Delayed transfusion reactions

[Terry Butler]

At my health system, we automatically perform a delayed transfusion workup when a patient's antibody screen changes from NEG to POS, when a new antibody is identified in a patient with previous antibodies or when the DAT strength increases during a 14 day period following transfusion with RBCs. This protocol involves retesting the original sample to include ASC, AC, DAT. We also pull the segments from units transfused, perform antigen typing and perform crossmatches on the pre and post samples. We were wondering if other transfusion services perform this type of extensive workup. Thanks!

[goodchild]

We do the same thing. We perform an investigation even if the transfusion took place at another institution. In those cases we use our state's HIE (health information exchange) website and/or contact the other transfusion service for information/testing that we need and see if they can provide it for us. We share the final interpretation from the medical director with the original institution in those cases.

 

We track the data and include it in our report at the transfusion committee.

[Eagle Eye]

We do the same as Terry. Many times they are delayed serologic transfusion reaction rather than delayed hemolytic transfusion reaction.

[R1R2]

We may do some testing depending on the antibody/symptoms/test results.   I prefer not to repeat previous testing.  I haven't pulled segments from units transfused in decades.  

[tbostock]

We do a delayed transfusion reaction workup when we suspect one:

Transfused within the last 2 weeks and:

 

Antibody screen now positive

DAT positive

Hemoglobin levels dropping

[Mabel Adams]

 

 

We would consider it a delayed transfusion reaction if the patient had signs & symptoms that were reported to us.  We consider finding a new antibody etc. a delayed serologic reaction and we don't have a mechanism for tracking them at this time.  Are we the exception or are all the other sites like us just keeping quiet on here?

[Sophie1210]

We do not automatically perform a workup. We only perform a transfusion workup if ordered by the physician, because that's only way we can charge for the work we've done. We also don't have the time or the staff to chase these down and try to figure out if they're reactions or not. If the patient is stable and not showing adverse signs, except a drop in hemoglobin, then it seems more academic than anything else. Unless it would change treatment I don't see the point in doing all of that work.

[tbostock]

We do not automatically perform a workup. We only perform a transfusion workup if ordered by the physician, because that's only way we can charge for the work we've done. We also don't have the time or the staff to chase these down and try to figure out if they're reactions or not. If the patient is stable and not showing adverse signs, except a drop in hemoglobin, then it seems more academic than anything else. Unless it would change treatment I don't see the point in doing all of that work.

We've only had a physician suspect a delayed transfusion reaction once.  We detect all of the others; in a few cases it did change treatment for the patient.  The physician couldn't figure out why the patient's H/H was dropping and was planning on doing endoscopy and other invasive procedures to rule out a bleed. 

 

It is part of our Transfusion Reaction policy that a physician does not need to "order" the workup as this is included in all blood orders in our EMR (a statement by the physician that he/she is authorizing a workup if indicated) so we're covered legally.

[Dr. Pepper]

We do as Terry Bostock does. I don't think that doing a "delayed reaction" workup (or calling it that) on every newly appearing antibody is always appropriate because it could be a primary antibody response that is not necessarily connected with potential RBC destruction. Some other thoughts:

- Why be concerned with the billing aspects? You found an antibody, so you ID it, do appropriate antigen typings on the patient, work up the positive DAT if your auto control on the panel is positive. I would think you would do this under any circumstances, and if your hospital transfusion policies, OKed by the medical staff, say this is what you normally do, it should be a standing order and you don't need to hunt down the doctor to place an order for it.

- Repeating past work: If your patient had a negative antibody screen last week and is positive today, wouldn't you like to know that that original result is correct? Could have been a technical or clerical error, specimen mixup etc.

-All the regulatory agencies want you to investigate and report out reactions, including delayed ones. I don't think working these up or not is optional. 

Edited April 18, 2014 by Dr. Pepper

[goodchild]

-All the regulatory agencies want you to investigate and report out reactions, including delayed ones. I don't think working these up or not is optional. 

 

AABB 7.4.3 Delayed Transfusion Reactions

If a delayed transfusion reaction is suspected or detected, tests shall be performed to determine the cause. The results of the evaluation shall be reported to the patient's physician and recorded in the patient's medical record.

 

CAP TRM.42150 Adverse Effects of Transfusion

The transfusion service medical director has established protocols for evaluation of adverse effects of transfusion, including follow-up for transfusion-transmitted diseases and delayed transfusion reactions.

[David Saikin]

We would consider it a delayed transfusion reaction if the patient had signs & symptoms that were reported to us.  We consider finding a new antibody etc. a delayed serologic reaction and we don't have a mechanism for tracking them at this time.  Are we the exception or are all the other sites like us just keeping quiet on here?

I am just like you Mabel

[MRPalisades]

If a recently transfused patient has a positive DAT and the Elution is positive for an antibody, we perform a Transfusion Reaction investigation and notify the patient's doctor and pathologist.

[John C. Staley]

I'm in league with Mable and David.  That's how we handled it at my previous life. 

[Sophie1210]

We do as Terry Bostock does. I don't think that doing a "delayed reaction" workup (or calling it that) on every newly appearing antibody is always appropriate because it could be a primary antibody response that is not necessarily connected with potential RBC destruction. Some other thoughts:

- Why be concerned with the billing aspects? You found an antibody, so you ID it, do appropriate antigen typings on the patient, work up the positive DAT if your auto control on the panel is positive. I would think you would do this under any circumstances, and if your hospital transfusion policies, OKed by the medical staff, say this is what you normally do, it should be a standing order and you don't need to hunt down the doctor to place an order for it.

- Repeating past work: If your patient had a negative antibody screen last week and is positive today, wouldn't you like to know that that original result is correct? Could have been a technical or clerical error, specimen mixup etc.

-All the regulatory agencies want you to investigate and report out reactions, including delayed ones. I don't think working these up or not is optional. 

We are concerned with billing because we are a small hospital and can't do DAT investigations, elutions etc. We have to send to the reference lab. If we don't have a specific order from the physician then we eat the cost of that reference lab workup. In terms of the regulatory agencies we have to work them up if they're suspected. It doesn't say that the blood bank is responsible for suspecting them or detecting them. If you have one tech (generalist) in blood bank on day shift and 1 covering heme/blood bank on evenings and nights, chasing these down ourselves is not possible. If a doctor suspects it then they can order the workup. That's what our policy states - transfusion reactions are called by the nurse or physician and not the blood bank.

Edited April 19, 2014 by Sophie1210

[rravkin@aol.com]

At my health system, we automatically perform a delayed transfusion workup when a patient's antibody screen changes from NEG to POS, when a new antibody is identified in a patient with previous antibodies or when the DAT strength increases during a 14 day period following transfusion with RBCs. This protocol involves retesting the original sample to include ASC, AC, DAT. We also pull the segments from units transfused, perform antigen typing and perform crossmatches on the pre and post samples. We were wondering if other transfusion services perform this type of extensive workup. Thanks!

Terry, as I wish my facility was as proactive as yours in practice and procedure I have to wonder about effect on patient outcomes, billing, reimbursements, use of reagents and tech-time, and again reimbursements. It's a shame that some are forced to work with restrictions.   

[cthherbal ☆]

We investigate each one we find (with a newly identified antibody) and consider it a potential delayed. Most are serologic only and patient is not symtomatic or showing signs of hemolysis.

[L106]

I am just like you Mabel

[Karrieb61]

I would like to revisit this and hope some of you will respond.

I looked at the Regulations and the AABB standard says "if a delayed TXRX is suspected or detected....well my question is- suspected by whom? I don't think we are the ones responsible for deciding that a patient has or has not had a suspected delayed TXRX. We are a small lab  like Sophie1210 and to test every potential donor segment and maybe sending the patient sample to our Reference lab for an eluate (under specific circumstances) because WE think a reaction has occurred seems to be valuable only academically and I doubt its legal to charge the patient if the patient's physician has not ordered the tests.

I am looking at this post because I just rewrote our previously unclear SOP on TX RXs and decided with our part-time pathologist (with no blood bank background) that we would perform a delayed workup only if ordered by the physician. That never happens basically. We have two oncologists who will order the usual chem and heme tests after a transfusion which implies that they are wondering about a delayed reaction (based primarily on continued low H&H) but there never is any conversation with the Blood Bank about their suspicions regarding a delayed TXRx.

So bottom line is- who is supposed to make the call to order an official workup? I want to meet AABB Standard 7.4.3 but don't feel its appropriate for us to order and  charge for additional tests if the order is supposed to come from the physician.

 

What we do now is the usual antibody ID on any patient with a positive screen, we send out an eluate to the Reference Lab when it meets our criteria (new or stronger pos DAT, transfusion within 3 months etc) and we charge for those tests but I don't want to see the techs pull out old segments, find that a donor unit is positive for the antigen that has now (possibly) caused the new antibody to form, and start declaring that the patient has had a delayed TXRX. Really, if a new antibody is identified, then we will obviously screen future donor units for that antibody and it does go into our LIS/HIS for the physician to review- what would be the point of the Blood Bank going any further without an official MD order?

[Malcolm Needs ☆]

I agree entirely with you Karrieb61.  It is NOT the place for a transfusion laboratory to declare a transfusion reaction.  Just because there is a positive direct antiglobulin test and/or a novel antibody specificity is detected, or a unit is later found to be incompatible, it does not mean that the patient is undergoing a delayed haemolytic transfusion reaction.  It is much more common for them to be undergoing a delayed serological transfusion reaction, where all the Blood Bank tests point to a reaction, but there are no adverse clinical sequelae.  A true delayed haemolytic transfusion reaction can ONLY be diagnosed if there are symptoms, and such a diagnosis can only be made by a doctor.

[goodchild]

Your medical director (in consultation with the blood bank section medical director/technical consultant and/or the general supervisor(s) for the department) needs to decide upon a transfusion reaction policy/process/procedure(s).

 

This would include the standards/criteria of when to 'suspect' a transfusion reaction and when one has been detected.

 

As far as billing stuff, check with the billing compliance officer at your hospital. I don't think it should be a problem.. If you get a positive antibody screen, do you page the physician to submit an order for the antibody ID before you start doing the workup? If the autocontrol is positive, do you page them to order a DAT before you perform it?  We don't because they're an inherent part of the testing and we've documented this in our policy/protocol/process/procedure documents. It should be the same way with your transfusion reaction work ups, most of the extra testing you have to do would be inherently part of the antibody ID itself anyhow.

 

And as far as not wanting to pull old samples and transfused unit segments, I remember when we detected a delayed reaction to anti-Js(a) in the post-crossmatch phase. Retesting the original specimen with additional panel cells showed that the antibody had been there all along, just waiting for the right donor unit.

 

If you're going to wait on the attending physician to make the call, good luck.

[Karrieb61]

Unfortunately, in our little hospital, the medical director has no blood bank background and our part-time Pathologist has no blood bank background. We just redid the trans reac SOP and decided that we wouldn't be the ones to "call" a delayed hemolytic reaction (with or without evident hemolysis) and that our Pathologist would have to call the patient's physician so they could discuss the situation, lab results etc and decide what to call "it". But I guarantee that our Pathologist in reality will make no such call. I did, BTW, rewrite the existing SOP to include all the usual criteria used to suspect a delayed TX RX but again, who makes the decision to fill out a form declaring a formal work-up and says its a "delayed hemolytic reaction"?

I have a call into the AABB to clarify Std 7.4.3 which does not say WHO suspects  or detects a delayed trans reaction. I am probably over thinking and over-worrying this but I don't want to be confronted with an assessor who asks to see the records of any suspected or detected tx rx. We will never have one to show if we wait for the MD to call it. I would hate to be considered out of compliance with the Standard.

[Malcolm Needs ☆]

Even evident haemolysis does not necessarily mean an antibody-related transfusion reaction; it could be hyperhaemolysis.  I'm sorry, but the Medical Director gets paid good money (very good money) for making these decisions, whereas you don't.

 

Make the wrong decision in the case of hyperhaemolysis (i.e., call it a delayed haemolytic transfusion reaction and give more blood) and the patient dies; who goes to court?  You, or the Medical Director?  I think you know the answer.

[Liz0316]

If we suspect a delayed serologic transfusion reaction, we will pull the segments from the previously transfused units (if transfused at our facility). We also call other BB if we know the patient may have been elsewhere. Pulling segments doesn't happen often, but hospital hopping patients are frequent. I like as complete a history as I can get when working with a new patient with antibodies. I have been known to call all over the country. Just last month, between 4 in-state hospitals, we were able to follow her right down the coast - making a new antibody with every admission! She now has 3 antibodies and all involved are aware. I'm willing to buy the train ticket out of the north east!

[goodchild]

It still fascinates me that there are so many subtle differences among all of the hospitals working off unique interpretations of a few sentences worth of guidelines and regulations.

[amym1586]

Anyone willing to share their Delayed Transfusion policy?