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A phased approach to transfusion reaction investigation.

Track a potentially fatal transfusion error systematically with a special form and procedure.

ONE AREA of transfusion service testing that can benefit from quality improvement is the investigation of suspected transfusion reactions. The time between recognition that a transfusion reaction (TR) has occurred and the ruling out of acute hemolysis is critical to the patient. JCAHO's focus on patient outcomes makes the investigation of TR a natural target for quality improvement (QI) efforts.

The scope of inquiry can range from a nurse's note in the medical record to a full-blown laboratory investigation that includes testing in several clinical lab sections. For clinicians, nurses, and technologists, the question has always been what to do and when.

* Problem solving. A quality assurance (QA) review of the correctness and completeness of TR investigation report forms used at Elmhurst (Ill.) Memorial Hospital, a 450-bed not-for-profit facility, showed that both the process of inquiry and the forms themselves needed improvement. Among the problems were incomplete documentation from nurses, incorrectly filled out forms by attending physicians, and the tendency by the transfusion service laboratory to overtest. It was time for interdepartmental problem solving.

According to QI strategies, investigation of an interdepartmental problem should include all departments involved. Consequently, we invited the nurse manager of the IV therapy team to participate. Using the Technical Manual of the American Association of Blood Banks (AABB) as a guide,|1~ we worked together to write a procedure that clearly states each step and to create a new form to accompany the procedure.

The interdepartmental group first met in the summer of 1991. Within a few months the new procedure and form were in use. Effects were felt immediately: better documentation, improved communication, more rapid completion of investigations, and faster notification when subsequent transfusion was needed. An additional important outcome was the reduction of unnecessary testing in the transfusion service laboratory, with concomitant lowered costs.

* Recognizing reaction. The transfusionist, whether nurse or physician, must recognize the symptoms of TR and know how to respond when any are observed. To heighten awareness and response, we attached to the inquiry form a half-page tearoff sheet that describes symptoms and explains how to report the problem.

* Design. The forms are printed on three pages: the pink instructional half-sheet; a white page, on carbonless paper, which automatically copies the information onto a yellow page underneath, printed with the identical form; and the reverse of the yellow undersheet, which contains the inquiry form. The sheets are fused along the top edge, in which five holes are punched to accommodate the medical chart.

On the white sheet, nurses and physicians enter important clinical observations and data. The medical director of transfusion service enters an interpretation of findings and categorizes the reaction. On the back of the yellow page, the technologist who is conducting the serologic investigation records observations and interpretations.

The pink instructional sheet is retained while the white and yellow copies are forwarded to the transfusion service with the specimens for the serologic investigation. Later, the white sheet is appended to the patient's medical record and the yellow copy is retained in the transfusion service.

* Investigating incident. The first step in the investigation of a reported TR is to rule out an acute hemolytic reaction--for example, when the patient has received blood from the wrong ABO group. The AABB manual lists four steps to follow. We called them phases and assigned each a special place in our procedure and inquiry form.

Phase 1. The transfusionist checks patient and donor unit identification at the bedside while the investigating laboratorian checks the same elements on container specimens and records. A visual comparison is made of the color of the pre- and posttransfusion plasma or serum for signs of hemoglobinemia. A direct antiglobulin test is done on the posttransfusion red cells. The form provides space for recording the date and component description of any previous TRs for that patient documented in our permanent record.

Once acute hemolysis has been ruled out, the nursing station is notified that any subsequent transfusions may be given. If the Phase 1 finding is positive, however, a Phase 2 investigation is launched.

Phase 2. We follow the AABB's recommended procedure to retest the major blood groups (ABO and Rh) of the patient's pre- and posttransfusion specimens and blood from a segment of the donor unit. The form also allows space in which to record the results of the direct antiglobulin test (DAT) on the pretransfusion and donor unit red cells. Additional space is provided for documenting the number and type of blood components the patient received in the two weeks immediately preceding the incident.

Red cell transfusions may have sensitized the patient to non-ABO blood group antigens, such as those in the Rh, Kell, Duffy, and Kidd systems. Transfusions of non-ABO-compatible plasma, whether in platelet pools, in platelet apheresis units, as fresh frozen plasma, or as cryoprecipitate, are often overlooked as a cause of a weak posttransfusion DAT.

Any suspicious findings from Phase 2 direct the technologist into the next phase.

Phase 3. Antiglobulin crossmatches are performed with both pre- and posttransfusion serum samples and donor unit red cells. A positive DAT on the donor unit in Phase 2 would explain an incompatible crossmatch in Phase 3. If the donor unit has an unexpected red cell alloantibody--a rare occurrence, since blood suppliers screen all donor plasma for unexpected alloantibodies--the results of a minor crossmatch between donor plasma and patient pretransfusion red cells are recorded. A Gram stain or cultures on the donor unit can be done any time clinical symptoms suggest bacterial contamination.

Phase 4. If any findings in Phases 1 through 3 reveal a transfusion error or if transfusion-related hemolysis is strongly suspected, creatinine, BUN, bilirubin, and other testing may be done to support the diagnosis of immune hemolysis.

* Other reactions. Some TRs require more extensive laboratory investigation than the form allows. Among these are febrile nonhemolytic transfusion reactions often associated with recipient white cell antibodies, transfusion-related acute lung injury attributed to donor white cell antibodies, and anaphylaxis, which is not uncommon with IgA antibodies.

On the bottom of the form a legend of codes and symbols appears. Spaces are provided on which the investigating technologist and supervisor sign and date the document.

* Medical director evaluation. When serologic testing is complete, the medical director evaluates the workup and may give instructions for further laboratory testing. At the bottom of the white form, the medical director classifies the reaction. Having this information will facilitate statistical tracking and reporting to the blood utilization review committee.|2~

The medical director may write recommendations to clinicians for future hemotherapy and treatment, perhaps including the use of leukocyte-depleted or antigen-negative red cells, premedication with antipyretics or antihistamines before transfusion, the use of crossmatch-compatible or apheresis platelets instead of random platelet concentrates, or obtaining the patient's tissue type in preparation for supplying HLA-matched components. Whenever the laboratory investigation rules out the primary causes covered in the AABB workup on which our procedure and investigation form were based, the medical director adds: "No evidence of clerical error, hemolysis, or serologic incompatibility found."

* Final steps. The form was introduced to the transfusion review committee to familiarize physicians with its appearance and with the phased investigation approach. With the committee's approval, the new form was introduced to nursing stations, where it was ceremoniously welcomed with the dumping of the old forms in the recycling bin. We understood that the QI process means establishing the validity of a new process before discarding the old, but were confident that our new form would work as planned. We were also concerned that, were the old forms left at the nursing stations, they would continue to be used.

Quality improvement requires colleagues to work together to resolve problems. Our transfusion service and nursing department cooperated to improve patient care by redesigning the system for investigating suspected transfusion reactions. As a result, costs dropped as patient care took a step forward.


1. Walker RH, ed. Technical Manual. 10th ed. Bethesda, Md: American Association of Blood Banks; 1990: 411-416.

2. DeChristopher PJ. Adverse effects of blood transfusion. In: Summers S, Smith D, Agranenko V. Transfusion Therapy: Guidelines for Practice. Bethesda, Md: American Association of Blood Banks; 1990: 113-155.

Lucia M. Berte, a member of MLO's Editorial Advisory Board, is director of laboratory quality assurance and manager of the transfusion service at Elmhurst (Ill.) Memorial Hospital. Dr. DeChristopher is medical director of the blood bank and transfusion medicine laboratory at the University of Illinois Hospital and Clinics, Chicago.
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Author:Berte, Lucia
Publication:Medical Laboratory Observer
Date:Nov 1, 1992
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