic necessary to pull the information needed from the hospital information system.
Over the course of two months the two-person team built and tested what became 11 widgets housed on a single electronic page that would soon be accessible to all clinicians in the hospital. During the building process the page was presented to multiple stakeholders, including the hospital Blood Utilization Committee and the Department of Surgery, in order to get feedback on the layout and the content displayed on the page.
The widgets
The Blood Bank QuickView page is composed of eleven widgets and two hyperlinks. The eleven widgets are the following:
- Sample Information: Lists the patient’s sample status and the expiration date; also provides expiration date information regarding neonates and extended life pre-op samples
- Type and Screen: Displays the patient’s type and antibody screen results
- Antibodies: Displays any atypical antibodies the patient may have
- Transfusion Requirements: Lists any special blood attributes required by the patient
- Transfusion Reactions: Lists any historical transfusion reactions by type of reaction, date and product
- Consults: Lists any transfusion medicine consults written for antibodies or transfusion reactions
- Blood Bank Orders: Lists any product orders within the last 24 hours
- Available Products: Lists any products assigned or crossmatched to the patient
- Dispensed Products: Lists any products that have been sent for transfusion to the patient
- Transfused Products: Lists products transfused to the patient within the last 90 days
- Rh Immune Globulin: Notifies clinician that RhIG work-up is required and indicates number of RhIG vials needed.
The page also displays when it was most recently refreshed so the clinician using the page knows the last time it was updated. This enables the clinicians to have real-time patient testing information and product availability. Looking at the widgets in more detail…
Sample Information
The Sample Information widget displays the status of a patient’s sample in the blood bank. If the patient does not have a current sample in the lab, one that is less than three days old, the widget will display that the patient has no current sample available for cross-matching. If the patient is an inpatient and had a sample drawn during this admission, but it is outdated for crossmatching, the widget will not only display that there is no current sample, but will add an extra statement alerting the clinician that plasma products may still be ordered. In our institution we require a type confirmation sample, in addition to the initial sample, be drawn on all first-time patients. If the patient has never been typed at our medical center, then the widget will display that there is no current sample and the patient will need a type confirmation sample.
The widget is designed to recognize different sample types and display the appropriate expiration date of the sample. A current sample in the blood bank is acceptable for crossmatch for three days, and the widget will display the expiration date. Samples drawn on neonates (infants less than four months of age) are acceptable for crossmatching until the infant’s four-month birthday, as long as the sample was drawn on the same admission. The widget will calculate the four-month expiration date based on the infant’s date of birth. If the infant is discharged and then readmitted within four months of birth, the widget resets and displays that the patient has no current sample. On the day the infant turns four months old, the widget automatically displays that the patient has no current sample.
Our blood bank has an extended life sample policy which states that if a patient has no atypical antibodies (current or historical), has not been transfused in the past three months, and has not been pregnant in the last three months, the patient is eligible to have the expiration date of the sample extended from three days to 14 days. When the patient comes in for surgery, the sample will be activated by an order for blood products, and then the expiration will become three days from the activation date. The widget is designed to display the 14-day expiration date until the sample is activated, and then it recalculates the expiration date to three days.
The widget will also display blood bank samples that are not yet completed. If there is a sample in the blood bank but the testing has not been completed, the orderable will display with the words “in-lab” next to it, indicating the sample is still in process. This allows the clinicians a way to check on the status of blood bank samples.
Type and Screen
The Type and Screen widget is designed to allow clinicians a way to view blood bank results on the patient’s current blood sample. If the patient has ever had an ABO/Rh type done at our facility, the type will display in the widget. We decided to display the patient’s blood type at all times on the widget so that it would be readily accessible to check against plasma products being transfused. The patient’s blood type will display with the results of the antibody screen. If the antibody screen results are positive, the widget will show a statement instructing the user to reference the Antibodies widget.
Antibodies, Transfusion Reactions and Consults
The Antibodies widget is designed to display any atypical antibody identified in the blood bank since the installation of the current hospital information system, which has been in place since 2000. The widget displays the antibody and the date it was identified.
The Transfusion Reaction widget works in the same manner, displaying any transfusion reaction worked up in the blood bank. This widget displays the type of reaction, the date, and the type of product transfused during the reaction.
The Consults widget lists any completed Transfusion Medicine physician consult. These include consults written both for transfusion reactions and for antibody identifications, in addition to those written for apheresis procedures. Both the antibodies and the transfusion reaction widgets have the date associated with them so the correct consult can be located, depending on what information the clinician is searching for. This allows clinicians to get a better understanding of what may be involved in obtaining blood for patients with complex serologic results.
Transfusion Requirements
The Transfusion Requirements widget displays any blood product requirement entered into the system by the blood bank. These requirements were previously visible on the laboratory information “side” of the system but not on the clinician “side.” For patients who are immunocompromised, the blood bank enters the transfusion requirements “Use Irradiated” “Use Leukoreduced” and “Use CMV neg.” The widget also searches for whether the patient has been tested for cytomegalovirus (CMV). If the most recent CMV test was positive, the widget will display that CMV products are not indicated, with the date of the positive result, so the clinician can easily find the results.
When the blood bank receives a transfusion reaction report on a patient, we enter a transfusion requirement into our system called “Transf Rxn” that alerts all technologists in the lab that the patient has a current transfusion reaction. It also alerts the entire laboratory staff that the patient has had a suspected transfusion reaction and keeps them releasing additional products until the transfusion reaction work-up has been reviewed by one of the Transfusion Medicine physicians. If the widget detects this transfusion requirement, it will display the statement “Current transfusion reaction, contact the blood bank for blood products.”
Blood Bank Orders
The Blood Bank Orders widget displays any orders for blood products placed within the previous 24 hours. The widget is designed so that the 24-hour time limit is calculated from the date and time the product is needed. This means that blood orders placed days in advance, i.e., pre-operatively, will remain on the widget until 24 hours after the date and time that the order stated the product will be needed, as entered in the system.
Available, Dispensed and Transfused Products
The Available Products widget will display any red blood cell product crossmatched to a patient or any plasma product assigned to a patient. When the clinical location enters a release for blood products into the system, this alerts the blood bank that the clinicians are ready to transfuse the unit. The blood bank then dispenses the product to the patient location not only physically but also in the computer system. Once the product has been placed in dispense status in the system, it will move from being displayed on the Available Products widget to the Dispensed Products widget. The hospital system automatically moves the “any” dispensed product to a transfused status after a designated time period. When this happens, the product will no longer be displayed on the Dispensed Products widget and will now display on the Transfused Product widget. The Transfused Product widget will display any product transfused to a patient within the last 90 days. These three widgets, along with the Blood Bank Orders widget, are all scrollable. This means that it does not matter how many orders are placed or products set up and transfused; the widgets will not take up large amounts of space on the QuickView page. Each widget can be scrolled after more than three products are added.
Rh Immune Globulin
The Rh Immune Globulin widget displays the number of doses of Rh immune globulin needed based on testing done in the blood bank following the baby’s delivery. The blood bank technologists answer the Fetal Bleed Screen and Fetal Hemoglobin Stain testing, if needed, with the calculated number of doses of Rh immune globulin to be transfused. The blood bank also orders a test based on newborn Rh typing results for cases in which the lab does not have a blood type on the mother or has not received a sample following delivery. If the newborn Rh typing is positive, the blood bank orders a “Blood Bank Sample Notification.” When this test is ordered, the widget displays a statement that Rh immune globulin may be indicated and then asks that a sample be sent to the blood bank for evaluation. The notification that Rh immune globulin may be indicated allows the blood bank to properly comply with AABB standards.
Two hyperlinks were also added to the page before implementation. The first is a link to a transfusion guideline document that was developed and maintained by the blood bank. The second is a help guide developed as an education tool for the clinicians. The help guide lists the widgets and explains what information each widget can display.
Validation of the QuickView page
Before implementation of the QuickView page, each widget was tested and validated to ensure proper functionality. A testing script was developed by Transfusion Medicine that tested various possible scenarios for each widget. The script was developed by creating a testing event which could be performed in a mock-computer environment that mirrored the live computer environment. It was necessary to test each widget to ensure that it was displaying the patient’s information appropriately. Upon completing the script testing in the mock environment, access was granted to select blood bank technologists and hospital clinicians in the live environment. The live environment widget information was compared to the information displayed in the blood bank LIS. It was important to validate the page in the live computer environment because not all scenarios could be accounted for in the testing environment.Upon finding all results acceptable, access to the QuickView page was granted to appropriate staff throughout the organization.
Organizational training
Once the QuickView page had proven to be reliable and consistent, training was conducted throughout the organization on how to utilize the new tool. Training was conducted using a variety of methods: presentations at unit meetings, poster displays, one-on-one discussions, organizational email, computer announcements, and screen saver announcements. This use of several training methods allowed for the organization to quickly begin using the available information.
The successful resolution
The collaboration among the Department of Clinical Information Systems, Department of Surgery, various intralaboratory and interlaboratory committees, and Transfusion Medicine produced an end product that allowed for critical transfusion medicine information to get to the clinicians in real time from a single convenient location. The various parts of the QuickView page organized transfusion medicine information in a consistent and easily accessible manner that decreases the time clinicians, nurses, and laboratory staff spend retrieving and disseminating this vital information. The QuickView page has further increased patient safety by allowing clinicians to easily access historical patient information regarding antibodies and transfusion reactions. By having this information readily available, the laboratory staff experiences fewer interruptions and delays in their patient care activities. The QuickView page may have been the vision of the Transfusion Medicine team, but it took a total organizational team effort to make it a reality.
April Hord, BB(ASCP), MEd, currently serves as the Medical Technologist Trainer in the Department of Transfusion Medicine (TM) at Virginia Commonwealth University Medical Center (VCUMC). April previously was the LIS Senior Technologist in TM. Steven M. Armstrong, MT(AMT) BB(ASCP)SBB, MSHA, is the Manager of TM at VCUMC. Susan D. Roseff, MD, currently serves as a Professor and Associate Director of Clinical Pathology, the Medical Director of TM, and Associate Director of the Resident Training Program for the Department of Pathology at VCUMC.
