Letters to the Editor a justification, documented at least by code, is included in the medical record. Ideally, a lucidly written progress note describing the indication for any transfusion order should be present, as well. HOWARDI. FINKLE,MD Department of Pathology and Laboratory Medicine Highland Hospital 1411 East 31st Street Oakland, CA 94602
A prospective blood utilization review system
To the Editor: The successful implementation of a prospective blood utilization review system using algorithms and a laboratory information system has been described.*P2At our institution, a 300-bedYacute-care, urban medical facility with a large trauma and surgical service and many rotating physicians-in-training, a similar prospective system was deemed essential to educate physicians in the proper use of blood components and to minimize risks to patients. We have successfully implemented a prospective system that accomplishes the educational and minimal risk objectives and does not cause delay in issuance of blood components. Implementation of our prospective review system required circulating a widely recognized valid list of criteria3e4to the medical staff for modification and acceptance. Once the criteria were agreed on, a code corresponding to each specific justification (e.g., C1, C2;Fig. 1) must be written, along with the order for the blood component, on the patient’s medical chart order sheet before the blood component can be issued. This justification code is then entered with the order, electronically or manually, onto the requisition form that is submitted to the hospital blood bank. All physicians receive a pocket-sized list of criteria and codes (copy available to readers of TRANSFUSION on request to the author) for easy reference. Figure 1 is excerpted from the list. If a physician believes that the transfusion of a blood component is necessary because of unlisted clinical circumstances, a justification code corresponding to “other” is allowed. The use of this “other” code results, however, in an automatic retrospective review by the Transfusion Committee. For this reason, this code is rarely used. A retrospective verification review is necessary to ensure that the codes submitted are accurate. Cases in which the justification code is discordant with relevant laboratory values or clinical findings are selected and referred to the Transfusion Committee for review and further action. Besides improved physician education, 100-percent compliance and nearly 100-percent appropriate utilization are achievable by this method. In addition,
References 1. Coffin C. Matz K, Rich E. Algorithms for evaluating the appropriateness of blood transfusion. Transfusion 1989;29:298-303. 2. Ayser CH, Cecalupo AJ, Wolf ML, Coe SA, Menke JA. The use of LIS for blood usage review. Am J Clin Pathol 1991;95:389-92. 3. Grindon AJ, Tomasulo PA, Bergin JJ, Klein HG, Miller JD, Mintz PD. The hospital transfusion committee: guidelines for improving practice. JAMA 1984;243:540-3. 4. Silberstein LE, Kruskall MS, Stehling LC, et al. Strategies for the review of transfusion practices. JAMA 1989;252:1993-7.
White cell reduction in platelet concentrates To the Editor: In the February issue of TRANSFUSION, Garcia et al.’ reported that white cell (WBC) reduction by centrifugation of plateletpheresis collections conferred no benefit with regard to preservation of platelet membrane glycoprotein Ib (GPIb) during 10 days of storage. While these findings are consistent with our previously reported observations2 on the role of mononuclear cells in total platelet GPIb stores, Garcia et al. did not address the problems related to neutrophil contamination. Several methodologic differences between the two studies should be pointed out. We2 did not attempt to measure platelet membrane GPIb by flow cytometry, but measured total GPIb by immunoblot using whole platelet lysates. If GPIb was lost from the platelet during storage, as others have demon~trated,~ intracytoplasmic GPIb would likely be mobilized and re-expressed on the platelet membraneY3and it might maintain constant membrane GPIb expression over time, despite the decrease in total platelet store^.^ Flow cytometry without permeabilization as used by Garcia et al. detects only membrane GPIb and is not a sensitive indicator of total platelet GPIb loss. Garcia et al. measured total platelet GPIb by polyacrylamide gel electrophoresis (PAGE) in combination with a protein stain rather than by immunoblot; the latter is a more sensitive technique for GPIb. In fact, when we used two different protein stains, Coomassie blue or periodic acid-Schiff, we were unable to detect differences in protein bands on PAGE in the molecular weight range of GPIb (100150 kDa) when platelets stored with either granulocytes or mononuclear cells were compared to those stored without. We reported that only granulocytes-not monocytes or lymphocytes-affected platelet GPIb stores. Garcia et al. did not perform differential counts on the WBCs contained in the platelet preparations; however, their estimated 5-percent granulocytes would be less than the quantity of such cells in our preparations. Nevertheless, the number of granulocytes in both studies is in the range normally found in apheresis concentrates.‘ Because Garcia et al. performed the WBC-reduction step at 24
Cryoprecipitate c1 Significant hypofibrinogenemia (< 100 mg/dl [ < 1.0 gL]) or factor XI11 deficiency c2 Hemophilia A if DDAVP or factor concentrate is not appropriate c3 Von Willebrand disease or uremic bleeding with prolonged bleeding time, if DDAVP is not appropriate c4 Uremic bleeding with prolonged bleeding time, if DDAVP and estrogen are not appropriate c5 Other, please specify. (This code will automatically trigger a review of your indication.) Notes 1.
2.
Document fibrinogen level before transfusion and after transfusion for indication C1. The recommended adult dose is 10 units of cryoprecipita te.
FIG.1. Partial list including the indication codes for cryoprecipitate. The entire list of indications with corresponding codes is printed on both sides of a 5 x 8” plain index card that can be folded into thirds, the triptych fashion, to fit the physician’s pocket.
787
A prospective blood utilization review system
To the Editor: The successful implementation of a prospective blood utilization review system using algorithms and a laboratory information system has been described.*P2At our institution, a 300-bedYacute-care, urban medical facility with a large trauma and surgical service and many rotating physicians-in-training, a similar prospective system was deemed essential to educate physicians in the proper use of blood components and to minimize risks to patients. We have successfully implemented a prospective system that accomplishes the educational and minimal risk objectives and does not cause delay in issuance of blood components. Implementation of our prospective review system required circulating a widely recognized valid list of criteria3e4to the medical staff for modification and acceptance. Once the criteria were agreed on, a code corresponding to each specific justification (e.g., C1, C2;Fig. 1) must be written, along with the order for the blood component, on the patient’s medical chart order sheet before the blood component can be issued. This justification code is then entered with the order, electronically or manually, onto the requisition form that is submitted to the hospital blood bank. All physicians receive a pocket-sized list of criteria and codes (copy available to readers of TRANSFUSION on request to the author) for easy reference. Figure 1 is excerpted from the list. If a physician believes that the transfusion of a blood component is necessary because of unlisted clinical circumstances, a justification code corresponding to “other” is allowed. The use of this “other” code results, however, in an automatic retrospective review by the Transfusion Committee. For this reason, this code is rarely used. A retrospective verification review is necessary to ensure that the codes submitted are accurate. Cases in which the justification code is discordant with relevant laboratory values or clinical findings are selected and referred to the Transfusion Committee for review and further action. Besides improved physician education, 100-percent compliance and nearly 100-percent appropriate utilization are achievable by this method. In addition,
References 1. Coffin C. Matz K, Rich E. Algorithms for evaluating the appropriateness of blood transfusion. Transfusion 1989;29:298-303. 2. Ayser CH, Cecalupo AJ, Wolf ML, Coe SA, Menke JA. The use of LIS for blood usage review. Am J Clin Pathol 1991;95:389-92. 3. Grindon AJ, Tomasulo PA, Bergin JJ, Klein HG, Miller JD, Mintz PD. The hospital transfusion committee: guidelines for improving practice. JAMA 1984;243:540-3. 4. Silberstein LE, Kruskall MS, Stehling LC, et al. Strategies for the review of transfusion practices. JAMA 1989;252:1993-7.
White cell reduction in platelet concentrates To the Editor: In the February issue of TRANSFUSION, Garcia et al.’ reported that white cell (WBC) reduction by centrifugation of plateletpheresis collections conferred no benefit with regard to preservation of platelet membrane glycoprotein Ib (GPIb) during 10 days of storage. While these findings are consistent with our previously reported observations2 on the role of mononuclear cells in total platelet GPIb stores, Garcia et al. did not address the problems related to neutrophil contamination. Several methodologic differences between the two studies should be pointed out. We2 did not attempt to measure platelet membrane GPIb by flow cytometry, but measured total GPIb by immunoblot using whole platelet lysates. If GPIb was lost from the platelet during storage, as others have demon~trated,~ intracytoplasmic GPIb would likely be mobilized and re-expressed on the platelet membraneY3and it might maintain constant membrane GPIb expression over time, despite the decrease in total platelet store^.^ Flow cytometry without permeabilization as used by Garcia et al. detects only membrane GPIb and is not a sensitive indicator of total platelet GPIb loss. Garcia et al. measured total platelet GPIb by polyacrylamide gel electrophoresis (PAGE) in combination with a protein stain rather than by immunoblot; the latter is a more sensitive technique for GPIb. In fact, when we used two different protein stains, Coomassie blue or periodic acid-Schiff, we were unable to detect differences in protein bands on PAGE in the molecular weight range of GPIb (100150 kDa) when platelets stored with either granulocytes or mononuclear cells were compared to those stored without. We reported that only granulocytes-not monocytes or lymphocytes-affected platelet GPIb stores. Garcia et al. did not perform differential counts on the WBCs contained in the platelet preparations; however, their estimated 5-percent granulocytes would be less than the quantity of such cells in our preparations. Nevertheless, the number of granulocytes in both studies is in the range normally found in apheresis concentrates.‘ Because Garcia et al. performed the WBC-reduction step at 24
Cryoprecipitate c1 Significant hypofibrinogenemia (< 100 mg/dl [ < 1.0 gL]) or factor XI11 deficiency c2 Hemophilia A if DDAVP or factor concentrate is not appropriate c3 Von Willebrand disease or uremic bleeding with prolonged bleeding time, if DDAVP is not appropriate c4 Uremic bleeding with prolonged bleeding time, if DDAVP and estrogen are not appropriate c5 Other, please specify. (This code will automatically trigger a review of your indication.) Notes 1.
2.
Document fibrinogen level before transfusion and after transfusion for indication C1. The recommended adult dose is 10 units of cryoprecipita te.
FIG.1. Partial list including the indication codes for cryoprecipitate. The entire list of indications with corresponding codes is printed on both sides of a 5 x 8” plain index card that can be folded into thirds, the triptych fashion, to fit the physician’s pocket.
787
