Sunday, September 02, 2007

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.

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?

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