Seattle Children's Seattle, Washington, United States
Background/Case Studies: In 2022, a pediatric patient with sickle cell disease (SCD) received an RBC unit that was not Rh/K antigen matched. This event spurred the enhancement of processes to monitor transfusion profiles retrospectively and in real-time for patients with SCD.
Study
Design/Methods: The hospital's enterprise data warehouse (EDW) includes data from the blood bank information system Haemonetics SafetraceTx and Epic electronic health record (EHR). Before this case, a Tableau dashboard that used EDW data identified patients with SCD diagnosis, their transfusion history, the presence of RBC antibody, genotyping, and phenotyping results, and if RBC transfusions were antigen matched. After this case, the team created an automated report and EHR triggers to prevent missing details for future RBC orders.
Results/Findings: A Tableau dashboard created in early 2022 showed that 27-40% of patients with SCD receiving transfusions have at least one antibody. The dashboard rate is consistent with alloimmunization rates reported in this population. However, the rate is higher than other pediatric patients' 2-4% RBC alloimmunization. Since 2020, 100% of patients with SCD had either a serologic phenotype or RBC genotype, with an increased % of transfused SCD patients having RBC genotype testing completed (2020 72.7%, 2021 81%, 2022 89.2%). The patient, in this case, is the only one who did not receive an antigen-matched RBC transfusion. The first automated report identified 87 patients with SCD diagnosis and missing Rh/K antigen selected or Hgb S negative requirements in the EHR. A dedicated team subsequently updated these EHR blood transfusion profiles. This team will receive monthly automated reports to confirm the correct EHR transfusion requirements. To prevent in real-time missing antigen-matched requirements on RBC orders, an analyst created an order validation extension which hard stops RBC orders lacking Rh/K antigen selected and Hgb S negative blood special requirements. Due to a history of reactions, patients with SCD have a higher risk of hemolytic transfusion reaction (HTR), with a potentially lethal outcome; thus, a Best Practice Advisory (BPA) alert was created. It is triggered by RBC orders on patients previously diagnosed with delayed or acute HTR. Conclusions: Dashboards, automated reports, and EHR ordering tools can improve safe blood product ordering for patients with SCD. The case spurred the creation of point of care tools to support transfusion ordering and increase provider awareness about blood transfusion standards for patients with SCD. Other future electronic tools such as the Alloantibody Exchange (alloantibody.org) will further enhance blood transfusion for patients with SCD.
Importance of research: Managing sickle cell disease (SCD) in children is complex, and safeguards are needed to ensure optimal care. Patients with SCD are at high risk of alloimmunization and hemolytic transfusion reactions with RBC transfusion, and thus extra caution is needed prior to transfusion and to ensure antigen-matched RBC units. This abstract presents some tools for hospitals to leverage blood bank information systems and electronic health record data to ensure safer transfusion in patients with SCD.
