Hell, no, I won't go? (musings on pandemic flu)

In the 1960s, a famous antiwar mantra about Vietnam was, "Hell, no, I won't go!" This blog's title is a take-off on that phrase as related to who of us will show up for work during a flu pandemic.

Having just participated in a provincial project to develop a contingency plan for blood shortages due to pandemics and other disasters, I got to wondering how many hospital transfusion services (TS) have developed such plans and particularly about contingencies for staff shortages.

For example, what would happen in your TS during a a flu pandemic, if a significant percentage of staff (30-40% or more) were too sick to work, some stayed home to take care of children or other family members who were ill or because schools had closed, and others stayed home out of fear of becoming infected in the hospital?

For interest, in Canada during the SARS crisis of 2003, health care workers (HCW) were at great risk. One small study showed that among 43 nurses who worked in two Toronto critical care units with SARS patients, 8 of 32 nurses who entered a SARS patient's room were infected.

• SARS among Critical Care Nurses, Toronto. Emerg Infect Dis [serial online] 2004.

A larger study showed that of 74 SARS cases reported during April 15 -June 9 to Toronto Public Health, 39% occurred among health care workers, 38% occurred as a result of exposure during hospitalization, and 23% occurred among hospital visitors.

• Update: Severe Acute Respiratory Syndrome --- Toronto, Canada, 2003. MMWR. June 13, 2003 /52(23);547-50.

Given that much has been learned from the SARS crisis, today, would you put the duty to care for pandemic flu and other patients above potential health risks to yourself and family and above your responsibility to care for your family?

For overviews of these issues, see:

1. Hospital pandemic preparedness: health care workers’ opinions on working during a pandemic. Med J of Australia 2007; 187 (11/12): 676.

• Key findings:
  
• 67% would work during a pandemic;
• 26% would stay home to care for dependents;
• 10% admitted they would stay away because of fear of catching influenza.

2. Will first-responders show up for work during a pandemic? Lessons from a smallpox vaccination survey of paramedics. Disaster Manag Response 2007 Apr-Jun;5(2):45-8.

• Key findings:
  
• More than 80% of respondents would not remain on duty if there were no vaccine and protective gear;
  
• Even if protective gear was available but the vaccine was unavailable, only 39% of respondents would remain on duty.

3. Influenza pandemic and professional duty: family or patients first? A survey of hospital employees. BMC Public Health. 2006; 6: 311.

• Key findings:
  
• 28% agreed that it would be professionally acceptable for HCW to abandon their workplace during a pandemic in order to protect themselves and their families;
  
• 77% disagreed with the statement that HCW should be permanently dismissed for not reporting to work during a pandemic;
  
• 21% of respondents agreed that HCW without children should primarily care for the influenza patients.

BLOOD CONTINGENCY PLANS
Most of the publicly available plans are designed to offer guidance at a national level, and, as would be expected, tend to focus mostly on the blood suppliers. See Further Reading below.

Blood shortage preparedness for hospitals is built around the twin pillars of
(i) Practicing sound blood management at all times;
(ii) Inventory levels triggering the contingency plan, at which point hospitals are expected to cut back on inventory and begin to triage which patients will be transfused and which will not.

In Canada several provinces are developing blood contingency plans targetted to hospitals. These plans are based in part on the UK integrated blood shortage plan (see Further Reading below) and provide guidelines for TS to use in developing their own plans. Only a few forward-looking hospital regions have begun planning for severe blood shortages that would occur during pandemics. Almost all have plans for short term shortages caused by mass casualties and similar events.

Existing blood contingency plans are mostly designed to cover blood shortages regardless of cause, e.g., pandemic, terrorist attack, natural disaster, mass casualty accident.

Hospital-focused plans tend to assume that associated problems such as power outages, transportation disruption, communication failures, and staff shortages with be covered by hospital emergency preparedness plans and regional emergency planners.

Emergency preparedness planners mainly use the Incident Command System (ICS) model to develop to their plans. Most people in the transfusion medicine community have never heard of ICS. (Also see information on disaster response systems in Canada)

STAFF SHORTAGES
Transfusion services must be prepared for severe staff shortages. In pandemics, the effects of a staff shortage may be lessened because fewer transfusions will occur due to a shortage of blood donors. Laboratories that use manual test methods and procedures that are more labour intensive will be hit hardest.

There are many strategies that TS labs can use to develop contingencies for staff shortages. Most revolve around identifying core services that must be maintained and ensuring an adequate supply of trained staff to perform them.

Bottom line: The results of research into the attitudes of HCW to caring for families and protecting their own health during pandemics suggest that preparedness strategies need to extend beyond the logistics of ensuring adequate staff. Equally important will be

• Staff education about pandemics and how the disease is spread, combined with
  
• Equipment and other strategies designed to protect HCW from infection.

QUESTIONS (food for thought)

1. Does your hospital have a blood shortage contingency plan?
2. If yes, does it include contingencies for staff shortages?
3. Have you received education about pandemic flu?
4. How do you think you will be protected when you come to work during a flu pandemic?
5. Do you know who will be given priority for available vaccine during a flu pandemic?
6. Other than being ill, under which circumstances would you not show up for work during a flu pandemic?
   
7. As a health professional, would you risk your life for others or is it Hell, no, I won't go?
   

If you care to contribute ideas or feedback, please comment below, anonymously or attributed.

New on TraQ

Further Reading (all PDF)

WHO. Maintaining a safe and adequate blood supply in the event of pandemic influenza. Guidelines for national blood transfusion services (19 May, 2006).

CANADA

• CBS. Pandemic Influenza Preparedness Plan Version 2.0 (Issue Date: 2006-11-24).
  

UK

• National Blood Service. Emergency planning - Command and control (2002).
  

• National Blood Service. Development of an integrated blood shortage plan for the National Blood Service and hospitals (December 2004).
  

• National Blood Service. An integrated plan for the National Blood Service and hospitals to address platelet shortages. 6 September 2006.

USA

• AABB. Disaster operations handbook. Coordinating the nation's blood supply during disasters and biological events (Feb. 2003).

• AABB. Disaster operations handbook. Coordinating the nation's blood supply during disasters and biological events. Hospital supplement (Feb. 2003).
  

• AABB interorganizational task force on pandemic influenza and the blood supply. Planning document version 1.0 - October 3, 2006.

• AABB interorganizational task force on pandemic influenza and the blood supply. Planning checklist version 1.0 - October 3, 2006.

Musings on the blood business

Several recent papers got me to focus once again on transfusion medicine as a business instead of as a branch of medicine. Some musings:

1. The first paper is an editorial in the 25 Sept. issue of the Canadian Medical Association Journal featuring a systematic review in the same issue on the use of erythropoietin in critically ill patients.

• Hebert PC, Stanbrook M. Indication creep: physician beware. (editorial) CMAJ 2007;177(7): 697. (full free text:)

One finding of the review was that when the treatment (costing ~$400/dose) is used off-label for critically ill patients, it typically saves less than one unit of blood, does not improve clinical outcomes, and potentially results in more thrombotic complications.

The editorial authors note that, in the USA, erythropoietin manufacturers have aggressively promoted the drug via direct-to-consumer advertising and incentive payments to physicians. The editorial mentions that, while off-label use may lead to treatment innovations, they also create a loophole for drug manufacturers to bypass regulatory oversight designed to protect patients.

2. The second paper is in the November issue of Transfusion:

• Constantine MM, Thomas W, Whitman L, Kahwash E, Dolan ES, Smith S, Caudle CJ, Burton E, Anderson DR. Intravenous immunoglobulin utilization in the Canadian Atlantic provinces: a report of the Atlantic Collaborative Intravenous Immune Globulin Utilization Working Group. Transfusion 2007; 47 (11), 2072–80.

The authors present as background these facts:

• Since its introduction in the 1980s IVIG use has steadily increased (since 1990 at an average annual rate of 12.5 %).
• Off-label uses have grown significantly.
• In Canada there is no direct charge for individual patients or hospitals for IVIG: provincial governments are billed annually by Canada's two blood suppliers (CBS and H-Q) for blood products used the previous year.
• CBS convened a national conference in 2000 on IVIG utilization: a key recommendations was for provinces to develop utilization boards.
• BC was the first to develop a utilization board and their report on IVIG utilization suggested that approximately 50 percent of IVIG use was for off-label indications. Also see

• IVIG utilization management handbook. Vancouver: British Columbia Provincial Blood Coordinating Office; 2002.

3. The last of the recent articles is from the 25 Sept. issue of CMAJ. The title says it all, but the humorous piece is about an attempt to develop and market a drug for premature ejaculation; the sub-theme is disease mongering:

• Cassels A. W is for Wilbert's wee willy (which tends to go off prematurely). CMAJ 2007;177(7): 816. (full free text)

All of which harkens back to two other humourous yet serious articles featured earlier on TraQ (both are full free text):

• Sackett DL, Oxman AD. HARLOT, plc. An amalgamation of the world's two oldest professions. A new niche company specializing in How to Achieve positive Results without actually Lying to Overcome the Truth. Br Med J 2003; 327:1442-5.

• Oxman AD, Sackett DL, Chalmers I, Prescott TE. A surrealistic mega-analysis of redisorganization theories. J R Soc Med 2005 Dec; 98(12):563-8.

Hope you enjoy the articles and their underlying messages to us as health providers.

Cheers, Pat

• New on TraQ
  

What's up doc? Welcome to docovigilance

This blog results from my take on two articles on vigilance schemes to promote transfusion and transplant safety:

1. AABB News article: Hemovigilance to biovigilance. An evolution of transfusion safety

Hemovigilance can be defined as

• A set of surveillance procedures, from the collection of blood and its components, to the follow up of recipients to collect and assess information on unexpected or undesirable effects resulting from the therapeutic use of labile blood products, and to prevent their occurrence or recurrence.

Source: IBTS website

The article in AABB News points out that biovigilance goes beyond blood to incorporate tissue, organ and cellular products. For many years the AABB has been working to expand beyond blood transfusion to include standards for cells, tissues, and organs.

Biovigilance -- nice name! Biovigilance can be defined as

The detection, gathering and analysis of information regarding the untoward and unexpected events of blood transfusion and transplantation of cells, tissues and organs, with the objectives of:

• early warning of safety issues
• exchange of valid information
• application of evidence for practice improvement
• promotion of educational activities
  

Source: A National Biovigilance Network

2. The second article was part of Improving blood utilization - Session 3 in the conference proceedings published as a supplement to the August issue of Transfusion:

The Role of Blood Centers in Transfusion Recipient Care. Second Joint Conference of America's Blood Centers and the European Blood Alliance

All of the blood utilization presentations are worth reading but this one caught my eye:

Dzik S. Use of a computer-assisted system for blood utilization review. Transfusion 2007;47(s2): 142S

The author's hospital uses multiple blood utilization strategies, including a hospital transfusion committee, educational conferences for clinicians, wallet cards with reminders of transfusion guidelines, and more. But the presentation focuses on

• Computerized physician order entry (POE)
• Computer-assisted blood utilization review and feedback
  

In brief, the computer-assisted system functions as follows:

1. All routine blood requests occur via POE software. Criteria for blood usage review are displayed on the computer screen at the time of the request. An unusual request triggers a pop-up window that alerts the physician to a possible error in the order. For blood components, a reason for transfusion must be selected before the software will process the order.

2. Once daily, a program automatically generates a report that identifies all patients transfused in the past 24 hrs, along with demographics such as age and sex, as well as pretransfusion lab results.

3. Patient reports are compared with criteria for RBC and FFP transfusion and those not meeting the algorithms are flagged for daily reports that include pretransfusion and post-transfusion lab results.

4. A TM physician reviews the daily reports and physicians who made questionable decisions to transfuse are targeted for education.

A non-judgmental e-mail is sent to the clinician within 24 hours of the decision to transfuse.The e-mail displays the pre- and post-transfusion lab data; provides the criteria for the review process; and links to an in-house educational site.

On the website, for each blood component the physiology of blood use is summarized and articles on the clinical use of blood are listed. Each article is linked to a summary of the paper's findings and to the published paper.

The e-mail invites the physician to reply if there are questions or concerns.

The author acknowledges that the program is rudimentary and that much could be done to improve its capabilities and expand future uses.

DOCOVIGILANCE
It struck me that what Dzik's computer program does is docovigilance, which can be defined as:

A set of surveillance procedures, from the ordering of blood and its components, to the follow up of recipients, to collect information on a physician's (doc's) decision to transfuse and to

• assess prospectively whether or not transfusion is warranted and, if not, to prevent its occurrence by alerting physicians to possible order errors
  
• assess retrospectively whether or not the transfusion met established criteria and, if not, to prevent its likelihood of recurrence by physician education
  

There's considerable potential for docovigilance. Dzik mentions several future uses, including

• Monitoring the decision not to transfuse
• Providing summary statistics on how each clinician's performance compares with that of peers (benchmarking)
• Generating data on transfusion decisions across many patients and linking data to patient outcomes with a view to assessing transfusion guidelines
  

Seems that docovigilance has growth potential. To an innovative computer company, it could be an opportunity for growing the business.

Hemovigilance to biovigilance to docovigilance. Thar may be gold in them thar hills! Of course, creating a viable product from a good idea is fraught with difficulties. Just think of artificial blood substitutes like hemoglobin-based oxygen carriers....

One last musing.... Despite receiving extensive education in transfusion science while an under-graduate, if a medical laboratory technologist who had worked in chemistry or another area of the clinical laboratory for many years was hired to work in a transfusion service, the technologist would receive comprehensive re-training and competency assessment before being allowed to perform pretransfusion testing.

Yet physicians are permitted to prescribe transfusions with only a few hours, if that, of transfusion medicine education. What is wrong with this picture?

New on TraQ

Hawthorne effect in transfusion research - a thorny issue?

I first came across the Hawthorne effect (HE) when taking a Masters of Education after teaching for 10 years. Teaching and then getting formal qualifications may seem bass-ackwards but that's how many health professionals do it. You get into teaching because you like it, then take another degree once you decide to make it a career.

Recently, I was surprised to see reference to the HE appear in a recent paper in the Supplement to the August 2007 issue of Transfusion. The Transfusion supplement reports the proceedings of this conference:

• The Role of Blood Centers in Transfusion Recipient Care. Second Joint Conference of America's Blood Centers and the European Blood Alliance

The HE is usually defined as the tendency of research subjects to act atypically as a result of their awareness of being studied, as opposed to any actual treatment that has occurred, and has come to be one of the confounding variables that applies to behavioral research.

The HE got its name from a project (1924 - 1932) by researchers from Harvard Business School on the impact of improved working conditions on productivity done in the Hawthorne Plant of the Western Electric Company (now Lucent) near Chicago.

A major finding - the one that became known as the HE - was that, regardless of the experimental manipulation, worker production seemed to improve. Researchers concluded that the workers were pleased to receive attention from the researchers, who expressed an interest in them, and therefore worked harder.

Since then the HE (which I have come to call the on stage effect) has been broadened to relate to almost every kind of human behavioral research, including educational, clinical, and transfusion medicine research.

Note that the original Hawthorne research was flawed and its findings suspect. For example, the most famous and longest study (1927 - 32), and the one giving rise to the HE, involved only five women, two of whom were replaced mid-study for insubordination and slow work with faster, more compliant workers. See:

• The Hawthorne defect: Persistence of a flawed theory
• Hawthorne effect

Regardless of the validity of the original research, the principle of the HE, that observation may have a significant influence on a study's outcome, seems to have life as a possible confounder in studies involving human behavior.

The HE is mentioned in this paper of the Transfusion supplement:

Tinmouth A. Reducing the amount of blood transfused by changing clinicians' transfusion practices. Transfusion 2007 Aug;47 (s2):132S-136S.

The research involved a systematic review to evaluate published literature to determine the relative effectiveness of interventions to improve transfusion practice. Researchers identified 25 studies from 1983 to 2005 that examined intervention effectiveness and provided data both before and after the introduction of the intervention. The most commonly used interventions were guidelines, education, and audit with feedback. Tinmouth concluded that

• Published literature suggests that even simple interventions may be effective
• Data are very limited because of the poor quality of the studies
• Confounders include lack of controls, publication bias, and the HE

Tinmouth recommends that more randomized controlled studies be done to properly evaluate strategies to improve physician practice.

The conference proceedings includes many papers that will interest laboratory, nursing, and medical transfusion specialists and is highly recommended. Sample breakout sessions include:

• Right patient, right blood
• Improving blood utilization
• Optimizing blood center-hospital relationships
• Better blood recipient, inventory & supply chain management

As to the HE, I suspect that it illustrates something that I have always believed and regularly practice:

• Never let the truth get in the way of a good story

Cheers, Pat

Sharing the heavy lifting at conferences

This month's blog is meant to stimulate discussion.

Today transfusion medicine (TM) associations are largely composed of medical laboratory technologists*, nurses, and physicians and not in equal numbers. In many TM associations, from most to least, it's often technologists -->physicians-->nurses, although the number of nurse members is growing. Other groups also belong to TM associations, e.g., scientists, recruiters, administrators, industry representatives, etc. But for purposes of this blog, I'll stick to the doc-tech-nurse troika, where a "doc" could be an MD or PhD level scientist or MD-PhD.

So why is it that at many conferences the speaker list is mostly docs with technologists and nurses a definite minority on the programs? Today more non-doc health professionals are speaking at conferences than in the past, but there is still a way to go.

And there may be a difference between countries as well. A quick glance at the AABB program shows something for all, as shown by Saturday's program for 2007

Similarly the May CSTM conference program had a selection of topics targetted at techs and nurses, with speakers from each group.

It may be my imagination but are there fewer non-docs in this Down Under program?

Possible rationales for the preponderance of doc speakers at TM conferences:

1: Annual meetings are scientific conferences and docs do the bulk of research. True, but should not conferences represent the interests of all an association's members? And there are many topics that involve research and best practices that could be presented by non-docs.

2. Only docs can afford to go to conferences these days, or possibly are better funded by their employers. And docs tend to listen only to other docs. Okay, this one's slightly tongue-in -cheek...

3. It's a hangover from the old days when the physician was the paternalistic "captain of the health care ship", in which "father knows best". See

• Doctors and nurses: doing it differently. The time is ripe for a major reconstruction

As someone who has spoken at many conferences over the years, I know that presenting is heavy lifting. It's more onerous if you need to create a brand new talk, as opposed to updating the same talk given many times before.

But there are many types of heavy lifting. For example, if you examine TM conference organizing committees, in Canada it's typically a physician who is the conference chair, co-chair, or scientific chair and he or she works long hours as a dedicated volunteer. However, it's often technologists who do most of the heavy lifting required to put on a successful conference. And usually their trench work happens after hours, eating into family, relaxation, and recreational time. The case can be made that it's a matter of technologists being more numerous than docs, but I suspect that it's more than that.

Volunteering is wonderful but it's only just that the load be shared equitably. I'm unaware of the situation in other countries that rely heavily on volunteers to organize conferences.

As an aside, I use the term volunteer loosely as sometimes staff are told they are volunteering.

In summary, many presentations by docs are relevant and of interest to non-docs. But it benefits everyone when all professionals in the TM community are active participants in the presentations at conferences, not relegated mainly to trench duties, and when every team member's expertise is validated by the honour of being an invited speaker.

I think it's a sign of a discipline's maturity and strength when there are lots of non-docs on the conference program. It would be nice to see more docs on organizing committees too.

Just some food for thought....

------------------------------------------------
* also known as clinical laboratory scientists, medical laboratory scientists, and biomedical scientists

Informed consent for transfusions - take this job and shove it?

If you know someone who has had a transfusion recently, ask them if a physician or nurse explained the risks and benefits and, if during or after their hospital stay, they were notified in writing that they were transfused. Chances are, maybe not, even though both policies have been promoted as best practice for years now.

In Canada more than a decade ago Justice Krever (Commission of Inquiry on the Blood System in Canada), made recommendations on informed consent and documentation:

• Capen K. Informed consent and blood transfusions: what does Krever's interim report mean to doctors? CMAJ 1998 Jan 13;158(1):92-4.

To quote Capen:

• In March 1995 the Krever inquiry released an interim report, which contained a strong warning that the informed-consent requirement applies specifically to the administration of blood or blood products, and the routine consent form signed upon admission to hospital does not fulfil this requirement.
• It also said physicians should prepare patients well in advance of scheduled surgery to give them adequate time to consider reasonable alternatives.
• As well, doctors should provide information on these alternatives.
• The interim report said doctors must ensure that documentation occurs every time consent is provided, and that all treatments or procedures are recorded in the chart.

Despite inclusion in blood safety standards, many transfusion services in Canada and around the globe are still developing processes for informed consent and documented notification of transfusion. A paper by Canadian authors and editorial in the April issue of Transfusion deal with these related issues:

• Killion DF, Schiff PD, Shoos Lipton K. Informed consent: working toward a meaningful dialogue (editorial) Transfusion 2007 Apr;47 (4), 557-8.
• Rock G, Berger R, Filion D, Touche D, Neurath D, Wells G, Elsaadany S, Afzal M. Documenting a transfusion: how well is it done? Transfusion 2007 Apr;47(4):568-72.

In brief, Rock and coworkers did a retrospective review of 1005 patient charts with these results for documentation of informed consent and transfusion:

• In 75% of cases the physician had not documented that any discussion had occurred regarding the risks and/or benefits or alternatives.
• Only 12% of charts included information that patients were subsequently told what blood components were transfused.
• The discharge summary recorded transfusion information in 32.1% of cases whereas the consult note had this information in 26.3%.

If informed consent is still not a reality, why not? The editorial authors propose as possible mitigating factors (1) distressed patients in pain and (2) health professionals who are rushed. They offer the following suggestions as a follow-up to the Rock study:

1. Perform more studies to determine how widespread informed consent is
2. Change the current model of informed consent so that, instead of relying heavily on physicians, who bear ultimate legal responsibility for transfusion, trained transfusion staff be used to obtain informed consent.

The advantages are that transfusion staff understand the risks and benefits of transfusion, as well as patient needs, and are better equipped to follow through with documentation.

To meet best practice standards most transfusion services in Canada are actively promoting informed consent and documentation:

• TraQ resource library - Informed consent

CHANGE THE MODEL?
Informed consent for transfusions - whose job is it, anyway? Is the answer to change the model and shift obtaining informed consent to trained transfusion staff? And who would these staff be? Nurse transfusion specialists? Transfusion safety officers, whether medical laboratory technologists or nurses? In some Canadian hospitals nurses already handle informed consent. What problems may this shift to transfusion staff potentially create for physician responsibility for transfusion when the inevitable mistakes are made?

In pondering the issue of shifting responsibility for informed consent, I could not help but think of a shift in responsibility that happens in some rural hospitals. In towns where the laboratory is not staffed after hours by technologists, nurses are asked to issue blood from the transfusion service. Presumably they are trained in issuing procedures, but how well is open to debate. And in some locales nurses have refused to issue blood, claiming it is an effort to shift work from the laboratory to the nursing staff, in effect making nurses subsidize the lab service, which saves money by not running the lab after hours.

Is the suggestion of a new model as proposed by the Transfusion editorial another example of offloading responsibilty to others, others who are supposedly less busy than physicians? Or is this view too cynical? With patient safety coming first (not politics), is the proposed model simply a pragmatic view - do what works best for the patient. Regardless, any new model must proactively deal with potential problems caused by a shift in responsibilty for informed consent to transfusion staff.

Lastly, how representative is the Rock study of Canadian hospital performance in obtaining informed consent from patients and providing written documentation of transfusion? We can only speculate. If you are not Canadian and think your hospitals perform better, my quess is, think again. The problem is likely widespread in the USA, the UK, and elsewhere. You will not know without extensive audits.

Clearly, much work remains to be done in fulfilling some of Justice Krever's most basic recommendations. In the meantime, informed consent seems to a case of take this job and shove it!

**Be sure to check out the "comments" section below.**

"STOP! Check the patient's wristband."

There is an excellent paper involving six countries by the BEST Collaborative in the May 2007 issue of Transfusion:

• Murphy MF, Casbard AC, Ballard S, Shulman IA, Heddle N, Aubuchon JP, et al. on behalf of the BEST Research Collaborative. Prevention of bedside errors in transfusion medicine (PROBE-TM) study: a cluster-randomized, matched-paired clinical areas trial of a simple intervention to reduce errors in the pretransfusion bedside check. Transfusion 2007 May; 47(5): 771-80.

The paper has much to recommend it:

1. The research concerns transfusion to the wrong patient, which is the most important serious avoidable hazard of transfusion. It's always nice to read research that tackles transfusion issues that are both serious and common, i.e., ones that are clearly and directly significant to transfusion practice and patient safety. And after complaining about the content of Transfusion and its relevance to practice for technologists and nurses in an earlier blog (Whither immunohematology in AABB's Transfusion? ), the May issue is loaded:

• Table of Contents: Transfusion - May 2007

2. The paper reports on a simple low technology intervention for reducing patient identification errors, namely a sticker tag that visually reminds transfusionists to stop and check the patient's wristband and requires removal to spike the unit.

• The sticker reads, "STOP: Check the patient's wristband."

Low tech processes that work are bound to have wider applicability in smaller rural transfusion services and in the developing world.

3. An accompanying editorial (Kaplan H. Safer design.Transfusion 2007 May; 47(5): 758-9) discusses the BEST low tech approach and a high tech approach using radio-frequency microchips, examples of which are in TraQ's technology clearinghouse.

• Sandler SG, Langeberg A, DeBandi L, et al. Radiofrequency identification technology can standardize and document blood collections and transfusions. Transfusion 2007 May;47(5):763-70.

4. The BEST paper can be used to teach how to analyse scientific papers. Besides having an interesting design (multicenter cluster-randomized controlled trial involving short-term and long-term follow-up), the authors discuss multiple weaknesses and strengths of the research and basic statistical concepts such as sample size and statistical power.

5. The paper is a rare example of a negative study that gets published - the stickers had no overall effect on improving compliance with the bedside wristband check. Indeed, the results were slightly worse in the intervention group at the late re-audit stage, 8 weeks after introducing the sticker tag.

The authors speculate that this may have been a chance finding or that the constant reminder may have irritated the nurses and/or added to the complexity, producing the opposite effect to the one intended.

One can speculate that, if one part of a process is stressed, other critical parts may be inadvertently de-emphasized and forgotten, such as forgetting to breath when learning a new exercise for the first time.

Interestingly, the Kaplan editorial notes that procedural strategies are perhaps the least reliable for managing risks, yet are the ones often employed in transfusion and nursing practice where redundancy is typically used to increase reliability, e.g., having a second person check the work of another as done with the 2-person nursing check of patient and donor identification at the bedside prior to transfusion; or the 2-person check done when issuing blood from the transfusion service.

It's the old dictum about catching an error on the first inspection. If you have just seen your colleague perform several checks, you may not be as rigorous when confirming their work.

This study reminds me of other studies that have shown that educational interventions sometimes have no effect on changing behavior. Such results seem counterintuitive because we all want to believe that education will produce a positive effect. The trick is in discovering the right intervention or combination of interventions to motivate the target audience to change.

It's hard to comprehend how a sticker-tag saying "STOP: Check the patient's wristband." could have the reverse effect on a heath provider's performance. Investigating why this occurred could have relevance for similar studies.

If you would care to speculate or discuss further, please leave a comment.

Blood shortages to be passé?

Hallelujah! Blood shortages may be passé!

Such were the headlines this past week with a flurry of news items about bacterial enzymes that can cut antigen-bearing sugar molecules from the surface of red blood cells. The enzymes can render A and B rbc into group O rbc, producing so-called "universal donor" cells that can be transfused to recipients of any ABO group, providing the rbc are Rh-negative and providing recipients lack unexpected antibodies.

The news was based on this recent publication by Danish researchers:

• Qiyong P Liu QP et al. Bacterial glycosidases for the production of universal red blood cells. Nature Biotechnology 2007 Mar;25(3):327-37.

Was it really news given that the concept has been around for about 25 years? For example:

• Goldstein J, Siviglia G, Hurst R, Lenny L, Reich L. Group B erythrocytes enzymatically converted to group O survive normally in A, B, and O individuals. Science 1982 Jan 8;215(4529):168-70.
• Dybus S, Aminoff D. Action of alpha-galactosidase from Clostridium sporogenes and coffee beans on blood group B antigen of erythrocytes. The effect on the viability of erythrocytes in circulation.Transfusion 1983 May-Jun;23(3):244-7.

Editorials back then were similar to today:
Cowart VS. Green coffee beans may solve a blood bank problem. JAMA 1982 Jan 1;247(1):12.

Similar research followed in the 1990s:

• The conversion of group B red blood cells into group O by an alpha-D-galactosidase from taro (Colocasia esculenta). Carbohydr Res 1991 Sep 18; 217:191-200.

Looking back, I think that I first became aware of the possibility of enzymes to cleave ABO blood group antigens in this 1994 paper and accompanying editorial:

• Goldstein J, Galbraith RA. Transfusions to group O subjects of 2 units of red cells enzymatically converted from group B to group O. Transfusion 1994 Mar; 34(3):209-14.
• Wilson RB, Spitalnik SL. Designer red cells. (editorial)Transfusion 1994 Mar; 34(3):189-91.

These early papers made nice discussion papers for students as they dealt with enzymes from coffee beans, soybeans, and taro (novelty) and helped reinforce the sugars responsible for group A and B antigens.

My joke when teaching ABO blood group chemistry was that no one in the transfusion service ran around asking for a crossmatch for two alpha-D-galactose red cells. <8-)

One problem was that the research dealt with converting B cells into group O red cells (stripping the terminal alpha-D-galactose) and would be more useful if A rbc could be converted using a naturally occurring alpha-N-acetylgalactosaminidase, since group A has a higher frequency in Western Europe and North America.

Another was that the research could not be applied to large scale production despite in vivo studies such as this one:

• Lenny LL, Hurst R, Goldstein J, Benjamin LJ, Jones RL. Single-unit transfusions of RBC enzymatically converted from group B to group O to A and O normal volunteers. Blood 1991 Mar 15;77(6):1383-8. (note link to full free text)

In a way, the current headlines remind me of the unmet promise of "artificial blood substitutes" (perfluorocarbons and hemoglobin-based oxygen carriers) whose history dates back to the 1960s. We have been waiting a long time!

Many of the news items on the possibility of converting other blood groups to group O include precautions. As noted by Ian Franklin, the national medical and scientific director of the Scottish National Blood Transfusion Service, in the Scotsman:

• "There are many hurdles to overcome, from changing the blood groups of samples in the laboratory to making this technique available to patients."

Quite an understatement by Dr. Franklin. Moreover, the conversion process would need to be cost-effective when applied to large-scale production (millions of blood donors annually).

So, will blood shortages may be passé any time soon? My guess is that this French saying applies:

• Plus ça change, plus c'est la même chose.

Keep on donating!

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Life as a blood eater

I read with interest "A lifeline of Blood" by Dr. B. Patrick Moore to mark the 60th anniversary of the opening of the first provincial unit of Canada's national blood transfusion service (BTS) in Vancouver, BC on Feb. 3, 1947. "A lifeline of blood" motivated me to write this blog, an updated rendition of a posting I originally wrote for MEDLAB-L in1998 and which later appeared as a 2005 entry in another blog I maintain.

Seeing Dr. Moore's historical note reminded me of the years when I worked as a medical laboratory technologist (aka clinical lab scientist) for Canada's national blood supplier, the Canadian Red Cross Blood Transfusion Service (now Canadian Blood Services) in Winnipeg. The facility was (and is) a combination blood center and transfusion service that performs all crossmatching for the city and small rural hospitals in the province, along the lines of Puget Sound Blood Center in Seattle. It was the mid-60s to late '70s, a time when we performed risky practices and never gave safety a thought.

Back then I knew of Dr. Moore, whom everyone called "Paddy" Moore. To my young eyes (I was practically a child laborer!) he was a "biggie" at National, meaning national headquarters from whence all wisdom seemed to flow.

Those golden days were pre-AIDS. See Pneumocystis Pneumonia -- Los Angeles. MMWR 1981Jun 5; 30(21);1-3 and AIDS timeline - click on each year for details. Syphilis and hepatitis B were the main concerns and we had tests for those, such as they were. I recall testing for the HBsAg (previously the "Australian antigen") using counterimmunoelectropheresis (CIEP).

Talk about a primitive test - you had to pipette just the right amount of liquid agar on a glass plate (an art in itself), wait for it to set, punch out wells, add reagents, incubate, then look for precipitin lines (positives) by holding the glass plate against a black background. I often had difficulty seeing even the positive control!

As an aside, it was an early indiction that my future lay more on the transfusion service side than on the blood centre side. The latter I eventually came to refer to as the "dark side" just to tease my blood centre buddies who worked increasingly with automated instruments. To me they were becoming less and less true blood bankers compared to those who worked in transfusion services and got "down and dirty" with their hands. Eventually, of course, automation made inroads into pretransfusion testing, so we are all now disciples of the dark side.

Back to HbsAg testing by CIEP: Once a colleague came running to me exclaiming, "Pat, help! I just swallowed the positive hep B control!" Frustrated with trying to control the tiny bulb on a tiny pipette (actually just a capillary tube), she had used her mouth to suck up the reagent and dispense it! We called National and their sage advice was to "drink lots and lots of water" and let nature take its course. Of course, the positive control was presumably not infectious as it was only the surface antigen, but who knows what all was in the darn reagent.

Those were also the bad old days in more ways than one. For example, we used no SOPs, if you can imagine. All instructions were passed from trainer to new employee. Talk about standardization - NOT!

Near the end of my time at the Winnipeg BTS (by now I was a senior technologist and trainer) one year I decided on my own to write a procedural and policy manual for the crossmatch laboratory on my holidays. I went to a cottage on a nearby lake for two weeks and in between canoe trips wrote the manual in long-hand (pre-computers days too). All on a volunteer basis without official sanction, and, of course, they used the manual.

Having recently gotten married, my husband thought I was nuts. But he soon grew to understood that the organization was family and that working for the BTS was getting paid to do something that my colleagues and I loved and was great fun to boot.

One of my fondest memories from my Red Cross days was how we used to "shuck" (pour out) blood clots from 100s of donor specimens into kidney dishes before preparing 5% saline suspensions for red cell testing. All the while smoking and drinking coffee, of course. Time was a factor and those clots got tossed with wild abandon - it was the start of what could be a very long day depending on the clinic size. We worked until all blood was tested and sorted (put into inventory), no matter how long that took. For the 1000+ donor clinics held on the day after New Year's Day that could be from 07:00 to 23:00 hrs. No union to influence working hours in those days, either.

But I digress. To start each day we would shuck like crazy until the kidney dishes were full. Blood would splatter everywhere, including all over us, our smokes and coffee cups. No gloves, of course, only white lab coats that we wore everywhere including into the lunch room. My most vivid memory from those days is the taste of blood on my cigarette filter (I gave up the cancer-emphysema sticks in 1987). The blood tasted awful, probably more so as I'm a vegetarian.

The second most vivid memory is of bloody finger streaks on the back of everyone's lab coat (after all, techs need to keep their hands clean and buttocks are as good a place to wipe as any). Some of us were regular Picassos!

When hepatitis B testing was instituted at the blood centre (during my years there we went through counterimmunoelectropheresis, reverse passive hemagglutination, and radioimmune diffusion, all now considered prehistoric), one year all lab staff were tested for both HBsAg and anti-HBs. Of the 20 or so technologists none were positive for HBsAg and only one was anti-HBs positive.

Of course, the BTS was testing healthy blood donors for hepatitis and Canada had a relatively low prevalence rate. Mind you, some of the specimens did test positive, and perhaps some of those made their way to my cigarette filters. Also, in the 1960s we bled donors from Manitoba's two penitentiaries. Indeed, once the rate of HBsAg in jails became known, prisoners were dropped as donor sources.

In retrospect, based on my experience working at the Red Cross BTS in the pre-AIDS days, I view the risk of contracting hepatitis and other blood-borne agents from lab-related activities as being low but certainly not zero. Consider that there were two technologists in the neigbouring province of Saskatchewan who contracted hepatitis B and died from mouth pipetting positive controls in the chemistry lab. We in the blood centres had luck on our side.Baruch Blumberg , awarded a Nobel Prize in 1976 for his discovery of HBsAg, tells the story of how his laboratory technologist came down with hepatitis B before they knew what the Australian antigen was.

Even given that the risk of contracting a blood-borne disease in a blood centre laboratory is low, personally, I would not want to play Russian roulette with a million-bullet gun cartridge containing only one bullet. Sooner or later, someone gets the bullet. The low risk may apply to all the risks that we try to prevent by using universal precautions, especially if the causative organism (unlike HBV) does not survive well on inanimate surfaces such as counter tops.

Today's students and younger lab professionals are astounded at the practices of smoking, mouth pipetting, etc., in the laboratory. In retrospect, even this vegetarian, once blood eater, finds them surreal.

It's hard to realize that when I first joined Canada's national blood transfusion service it was less than 20 years old. A Yikes! thought but somehow it puts everything in perspective.

Cheers, Pat 

Whither immunohematology in AABB's Transfusion?

As a longtime member of AABB, having joined in1975 to get the member rate for attending the annual meeting in Chicago, I have always made it a habit to read the association's journal Transfusion from cover to cover. Typically, the journal sits in the bathroom where it helps time pass when I'm otherwise engaged.

Generally speaking, I find editorials and letters to the editor particularly useful in presenting the big picture of transfusion medicine. Reading the abstracts of all scientific papers, even those that are of minimal interest, may seem to be a time waster, but I believe they help keep me informed of the breadth of the latest research, something that is always prudent for a teacher. Sometimes, if an article is particularly fascinating, the journal makes it onto my night table for restful bedtime reading.

For many years I've been aware that few of my fellow medical technologists read Transfusion from cover to cover. Indeed it's a stellar issue if they read even one article. The most common proffered reasons have been that

1. almost all articles have nothing to do with their professional practice and
2. they cannot understand the science of many articles.

The latter reason is largely because many experienced technologists (the profession, like all health professions, is aging) were not trained in molecular genetics.

A very long time ago immunohematology with its antigens, antibodies, and serologic tests was king to blood bank technologists. Blood banking has long since evolved into transfusion medicine, a broad, multidisciplinary field. Now IH is relegated to a section of Transfusion, and a small one at that.

Consider these two articles, the sole papers in the IH section of the Jan. 2007 issue:

1. The molecular diversity of Sema7A, the semaphorin that carries the JMH blood group antigens

• BACKGROUND: Semaphorin 7A (Sema7A), the protein that carries the JMH blood group antigen, is involved in immune responses and plays an important role in axon growth and guidance. Because previous serologic studies on red blood cells (RBCs) suggested a considerable diversity of Sema7A, the present study was designed to elucidate the complex picture of the molecular diversity of this protein.
• STUDY DESIGN AND METHODS: The JMH antigen status was determined by serology, flow cytometry, and Western blot. Genomic and transcript analysis of SEMA7A was performed by nucleotide sequencing. Recombinant Sema7A proteins were used for genotype-phenotype correlation. A three-dimensional model of Sema7A was generated for topologic analyses.
• RESULTS: Our studies on 44 individuals with unusual JMH phenotypes and their family members revealed that aberrant Sema7A expression can be an inherited or an acquired phenomenon and is based on reduced surface expression or qualitative changes in Sema7A. These different phenotypes are caused by variations of the SEMA7A gene or seem to be generated by autoimmune-related or RBC lineage?specific mechanisms. The variant JMH phenotypes were related to the presence of missense mutations in SEMA7A, predicting amino acid changes in the semaphorin domain of Sema7A. Sequence analysis of the variant SEMA7A alleles revealed mutations affecting codons 207 and 460/461. Topologic analyses showed that Sema7A polymorphisms were prominently located on the top and bottom of the semaphorin domain, suggesting a functional relevance of these sites.
• CONCLUSION: These findings provide a basis with which to delineate the various ligand-binding surfaces of Sema7A.

2. Knops blood group haplotypes among distinct Brazilian populations

• BACKGROUND: The Knops blood group system consists of antigens encoded by exon 29 of complement receptor 1 (CR1) gene. To better elucidate the complexity of Knops group system, the frequency of six single-nucleotide polymorphisms (SNPs) in three Brazilian populations is determined...
• .....Design and results omitted to give neurons a break....
• CONCLUSIONS: In this study, a new SNP substituting serine for asparagine at amino acid 1540 was identified. Moreover 12 haplotypes were identified. The differences in haplotype frequencies strongly suggest that the H1 and H2 might be the ancestral one while the H3 may have originated in Africa and may have fixed there by positive selection.

Are these papers really immunohematology?

Most of my colleagues would say no. How much is understandable to someone with no education in molecular genetics? To some, phrases such as axon growth and guidance, missense mutations, and semaphorin domain may be as meaningful as those generated by the infamous and hilarious Buzz Phrase Projector

The publisher's website says that "Transfusion reports on the latest technical advances, discusses opposing viewpoints regarding controversial issues, and presents key conference proceedings."

The posters from the annual meetings have much to interest working technologists, e.g., serologic studies, educational initiatives, quality management projects, management issues, and more. Why do so few of these studies make it to Transfusion as full research papers?

Moreover, how many articles in Transfusion are relevant to nursing transfusion practice? Some for sure, but enough? Food for thought for another blog....

Cheers, Pat

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Web 2.0, say what?

Transfusion medicine has its own language, including acronyms such as AIHA, DAT, HDN, T&S, and TRALI. To the outsider, such language is gobbledegook and may sometimes be resented as being non-inclusive.

I was reminded of this when reading How Web. 2.0 is changing medicine (BMJ 2006 Dec 23;333:1283-4) by Dean Giustini, a medical librarian from UBC, creator of the UBC Academic Search - Google Scholar Blog

My guess is that many readers will not know what Web 2.0 is or even care or, worse, will think it another example of jargon designed to make people feel outside the loop, or perhaps an example of the latest Internet buzzword.

Most techno-geeks are rhapsodic about Web 2.0:

• How to Use Web 2.0 in Medicine? by Ves Dimov, M.D., creator of Clinical Cases and Images
• Others are more skeptical
  

So what is Web 2.0?

Many answers exist, but the one I like best is Dimov's:

• Web 1.0 users follow links to websites
• Web 2.0 users comment, edit, and create content

Using this framework, Web 2.0 is anything web-based that is interactive and participatory. For example:

Blogs like On TraQ are part of Web 2.0. You, the reader, can create content here by posting a comment (anonymously or attributed) to anything I've written.

Wikipedia is Web 2.0, with user-created entries such as

• Blood substitutes
• ABO blood group system

You too can be a Wikipedia author by contributing to Wikipedia. Creating an entry requires only a small learning curve - it's pretty easy.

Google Docs and Spreadsheets (was Writely) is another Web 2.0 example.

As someone attempting to write a book (attempting is the operative word!), I find Goggle Docs to be a fun and easy way to get feedback and collaboration from friends kind enough to help.

The British Medical Journal has embraced Web 2.0 "big time":

• Let's start at the very beginning...
• Rapid Responses - see responses at the end of this letter:
• Changes in policy of refusal of blood by Jehovah's Witnesses

YouTube (a free video sharing website) epitomizes Web 2.0. Interestngly, YouTube videos can be embedded in other sites, e.g.,

• 2007 CSTM annual conference

Flickr (a free photo-sharing service) offers similar participatory opportunities. Here's a Web 2.0 example administered by Dr. Ed Uthman, a pathologist in Houston, Texas:

• Pathology and Lab Medicine image pool

No doubt Web 2.0, whatever it is, will continue to evolve. I'm exploring ways to make it more useful to transfusion medicine professionals. If you have ideas or feedback, please click on the "comments" link below. Many thanks.

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