CE update [blood banking/transfusion medicine | compliance/regulation]
Suspected Transfusion Reactions:
Can They Be Computerized?
Gifford Lum, MD, Michael D’Amarino, MT(ASCP)
VA Boston Healthcare System, Boston, MA
DOI: 10.1309/XQF0LWEQCL4FY5WB
After reading this article, the reader should understand the issues for developing and implementing a computerized system
for tracking and recording suspected transfusion reactions.
Blood banking exam 60401 questions and corresponding answer form are located after “Your Lab Focus” section on p. 311.
왘 The blood bank at the VA Boston
Healthcare System, using existing
resources and a procedure for
modification of an established generic
electronic consult, has developed a
computerized, integrated process for
streamlining adverse transfusion
reactions, electronically linking the
notification, laboratory evaluation,
interpretation/signature, and final
documentation processes.
Blood banks, regulatory and
accreditation agencies require a medical
and laboratory protocol for the investigation of a suspected transfusion reaction, including detection, notification,
laboratory evaluation, interpretation, and
documentation of the reaction in the
patient medical record.1-5 Processes for
handling suspected transfusion
reactions are universally in place at all
medical centers, but these processes are
almost always a cumbersome paper system, requiring the handling, recording,
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storing, and retrieving of paper documents. In this electronic age, would it be
possible with existing resources to develop a computerized workup for a suspected transfusion reaction fulfilling
medical and regulatory requirements for
record keeping and appropriate documentation? In this report, the development and implementation of a
computerized process for the workup
and documentation of the suspected
transfusion reaction in the patient record
using available computer resources and
an existing interactive electronic consult
adapted to meet the needs of the transfusion service, are presented.
Available Computer
Resources and Existing
Electronic Service Consult
The Department of Veterans’Affairs
in 1995 introduced the Computerized
Patient Record System (CPRS): a
patient-focused electronic system,
designed to replace the paper system for
laboratorymedicine> may 2004> number 5> volume 35
medical records and to allow requests for
electronic consults. In 1999, the Graphic
User Interface (GUI) version was added
to CPRS, which enhanced dialogue between the electronic consult and consulting service and facilitated consult workup
through the use of interactive templates
with linkage of the consult to the
patient’s medical record.
The electronic service consult was
developed as a function of the electronic
patient record system. The generic service consult was designed to facilitate
communication between the physician
and the consulting service, including a
notification function that a patient consult had been requested. It is also a computerized tracking system to document
where and to whom the consult was directed. When a generic service consult
is requested, a prerequisite section will
automatically appear which allows the
consulting service to provide essential
information and instructions to ensure
that all conditions are fulfilled before
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the consult is actually submitted. Following the prerequisite section, the
provider is prompted to continue to
the next section of the consult which
features an interactive service specific template with required fields
designed to force the physician to
provide information considered essential by the consulting service to
complete the consultation. After the
consult is electronically signed, the
consulted service is notified by a
computer alert as well as a paper
copy automatically printed to a designated service location. Completion of
the consult is accomplished electronically in the form of an interactive
template which may be in the form of
a free text medical progress note or
by an interactive template designed to
meet the needs of the consulting
service. The electronic signature
completes the electronic consult
which then becomes a permanent part
of the patient medical record.
Development of Suspected
Transfusion Reaction Consult
The VA Boston Healthcare System
blood bank adopted a systematic
approach to the development of a computerized suspected transfusion reaction
workup which is outlined in T1. The
process was organized into discrete inquiries. Each question was separately
addressed according to whether or not
that particular step could be computerized. Personnel involved in the computerization project were the blood bank
director, supervisor, and the clinical application coordinator (CAA) for the VA
Boston Healthcare System.
Detection and Reporting of
Suspected Transfusion
Reaction
Suspected transfusion reactions are
usually detected by the clinical staff:
usually a nurse because of the close
clinical interaction between the patient
and nursing staff. The clinician or
Development of a Computerized Suspected Transfusion
Reaction Form
T1
Blood Bank or Regulatory Need
Possible to Computerize?
Detection (Nurse or provider)
Reporting (Notification of blood bank)
Evaluation (Clerical check, laboratory workup)
Interpretation/Signature
Documentation
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
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[F1] Prerequisites for suspected transfusion reaction consult.
laboratorymedicine> may 2004> number 5> volume 35
provider may also be the first to detect
a possible transfusion reaction, but in
most cases, the clinician is consulted
because the nurse may request evaluation of the patient for a suspected transfusion reaction. Recognizing that a
patient may have experienced an adverse transfusion reaction requires clinical judgment and is not readily
amenable to computerization.
Most medical centers require telephonic notification or submission of a
paper form for reporting a suspected
transfusion reaction; neither reporting
process is optimal since telephone
calls are often not recorded and paper
forms are often misplaced or lost, require storage, are difficult to retrieve,
and documentation may be difficult.
The reporting of the suspected transfusion reaction can be readily computerized using existing electronic
resources and the generic electronic
service consult. The blood bank modified the generic service consult to assist the clinical staff in the handling of
a suspected transfusion reaction by
including a prerequisite section of
“what to do” and what laboratory
specimens are needed to evaluate an
adverse reaction [F1].
F2 shows the computer screen displayed when the provider is ready to
complete the reason for request dialog.
The interactive blood bank electronic
template was designed to include essential information, such as provider
name, contact number, date of reaction, product transfused, clinical symptoms, and vital signs. The asterisks in
the form denote required entries which
must be completed. If the entry is left
blank, the computer will not process
the consult submission and will
prompt the user for a response. The
electronic blood bank interactive template allows for free text such as clinical diagnosis and comments to the
blood bank. It also contains the blood
bank telephone and fax numbers to
facilitate communication. After the
provider signs the consult form, an
alert e-mail is sent electronically to a
blood bank group (blood bank medical
director, supervisor, and technologists),
and a copy of the consult is printed on
the blood bank printer.
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Evaluation of Suspected
Transfusion Reaction
Most laboratories have a form to
provide the blood bank, complete
with a checklist to complete the laboratory assessment of the adverse
transfusion event. This form can
readily be computerized so it can be
completed electronically. F3 shows
the interactive electronic dialog form
developed at the VA Boston Healthcare System. The template appears
after the consult is submitted and is
completed by the blood bank. The
asterisks in the form denote required
fields which must be completed. If
the field is left blank, the computer
will not allow the laboratory to complete the consult and will prompt for
a response. For most routine
suspected transfusion reactions, the
laboratory workup stops at the stage
after it has been determined that the
reaction is not hemolytic and the results of the pre- and post-Direct
Coombs test are negative. If a
hemolytic transfusion reaction is suspected, the electronic form allows for
an extended laboratory workup including antibody screen, compatibility testing, and additional laboratory
testing such as urine dipstick results
and blood cultures.
After the laboratory workup and
clerical checks have been completed,
the blood bank director provides an
interpretation of the suspected transfusion reaction. This step can be handled
by signing a paper form or it can be
done electronically. The consult form
[F3] allows the blood bank director to
sign the form electronically (interpretation/conclusion) and also permits
him/her to make recommendations for
the patient.
Documentation of Suspected
Transfusion Reaction in
Patient Medical Record
The final step in the process of
working up a suspected transfusion
reaction involves documentation of the
adverse reaction in the patient medical
record and appropriate notification of
the provider, especially in cases of severe transfusion reactions. Before the
development of an electronic system,
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[F2] Reason for suspected transfusion reaction consult.
the blood bank of the VA Boston
Healthcare System sent the signed
form for the suspected transfusion
workup to the patient’s chart, and if
necessary, the blood bank director sent
an e-mail message or telephoned the
provider for serious transfusion reactions such as an acute hemolytic transfusion reaction. Documentation of the
transfusion reaction can be readily
computerized because the consult form
is linked to the patient medical record
and the entire workup is automatically
incorporated into the patient chart once
the consult is completed and signed by
the blood bank director. The computerized process also generates an
electronic view alert and e-mail message to the provider of record, thus
eliminating the need to contact the
provider directly.
The electronic forms developed can
easily be modified to incorporate changes
in medical center policies or regulatory
and accreditation agency requirements.
Because the forms are already computer-
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ized, revisions can be made instantly and
disseminated throughout the medical
center without the need to revise or distribute paper forms.
Comments
Suspected transfusion reactions
need to be detected, require notification
of the blood bank for evaluation and
interpretation, and incorporated into the
patient medical record. In most medical
centers, the process for workup and
documenting adverse transfusion reactions is often cumbersome, requiring
the integration of a paper and computer
system. Faced with the need to streamline suspected transfusion reaction reports into an integrated process from
detection to final documentation, the
VA Boston Healthcare System blood
bank, using existing computer resources
and a generic electronic service consult
system, developed a single, continuous,
logically linked and computerized
process for handling suspected transfusion reactions.
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electronic newsletters. Informational
and educational material was also included within the text of the consult
itself, delineating, for example, the responsibility of the physician to obtain
specimens needed to complete the laboratory workup of the suspected transfusion reaction. One significant
advantage of the electronic consult for
suspected transfusion reactions is the ease
of revising the electronic forms to incorporate changes in accreditation, regulatory, or medical center policies. Such
revisions can be disseminated without the
need to replace outdated paper forms. An
example of a revision recently made was
updating the electronic consult to include
ABO recheck of the post transfusion
specimen, a 2003 AABB standard
[7.4.3.1.4].1 Twelve VA medical centers
have so far expressed interest in the
computerized consult form and many of
these facilities have set up and instituted
the electronic consult. The electronic
templates provided to these VA facilities are very flexible and can be easily
modified to meet site-specific needs.
Conclusion
Suspected transfusion reaction
workups, which fulfill accreditation,
regulatory, and individual medical center needs, can be computerized at any
medical center using existing electronic
resources and a computerized interactive process for linking the notification,
interpretation, and documentation procedures. The computerization model
presented in this study indicates that it
can be extended to other medical center
blood banks and used as a paradigm for
other medical facilities in their effort to
develop an integrated, computerized,
single system for a suspected transfusion reaction.
[F3] Laboratory evaluation and interpretation/signing of suspected transfusion reaction consult.
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Following the development of the
computerized suspected transfusion
reaction consult, the VA Boston Healthcare System next implemented the
computerized suspected transfusion
reaction consult as its only standardized method of handling such
reactions. The effect of the standard-
ized consult was to formalize the notification process, eliminating the need for
informing the blood bank by telephone
or submission of a paper form by the
provider or nurse. The blood bank then
initiated educational training for the
medical and nursing staffs including
audio-visual presentations and
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1. Standards for Blood Banks and Transfusion
Services. American Association of Blood
Banks. 22nd ed. Bethesda, MD. 2003
2. Technical Manual, American Association of
Blood Banks, 14th ed. Bethesda, MD. 2002.
3. Transfusion Medicine Checklist, College of
American Pathologists. Northfield, IL. 2002.
4. Code of Federal Regulations, 21, 606.170
(Adverse Reaction File), Food and Drugs, US
Government, Washington, DC, 1995.
5. Department of Veterans’ Affairs, VHA
Directive 1106, Veterans Health
Administration, Washington, DC. 1997.
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