January 2019

Canadian Blood Services’ Hospital Disposition Reporting

By: Rob Romans, BSc, ART, Associate Director, Utilization/Account Management, Canadian Blood Services

The method of reporting disposition and inventory data to Canadian Blood Services has evolved over the years. Prior to April 2006, a manual paper form (known as the L69 report) was filled out and submitted. At that time, there were no published standardized definitions for the different form fields, and if anyone wanted to analyze the data, it had to first be manually entered into a database or spreadsheet.

In April 2006, an electronic data submission Adobe Reader (PDF) form was released. It included:

• Definitions for the fields (what to include, what not to include)
• Data was typed into the form and submitted attached to an email. Data was extracted and uploaded into the Canadian Blood Services biwarehouse, allowed for a series of hospital specific disposition trend reports to be generated to assist hospitals and for data analysis.

Then, in April 2014, a web-based reporting system was introduced, and the data collection was expanded to include reporting by ABO/Rh, inventory data, and plasma protein disposition data.

In 2018, we now are in the very early stages of a pilot to allow automatic data exchange of both inventory and disposition data between hospitals and Canadian Blood Services. A critical component of our data sharing advances is the ongoing introduction of automation to reduce transcription errors, and the adoption of common data definitions.

We recently discovered an example of a data definition interpretation that could compromise data integrity. Most hospitals follow this standard practice: If Hospital A receives a redistributed/transferred unit from Hospital B, and the unit was received out of specifications and needs to be discarded, it is Hospital A that receives and then discards the unit, and then records the event using the data field “discarded – improper storage”. Hospital A should follow up with Hospital B to explain the issue, and if preventable, they can take steps to prevent a reoccurrence.

However, non-standard practices can occur. For example, if instead of the scenario above, Hospital A may (or may not) send the unit back to Hospital B, which has to receive the unit back into inventory and then discard it. This is not ideal as it results in extra time spent packing and transporting the unit.

The Hospitals in the latter scenario may be concerned about being held accountable for reporting discards that were out of their control, but this shouldn’t be the case. Thankfully such events are infrequent. Rest assured that Canadian Blood Services understands that hospitals employ validated redistribution/transfer processes to maintain specifications during shipment. Further, inter-hospital movement of blood components is an effective strategy to reduce blood system wide outdates.

Currently, Canadian Blood Services’ Blood Component and Product Disposition System User Guide (version 3.0.1.1) is not explicit on what to do in this situation, but the next release will include details about how these circumstances should be handled for disposition reporting purposes and improved data integrity.

8 Rights of Transfusion 3×4″ Lanyard is in stock!

Good news! The 8 Rights of Transfusion 3×4” Lanyard Card is in stock again. This resource highlights eight important checks for administration of blood products/ components to be performed at the bedside. Lanyard cards are available as a quick reference to promote and reinforce the need for these eight checks and are bilingual.

As a result of a 2011 province-wide audit of blood administration at the bedside, The 8 Rights of Transfusion Lanyard Card along with some other tools were developed to help hospitals improve patient safety at the bedside. The 2018 Bedside Audit was completed on November 30th, 2018. The 2018 report will be released in the next couple of months. For more information on the bedside audit and tools, please click here.

To order The 8 Rights of Transfusion 3×4” Lanyard Card, visit our website at https://transfusionontario.org/ and click Order Resources under the ORBCoN Resources tab.

Bloody Easy Tech Assess: Advanced – If you got these wrong too, you were not alone (again!)!

By: Lisa Mantifel, Regional Project Coordinator, ORBCoN

In December’s newsletter, the five most challenging questions in Bloody Easy Tech Assess: Basic Competency 2017/2018 were discussed. Now we will focus on the Bloody Easy Tech Assess: Advanced Competency 2017/2018 and the top five questions that stumped users.

To recap, Tech Assess is an online educational program that tests theoretical knowledge in eleven areas of transfusion medicine and can be used as part of a laboratory competency assessment program. New tests are released approximately every year with a selection of previously used questions combined with at least 20% new questions. Previous year’s data on the top incorrectly answered questions in basic and advanced modules are reviewed each year by the ORBCoN working group. The questions that prove difficult for users are analyzed for issues with respect to:

• Knowledge – does this question reveal a knowledge gap?
• Misleading – is the question or are the answer options misleading or confusing?
• Fair – is this question fair?
• Is this question at the correct knowledge level (i.e. basic vs advanced)?

The five most challenging questions in Bloody Easy Tech Assess: Advanced Competency 2017/2018 version will be discussed below with regards to their fail rate, the logic behind the answer and if the question is reasonable or not. The data shown below is from April 30th, 2018 to December 13th, 2018.

Question 1: Donor Blood Collection and Testing Advanced

What is the maximum allowable age for allogeneic blood donation without a physician certificate?

a) 60 years of age if a first-time donor ✓
b) 70 years of age if a first-time donor
c) 70 years of age if a repeat donor 
d) 60 years of age if a repeat donor

The best answer is A. If a donor is donating for the first time, they must be under the age of 61 unless they have been examined by a licensed physician and certified suitable to donate (1). If a previous donor has donated in the past two years, they can donate even over the age of 66 (1). After this age, if the donor has donated in the past but not in the past two years, they need to be certified as suitable by a licensed physician (1). Technically, as long as the donor is certified as healthy enough to donate by a physician, there is no maximum age. This question is fair. The distractors (B, C, and D) are not misleading. The fail rate can be attributed to a knowledge gap in the criteria for acceptable blood donation.

Question 2: Reporting Advanced

If a dose of platelets is requested from Canadian Blood Services (CBS) but is discarded because it outdates because the physician no longer felt the patient requires it, how should this be recorded in the CBS Blood Component and Product Disposition System?

a) It should be recorded as a discard: patient related ✓
b) It should be recorded as a discard: due to expiry
c) It should be recorded as a discard: improper storage
d) It should be recorded as a discard: failed visual inspection

The correct answer is A. CBS Patient Blood Component and Product Disposition System User Guide defines patient-related discards as: the patient did not require the component, the patient did not show up for the transfusion, the patient is deceased, or the patient was transferred before the transfusion (2).

The wording of the question should be revised to eliminate the double-use of “because”. A suggestion might be:
“If a hospital transfusion service requests a dose of platelets from Canadian Blood Services (CBS) but it outdates because the physician no longer felt the patient requires it, how should this be recorded in the CBS Blood Component and Product Disposition System?”

The platelets were not discarded due to improper storage (C) or failing visual inspection (D). Option B is a good distractor as the platelet unit did expire, however the unit was ordered for a patient and discarded due to the patient not requiring the component anymore. The wording of the question will be reviewed by the ORBCoN working group, however the fail rate can be associated with the user not having a thorough understanding of the definitions within the CBS user guide.

Question 3: Blood Group (ABO / Rh) Advanced

Which of the following (weak-D) phenotypes are at risk of developing an anti-D if exposed to Rh positive red cells through pregnancy? Choose all that apply.

a)  Type 1
b)  Type 2
c)  Type 3
d) Type 11 ✓

The correct answer is D. Persons with weak D types 1, 2 and 3 are unlikely to make anti-D when transfused with D positive red blood cells (3). In 2015 an evaluation of scientific literature on weak D types concluded that people with weak D types 1, 2 and 3 can be treated as D positive during pregnancy (3). People with the less common weak D type 11 have been reported to make anti-D when transfused with D positive red blood cells (3). The question is well written and straight forward. The distractors are not confusing. The fail rate identifies a knowledge gap and the question is fair for the advanced level.

Question 4: Reporting Advanced

What is a recent additional requirement for hospital patient laboratory reports in Ontario?

a) The identification of the laboratory performing the test
b) The patient identification and location
c) The page number in relation to the total number of pages ✓
d) The date and time of specimen receipt by the laboratory

The correct answer is C. In the most recent version of the Institute for Quality Management in Healthcare (IQMH) Medical Laboratory Accreditation Requirements, the requirement to include the page number in relation to the total number of pages was added (4). Adding the page number to patient reports helps to ensure there is no confusion over the sequence of results, the completeness of the report and the final interpretation of the examination. Options A, B and D have been required on hospital patient laboratory reports for some time. The fail rate could be attributed to the question not identifying what regulatory body recently added the requirement, and lack of year to define how “recent” it was. The question will be flagged for review by the ORBCoN working group.

Question 5: Antibody Identification Advanced

Which of the following is true regarding differential adsorption?

a) The cells used are usually R₁R₂, R₂R₂ and rr
b) One cell must be negative for K, another negative for Jk^a and the third negative for Jk^b ✓
c) It is usually used when the patient has not been transfused
d) This is also known as an autoadsorption

The correct answer is B. Differential adsorption may be performed to complete antibody investigation on a recently transfused patient who presents with autoantibodies (5). The patient’s serum is divided into three aliquots and each aliquot is adsorbed with a different cell (typically an R₁R₁, R₂R₂ and rr) and among the three cells, one must be negative for K, another negative for Jk^a and the third negative for Jk^b (5).

The difficulty of this question can be attributed to the user needing to know the method of differential adsorption. The distractors A, C and D are strong. Option A is incorrect because the cells used in the method are typically an R₁R₁, R₂R₂ and rr. Option C is incorrect because differential adsorption is used in cases where a patient has been recently transfused. Option D is incorrect. Autoadsorption is a method used to remove autoantibodies from serum or plasma using the patient’s own red blood cells (5). Autoadsorption can be used when a pre-transfusion sample is available.

Tech Assess is a tool that benefits MLTs, supervisors, laboratory managers and students in hospitals, blood services and post-secondary schools by aiding in documentation and assessment of knowledge in the field of transfusion medicine. If you have any questions, comments or feedback on these questions, or any ORBCoN resources, please contact ORBCoN here or at transfusionontario@gmail.com.

References:

1. Canadian Standards Association. CSA Z902-15 Blood and blood components 5.2.2 Toronto: CSA Group; 2015.
2. Canadian Blood Services. Blood Component and Product Disposition System User Guide Version 3.0.1.1; 2016. Appendix A – Data Entry Field Definitions p20.
3. Fung MK ED. AABB Technical Manual 19th Edition Bethesda; 2017.
4. IQMH. Institute for Quality Management in Healthcare (IQMH) Medical Laboratory Accreditation Requirements Verson 7.1: IQMH Centre for Accreditation; 2017.
5. Harmening D. Modern Blood Banking and Transfusion Practices 6th Edition Philadelphia; 2012.

Question about target INRs when treating coagulopathic patients with frozen plasma or prothrombin complex concentrate (PCC) Question: On page 36 of Bloody Easy 4: Blood Transfusions, Blood Alternatives and Transfusion Reactions. A Guide to Transfusion Medicine Fourth Edition (1), the threshold INR for plasma transfusion is greater than or equal to 1.8. On page 126, regarding the use of prothrombin complex concentrate (PCC) for emergency warfarin reversal, the threshold INR is greater than or equal to 1.5. Why is the INR threshold for plasma 1.8, and the threshold for PCCs 1.5? Shouldn’t they be the same? Answer by Dr. Allison Collins, MD: Coagulation factors are at sufficient levels (30% of normal) for normal hemostasis at an INR of about 1.7 (2). The INR is a poor predictor of bleeding risk, particularly if only mildly elevated, and there is no good evidence for use of a target INR of 1.5 vs 1.8 for prevention or treatment of bleeding.   INR reversal with plasma is not as effective as INR reversal with PCC (3). With plasma, it is very difficult to get the INR below 1.8 (4) because the INR of plasma itself is about 1, and the coagulation factors in the transfused plasma become diluted as a result of the transfusion itself. So, if plasma is transfused to ‘correct’ an INR of less than 1.8, patients will be exposed to a blood product and possible transfusion-associated circulatory overload (TACO) or other adverse event, with no benefit in 40-99% of them (4, 5). Plasma may be indicated in conditions such as liver disease, disseminated intravascular coagulation, or massive transfusion when all coagulation factors are required. PCCs, which contain only the Vitamin K-dependent coagulation factors II, VII, IX, and X, are not usually used in these patients.   Because PCC is a ‘warfarin antidote’ containing specifically the Vitamin K dependent coagulation factors, correction to a near-normal INR is achievable and rapid (6). PCC, unlike plasma, is used for emergency warfarin reversal when the anticoagulated patient is bleeding or requires emergency surgery (defined as surgery within 6 hours). In a patient with an INR of 1.8 who needs emergency warfarin reversal PCC may still be indicated because, unlike the situation with plasma, a lower INR of at least 1.5 is achievable. The only time that plasma should be used for urgent warfarin reversal is when PCC is not available.   The bottom line: Plasma and PCCs are used for different reasons. The threshold is an INR <1.8 for plasma because that’s the best we can do for patients who need all the coagulation factors in plasma, but the threshold is an INR of <1.5 for PCC because it is possible, and we do not really know whether an INR of <1.5 or <1.8 is the optimal threshold.   Finally, non-urgent warfarin reversal is not achieved with either PCC or plasma (7). The better approach is to withhold warfarin and administer oral or intravenous Vitamin K.   References Callum, JL and et al. Bloody Easy 4: Blood Transfusions, Blood Alternatives and Transfusion Reactions. A Guide to Transfusion Medicine Fourth Edition. Toronto: Ontario Regional Blood Coordinating Network, 2016. Dzik WH. Predicting hemorrhage using preoperative coagulation screening assays. Current Hematology Reports 2004;3:324-30. Sarode R, Milling TJ, Refaai MA, et al. Efficacy and safety of a 4-factor prothrombin complex concentrate in patients on vitamin K antagonists presenting with major bleeding: a randomized, plasma-controlled, phase IIIb study. Circulation 2013;128:1234-43. Abdel-Wahab OI, Healy B, and Dzik WH. Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities. Transfusion 2006;46:1279-86. Warner MA, Hanson AC, Weister TJ, et al. Changes in international normalized ratios after plasma transfusion of varying doses in unique clinical environments. Anesthesia & Analgesia 2018;127(2):349-57. Pabinger I, Brenner B, Kalina S, et al. Prothrombin complex concentrate (Beriplex® P/N) for emergency anticoagulation reversal: a prospective multinational clinical trial. J Thrombosis and Haemostasis 2008;6:622-31. Callum JL, Waters JH, Shaz BH, et al. The AABB recommendations for the Choosing Wisely campaign of the American Board of Internal Medicine. Transfusion 2014;54:2344-