October 19, 2021
Hemovigilance is an evolving part of patient blood management intended to promote the development of processes to capture adverse consequences of blood therapy, according to Arthur Bracey, MD, from the Baylor St. Luke’s Medical Center and program chair of the education session “Leveraging the Electronic Health Record to Better Perform Hemovigilance in Hospital Based Settings,” held during the 2021 AABB Annual Meeting.
The first session speaker was Chester Andrzejewski, MD, from the University of Massachusetts Medical School, Baystate Health. He discussed what his institution is doing to enhance patient care via innovative electronic health records (EHRs) used to document hemotherapy. At Baystate, data are collected both by automated and manual approaches from the patient’s blood bank and EHR. The tools to tackle transfusion associated adverse events include hardware, software and “peopleware.” The hardware includes the EHR, transfusion medical services (TMS) and the laboratory information system (LIS). The software includes both electronic and paper-based forms, checklists, etc. The peopleware includes staff from the TMS and clinical labs, physician and nursing services, information technology, biostatisticians and patients.
Andrzejewski said that to track transfusion-associated adverse events, Baystate uses a hybrid system with both electronic and paper transfusion documentation. The paper forms are important for times when the computers are down. If electronic documentation is put in in real-time by nurses, a physician can review it from his office or anywhere else.
In addition to the standard documentation, the Baystate form includes calculated vital sign values, such as pulse and arterial pressure, and any changes from baseline systolic pressure at two points in time during the transfusion. There is also a place on the form to report a potential transfusion reaction; when one is reported, it automatically alerts the transfusion service.
He said that using this system has sped up the process of reporting suspected transfusion reactions. This “bedside and laboratory hemovigilance” — especially incorporating the use of patients’ EHRs — has had a key role in recognizing, managing and mitigating transfusion-associated adverse events.
The next speaker, Fernando Martinez, MD, MScPH, from the University of Texas MD Anderson Cancer Center, discussed the development of the hemovigilance unit both historically and, more specifically, at MD Anderson. He noted that transfusion is never risk-free and that a hemovigilance system captures adverse events related to the donation and transfusion of blood components to mitigate those risks and avoid future adverse events.
Hemovigilance systems were introduced at the end of the last century, with the first being the French system followed by the British Serious Hazards of Transfusion (SHOT) reporting system. The United States implemented the National Healthcare Safety Network (NHSN) Biovigilance Component Hemovigilance Module to track adverse transfusion events. Martinez noted that all of these different systems have methodological differences in data collection plus differences in definitions and times.
Overall, there is an adverse reaction rate of 0.22% across all of these different hemovigilance systems. Although transfusion reactions are usually captured by a passive reporting system, many more are identified by active surveillance, which is more accurate.
In 2019, MD Anderson Cancer Center developed the Hemovigilance Unit with the premise that knowledge about transfusion reactions could be improved. The Hemovigilance Unit is a hospital-based system embedded in the EHR that uses an algorithm based on NHSN definitions. The goal of this system is to detect events that are temporally related to transfusion to allow for real-time detection of transfusion reactions.
Collaboration with the nursing staff and other health providers is key to the program, as early detection leads to better outcomes.
The EHR-based dashboard allows quick access into the medical record, so all patients can be evaluated virtually as new information enters the EHR. The risk score allows for prioritization so providers can focus more frequent reviews on patients with the highest risk.
Martinez concluded that real-time reporting and active collaboration between the nursing and laboratory medicine staff has resulted in increased safety for patients. Specialist advanced providers can reach a patient within 12-15 minutes of an adverse event being detected and stop the transfusion. In addition, the institution has been able to increase detection of adverse events — and provide early interventions — at a transfusion reaction rate of 1.3% in their population of patients with cancer. This higher rate probably reflects the true rate of transfusion reactions, Martinez said.