Faculty Bibliography

Background/Case Studies: >25% of the 15 million RBC transfusions (TXN) in the US are probably medically unnecessary. Many studies have demonstrated the safety of using lower hemoglobin (Hgb) TXN thresholds. In 2010 the 11 acute care hospitals in our system adopted a common set of RBC TXN triggers to standardize practice and improve patient care. The adult triggers were A) Hgb <7 g/dl and symptomatic anemia, B) Hgb <9 g/dl with significant cardiac, neurological, or respiratory disease, C) Blood loss >20% refractory to fluid resuscitation, and D) Pre-op for major surgery with anticipated blood loss >1000 ml and Hgb <7 g/dl. Education was part of the roll-out of the new triggers. In 2011 we sought to evaluate the adherence to the triggers. Study Design/Methods: The pre-TXN Hgb result just prior to each RBC order was pulled from the EMR into a data warehouse where it could be manipulated. The number of RBC orders placed at pre-TXN Hgb values were sorted and grouped. Because of the way the messages come from the blood bank computer system into the EMR, it is not possible to electronically extract the Hgb just prior to RBC issuance. Thus we were forced to look at the Hgb just prior to RBC order as a surrogate for adherence to the RBC TXN triggers Results/Findings: From 1/1/11 to 10/31/11, 16,375 RBC orders were placed of which 13077 had a preceding Hgb level. 34,891 RBCs were transfused. 4474 orders were placed with a pre-TXN Hgb >/= 9 g/dl. 3481 orders were placed with a pre-TXN Hgb <7 g/dl. 5695 orders were placed with a pre-TXN Hgb 7- <9 g/dl. 9.6% of RBCs were ordered at a Hgb >10 g/dl. A portion ordered at higher Hgb levels were for pre-operative patients. 10% of RBCs issued were returned to the blood bank. 3% of RBCs were issued using emergency release, presumably for trauma and other rapidly bleeding patients, and thus may explain a portion of the RBC units ordered at Hgb >10 g/dl Conclusion: 27% of RBCs are being ordered and transfused to patients with Hgb >9 g/dl. The more restrictive RBC TXN triggers adopted have not eliminated unnecessary transfusions. While computers are able to sort blood orders based on the use of lab data and the physician selected TXN triggers, smarter computers which are able to assess lab values and supporting clinical documentation are needed. The blood bank needs to play a proactive role in ensuring that RBCs are not issued to patients who do not satisfy the specific TXN trigger selected by the ordering physician. Until such clinical support exists from the EMR, auditing must continue to ensure adherence to the RBC TXN triggers and prevent clinically unnecessary TXN. (Table presented)

Background/Case Studies: Most US medical school curriculums devote little attention to teaching transfusion medicine (TXNM). From early stages of their residency, however, physicians are expected to be able to obtain informed consent for transfusion, administer transfusions, and recognize and treat transfusion reactions. Although there are many transfusion standards designed to assure patient safety, they can also lead to a false sense of security. The overall limited knowledge of TXNM by most physicians and reliance on this false sense of security can adversely impact patient safety. 0.5-1% of all transfusions is expected to result in a reaction. In 2008 and 2009 targeted education was done. In 2010, all incoming house staff (HS) were required to take an online tutorial and pass an exam prior starting work on 7-1-10. The impact of education was assessed by evaluating the number of transfusion reactions reported pre- and post-training. Study Design/ Methods: A Transfusion Guidelines tutorial and competency exam, consisting of 25 true/false questions, was created. All HS were required to take and pass (>=80%) the exam. The instruction course and competency exam were accessible to all HS on the medical school's advanced learning exchange. The competency exams were instantly scored and reported to the test taker. The number of transfusion reactions reported between 7-1-10 and 3-31-11 was assessed and compared to the numbers between 4-1-07 and 12-31-08. Results/Findings: Prior to starting work on 7-1-10, all 380 incoming HS took and scored at least 80% on the exam. Approximately 34.5% of the 380/1100 HS in all departments have completed the training. From 4-1-07 to 12-31-08, 89 (average of 12.7 per quarter) transfusion reactions were reported versus the 140-280 that were expected. From 7-1-10 to 3-31-11, 1921 patients were transfused more than 11000 blood products and 23 (average of 7.6 per quarter) transfusion reactions were reported versus the 53-106 that were expected. Conclusion: Formalized education for all HS involved in the transfusion of blood must continue to be conducted. Administrative and Departmental support were necessary to assure existing HS took and passed the exam. Under recognition and/or under reporting of transfusion reactions continues to be a challenge to improving patient safety. Mandated education prior to starting as HS must be followed up by additional and frequent teaching

Background/Case Studies: Wrong blood in tube (WBIT) continues to be one of the leading causes of serious adverse transfusion outcomes. WBIT occurs from misidentification of the intended recipient at the time of sample collection. In the USA WBIT is reported to occur in 1/1000 samples, and internationally it is 0.5/1000. My institution's rate of WBIT while meeting the USA standard has been a persistent concern and potential patient safety problem. I sought to assess whether my institution's rate of WBIT was in line with other local metropolitan hospitals that face similar financial, staffing, and patient population challenges. Study Design/Methods: The results of all of my institutions type and screen ABO/Rh confirmation samples from 1-1-09 to 3-31-11 were evaluated. The number of identified ABO discrepancies at my institution during this period was compared to the numbers reported by 10 other institutions (some reported for more than one year). Statistical analysis was performed. Results/Findings: My institution reported 109,942 ABO/Rh results and 68 WBIT discrepancies. The other 10 labs reported 372,014 ABO/Rh results and 83 WBIT events. My institution's mean rate of WBIT was statistically significantly higher (p < 0.05) at 0.069 +/?0.022 (0.67/1000) than the others at 0.022+/?0.023 (0.22/1000). The rate of WBIT was similar (0.069 versus 0.073) at the two largest public hospitals. However, some of the lowest WBIT rates were found at other public hospitals and large institutions. Conclusion: WBIT remains a challenge. Clinicians must understand the importance of and buy into the importance of proper patient identification to prevent WBIT. Unless everyone who draws blood bank specimens follows the protocol for patient identification, safety will not be improved. Human errors continue to lead to WBIT errors. Electronic barrier systems need to be considered. (Table presented)

Introduction : Rapid infusion devices are becoming increasingly popular for the administration of warm fluids and blood in hypovolemic patients. A recently developed system, Thermacor 1200 (Smisson-Cartledge Biomedical LLC, Macon, GA), consists of a central device to which a disposable cartridge of fluid lines attaches. Performance characteristics of this device have yet to be evaluated. We compared the Thermacor 1200 with a currently utilized infusion device, FMS 2000 (Belmont Instrument Corp., Billerica, MA), to evaluate maximum flow rates, accuracy of actual versus set flow rates, fluid warming capabilities, and air bubble elimination. Methods : A ThermaCor 1200 and an FMS 2000, owned by our institution, were evaluated in vitro after being tested for proper functioning. FMS 2000 was tested with the packaged 4.5ft patient line, and Thermacor 1200 with packaged 3ft (TC3) and 6ft (TC6) patient lines. Maximum flow rates of lactated Ringer's (LR) and expired packed red blood cells (PRBCs) were measured with 22, 20, 18, 16, 14 and 8.5F gauge catheters, using a graduated cylinder and stopwatch. Flow rate accuracy was determined by comparing the actual versus displayed flow rates, for LR and PRBCs. Temperature was measured, at various flow rates, with an electronic probe (Wavetek 23XT, San Diego, CA) positioned 3cm from the distal port of the outflow tubing, for LR and PRBCs. Air elimination capability was determined, for LR only, by infusing fluid into an inverted 20mL syringe submerged in a bucket of water, and measuring the resulting air trapped in the syringe. All measurements were repeated six times. Data were analyzed using one-factor ANOVA, and the Tukey multiple comparisons method. Statistical significance was defined as p<0.05. Results : Maximum flow rates were higher with TC3 and TC6 than with FMS 2000 in most instances, especially when using larger catheter bores (Table 1). Flow rates were more accurate with TC3 and TC6 than with FMS 2000 for LR (1.4, 1.6, and 3.5% variance from target rate, respectively; p<.001) and for PRBCs (2.1, 2.6, and 5.9% variance from target rate, respectively; p<.001). Temperatures of delivered fluid were higher with TC3 and TC6 as compared to the FMS 2000 for LR (38.0, 37.8, and 36.8degreeC. respectively; p<.001) and PRBCs (38.2, 38.1, and 37.2degreeC, respectively; p<.001). Air was not detected in fluid infused from either device. Discussion : In this experiment, the performance of the Thermacor 1200, at both lengths of patient line, was superior to that of the FMS 2000 in that it infused LR and PRBCs at higher and more accurate flow rates, at higher temperatures. (Table presented)

Mendelian disorders are individually rare but collectively common, forming a 'long tail' of genetic disease. A single highly accurate assay for this long tail would allow the scaling up of the Jewish community's successful campaign of population screening for Tay-Sachs disease to the general population, thereby improving millions of lives, greatly benefiting minority health and saving billions of dollars. This need has been addressed by designing a universal carrier test: a non-invasive, saliva-based assay for more than 100 Mendelian diseases across all major population groups. The test has been exhaustively validated with a median of 147 positive and 525 negative samples per variant, demonstrating a multiplex assay whose performance compares favourably with the previous standard of care, namely blood-based single-gene carrier tests. Because the test represents a dramatic reduction in the cost and complexity of large-scale population screening, an end to many preventable genetic diseases is now in sight. Moreover, given that the assay is inexpensive and requires only a saliva sample, it is now increasingly feasible to make carrier testing a routine part of preconception care