What Donors Don’t Know Could Hurt …Someone Else

By Tanya Brown

AABB Staff Writer

What could have been a nightmare turned out to be good exposure for the Oklahoma Blood Institute last December, when reporters and television cameras knocked on the facility’s doors demanding to know why women were being “banned” from donating blood.

“Any publicity is good publicity,” said Jean Forsberg, MD, associate medical director at the Oklahoma Blood Institute in Oklahoma City. “Someone contacted the press and let them know that we were not accepting female apheresis plasma donations. The press came to us and that gave us an opportunity to talk about TRALI, explain what it is, what causes it and what steps are being taken to prevent it.”

The headline that started the barrage of media inquiries ran in The Oklahoman newspaper — “Women Plasma Donors Spurned.” Forsberg said she cringed when she first saw it, “but I think more people read the article based on the headline, so it helped get the word out.”

OBI is one of several hundred blood centers that have devised a plan to educate women donors on transfusion-related acute lung injury, a rare but serious pulmonary syndrome that can lead to death if not recognized and treated appropriately.

The center began its donor notification campaign by first training its recruiters and staff. “We had to educate those who are on the front line about TRALI and why we are doing what we are doing,” said Forsberg. “Then we took the same information to our other staff and the phlebotomists so they would be equipped to answer questions.”

Last fall, OBI mailed letters to all of its female donors. Forsberg said she included her phone number and encouraged people to call her with any questions. Several donors contacted her, but they were more concerned about whether or not their blood had injured a patient. According to Forsberg, the overall response from female donors was positive.

The letter was followed by a question-and-answer page posted on OBI’s Web site and other reading material to help donors understand the seriousness of TRALI. “By no means are we turning women away, but rather requesting that they donate platelets, whole blood or a double RBC donation instead. That was one of the main points we wanted to get across,” she said.

OBI currently diverts or encourages all females to donate other blood components instead of apheresis plasma, even if they have never been pregnant or had a blood transfusion or organ transplant.

But every center is different. United Blood Services in Las Vegas accepts plasma from females who indicate on the donor questionnaire that they have never been pregnant, had a miscarriage or an abortion, organ transplant or blood transfusion. That group represents 39 percent of the female population that voluntarily donates at UBS, according to Ron Hein, executive director of the center.

As for the other 61 percent, UBS “doesn’t defer, but we refer or triage them to a different protocol,” said Hein, who added that he has seen a major drop in the facility’s collection of plasma since the TRALI policy was implemented. Previously, the center was able to boost its supply by collecting “jumbo plasma” — a 600 ml unit that is then divided into three smaller volume units — but its new TRALI policy no longer allows this type of donation. Hein said the facility now relies on whole blood plasma to fill orders and directs some women donors in that direction. “We will always find a platform for our donors,” he said.

United Blood Services began educating its donors about TRALI more than a year ago by providing brochures and literature to female donors who were being diverted. Staff members were trained and standard operating procedures were created to specifically address the issues.

To date, Hein said donors have been cooperative. “Everything has been low-key. When donors who are used to doing automated procedures are asked to go back to whole blood, they ask why and we explain. It really hasn’t been a problem.”

The only problem is a drop in plasma donations, according to Hein, but he is seeking avenues to help increase those numbers. “There is a positive way to deal with the TRALI issue we face. If you actively seek and recruit male donors, it helps to offset the effects of TRALI,” he said.

Many centers are taking a pro-active approach not only to educate donors, but to create procedures for notifying donors if a recipient has a reaction to the donated blood.

The blood donor center at St. Joseph Hospital in Orange, Calif., stopped production of fresh frozen plasma, and established a process to educate staff and donors about TRALI as well as how to contact donors that may have caused a patient to develop the transfusion-related complication.

“We are in the process of switching over to male-only plasma,” said Alan Magray, MS, MT(ASCP)SBB, the hospital’s blood bank supervisor. “Much of our focus will be on donor notification, but so far we haven’t had any cases of TRALI. Because it is so rare, we will treat each case individually and take steps to notify the donor.”

Magray said the hospital’s donor notification process involves a phone call to the donor letting her know that she should not donate plasma and the reason why. He said the phone call also would stress that there is nothing an individual can do to “get rid of” the antibodies that cause TRALI.

“There’s not much you can do other than to tell them not to donate plasma. It’s not like the donor can get treatment or can be cured,” said Magray. “So we will tell them about the antibodies that they’ve developed and that these antibodies may cause a reaction in some patients, but we will also let them know that they are not infected with anything and they do not have a disease.”

Magray noted that TRALI is such a rare occurrence that it often is not always recognized or appropriately diagnosed. That still creates a problem, because donors — even those educated about TRALI — won’t be notified unless a patient who had a reaction was correctly diagnosed.

With that in mind, many hospitals, like Long Beach Memorial Medical Center in California, hope to someday implement the use of a computer alert or trigger that would notify a physician if a patient’s symptoms match that of a TRALI reaction.

“It would be great to have something in place to work with our electronic medical records to assist in identifying potential TRALI reactions,” said Janet Wilson, MT(ASCP)SBB, quality assurance supervisor in the department of pathology and the hospital’s blood bank. The facility currently is implementing a hospitalwide electronic medical records system, which Wilson hopes eventually will be able to handle the task of triggering an alert if TRALI symptoms appear.

“I attended the AABB Annual Meeting in Anaheim, and I went to a session that had someone speaking about a computer-based screening system for TRALI and I thought, ‘Wouldn’t that be great if we could get something like that here,’” said Wilson.

A study published in October 2005 in the American Journal of Clinical Pathology, authored by Heather E. Finlay; Lydia Cassorla, MD, MBA; John Feiner, MD; and Pearl Toy, MD, concluded that a computer-screening system identifies more cases of TRALI than are reported voluntarily by physicians. The study reviewed medical records of identified cases during a 45-day period at a teaching hospital. During that time period, 820 patients received 6,888 blood products. The computer-screening program diagnosed seven cases of TRALI, but only two had been reported by physicians. The system boasted a 99 percent accuracy rate and a 26 percent positive predictive value for detecting potential cases of TRALI.

For Wilson, this type of computer screening would not only benefit patients and physicians, but also assist in notifying donors. “It would be even better if the system could be set up so that if a patient is diagnosed with TRALI, a notice would come to the blood bank and the medical director could investigate.”

Many blood centers and hospitals are implementing programs to educate and notify donors. Whatever the method, Forsberg said it takes more than just a written plan. “It’s a collective effort and takes everyone to be involved in order to roll out a program and make it work.”

This article was published in the current issue of AABB News.