AABB24: Enhancing Patient Safety Through Real-Time Hemovigilance

The 2024 AABB Annual Meeting kicked off with a Saturday morning session focusing on the critical role of patient safety in transfusion medicine, highlighting the use real-time hemovigilance and laboratory data to reduce harm during care delivery.

A Tragedy Become a Call to Action

The session began with a presentation by James Kelley, MD, PhD, chief medical officer at OneOme and a former assistant professor at MD Anderson Cancer Center. Kelley explained that while blood transfusions are one of the most common inpatient procedures and are generally safe, the risk for mortality remains.

To illustrate this point, Kelly described a serious adverse event at MD Anderson where a contaminated platelet transfusion led to a patient’s death. The incident – and subsequent media coverage – prompted leaders at MD Anderson to reassess their transfusion practices and strive for global leadership in transfusion safety.

MD Anderson responded by launching a comprehensive real-time hemovigilance unit (HVU), which monitors blood administration in real time. The program uses real-time data monitoring, powered by AI algorithms based on CDC guidelines, to predict potential transfusion reactions and allows nurses to focus on patient risks with the greatest risk. The program also includes advanced practice providers – nurse practitioners and physician’s assistants – who staff the hemovigilance unit 24/7 and enable immediate responses to flagged cases. 

“This allows someone to, in real time, stop the transfusion, find a new product, give Benadryl or Tylenol to manage the patient, and to also make sure that they capture all of the appropriate documentation,” Kelley said.  

The HVU also provides tools to mitigate possible future transmission reactions, including putting the transmission reaction on the pop-up list in the electronic health record, triggering specific guidance to meet that individual patient's need.

Kelley concluded by sharing the program’s benefits beyond transfusion reaction management, including improvements to blood management, massive transfusion protocols, patient experience and turn-around time monitoring. MD Anderson also introduced a blood hotline, allowing any clinician in the institution to call with any transfusion-related questions.

Operational Enhancements and Future Innovations

The session continued with a presentation by Kimberly Klein, MD, medical director of the hemovigilance unit at MD Anderson, who focused on updates to the program and operational insights. Regulatory changes following an April 2020 inspection required updates to MD Anderson’s deferral workups to align them with CDC guidelines. These adjustments included new criteria for capturing delayed serologic transfusion reactions and extending respiratory monitoring post-transfusion.

According to Klein, a notable benefit of the real-time vigilance system is its ability to capture and manage complex transfusion reactions, such as delayed hemolytic reactions. The system employs deferral algorithms for conditions like shortness of breath, fever and hypotension, ensuring that even minor reactions, including allergic ones, are accurately documented.

Klein shared several cases to demonstrate the system’s effectiveness. One example was a real-time case of a transfusion exceeding the four-hour transfusion time limit, which led to immediate nursing education and the development of a monitoring tool to prevent future occurrences. Another example involved a patient with IgA deficiency who experienced a hemolytic reaction. In another instance, a patient with a known JKA antibody benefitted from the system’s ability to manage transfusion reactions and address laboratory errors.

Klein emphasized the importance of multidisciplinary collaboration in the success of the hemovigilance program. Real-time monitoring and data analysis, supported by contributions from physicians, nurses and IT teams, have improved patient safety and transfusion quality.

Future plans include further refining data capture tools, introducing an electronic maximal blood ordering system to enhance blood product usage during surgeries and replacing manual processes with more efficient electronic forms.