CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
Sherrie Rice
July 2022—Myriad questions had to be answered and plans made to put low titer O whole blood in the trauma bay at Thomas Jefferson University Hospital. Julie Katz Karp, MD, associate professor and director of transfusion medicine, reported why, when, and how it was done and where they stand today, in a process she describes as “a never-ending series of hoops.”
“We make a lot more than we use, and it is a lot of work, but it’s highly valued in our trauma service,” she said in a CAP21 session on the use of low titer O whole blood in trauma care.
Thomas Jefferson University Hospital is a level one trauma center whose annual transfusion numbers are as follows: 19,000 red blood cells, 6,600 platelets, 4,400 plasma, 900 cryoprecipitate. About 2,000 trauma patients are seen each year.
The blood bank is on the eighth floor of the main hospital building, and the trauma bay is on the first floor of a building a block away. Though the buildings are connected by flyover bridges, “there’s no easy way for us to get magically from the eighth floor of one building to the first floor of another,” Dr. Karp said. There was no relocation plan for either area and, amid staffing shortages, limited availability of couriers to transport blood.
A new electronic medical record went live in April 2017, which added to the trauma team’s difficulties of “arriving” patients. By July, there was talk of acquiring a secure access blood refrigerator for the trauma bay. “And it wasn’t long after that we started to discuss what we were going to put in this mythical refrigerator,” Dr. Karp said, noting that the literature about low titer O whole blood’s benefits was appearing at about the same time (see story, June issue, https://bit.ly/LowtiterO).
“Low titer O whole blood was starting to become common,” she said, “and it wasn’t just one trauma program here or there.” Many were adopting use of LTOWB, “so our trauma surgeons were getting excited about it.”
“That’s when we started asking the hard questions” about it—questions that would apply to any institution considering the same, she said—and how it would fit into practice at Thomas Jefferson. Starting with: Who is supplying the LTOWB—the hospital-based donor center or blood suppliers—and what is the cost of each option and how can the two be balanced? How reliable is the supply? “It’s not always so easy. Frankly, in more recent years, red cells aren’t so easy. Nothing’s easy anymore,” Dr. Karp said. “So if we say we need 10 units, are we getting 10 units?” And how much would be needed to support the trauma service? “We didn’t know because we’d never done this before,” she said, so it had to be determined as time went on or in advance, “or maybe a little of both.”
Will LTOWB be available to other services beyond trauma? Though expanding it to other services was discussed, it never was.
Where will it be stored? In the blood bank, in the secure refrigerator in the trauma bay, or both?
How will its expiration be managed? “Will we spin it down to manufacture red cells at 14 days? Will we allow it to expire on the shelf at 21 or 35 days, depending on which anticoagulant preserving solution it’s in?”
Is only O positive stored, or will O positive and O negative be stored? What are the logistics of replenishing it in the secure trauma refrigerator? “We don’t have infinite amounts of staff to do that, so we had to discuss the expectations with our trauma surgeon colleagues,” Dr. Karp said.
Dr. Karp
What happens if LTOWB is not available, either because what was stored was used amid a large event or the supplier couldn’t deliver? “What is the plan because not having any blood is not an option. Presumably component therapy would be the default,” she said, “but it should be discussed ahead of time.”
How are the regulatory requirements related to use of LTOWB fulfilled?
Thomas Jefferson has a fixed-site, hospital-based blood donor center that collects about 10 percent of the hospital’s inventory. “Small but mighty” is how Dr. Karp describes the center, which has a dedicated donor staff and donor coordinator. The blood bank manufactures the blood components, so they wondered if they could make their own LTOWB. The center collects about 100 O positive and 15 O negative whole blood donations monthly, “so we thought it would be feasible to collect our own,” Dr. Karp said, noting it would come from only male donors and never pregnant females to circumvent concerns about TRALI mitigation and HLA antibody testing.