(1258) Assessment of the Use of Electronic Notification System in Identifying Transfusion Reactions

Introduction: Blood product transfusions are common in hospitalized patients. Severe adverse events, while rare, can cause significant morbidity and mortality. These acute transfusion reactions (ATR) include acute or delayed hemolysis, transfusion-associated infection, transfusion related lung injury (TRALI) and transfusion-associated circulatory overload (TACO). Early identification and response to ATR can help prevent morbidity and mortality. Vital signs have long been the standard to identify ATR. We theorized that by harnessing the power of electronic medical records, we could increase the number of reported possible ATRs and thus increase the identification of reactions within our medical system.

Methods: We designed a best practice advisory (BPA) within EPIC to monitor patient vital signs before, during and after transfusion. Whenever vital signs met criteria for change in temperature, respiratory rate, heart rate, blood pressure or oxygen saturation, a BPA would fire to the nurse. This would alert them to a possible transfusion reaction and prompt consideration of submitting blood for further evaluation. We retrospectively reviewed the number of samples sent to pathology and number of ATRs in the 6 months prior to intervention. There was a 2 year learning period after launching the BPA. Then a 6 month time period post intervention was reviewed.

Results: In the 6 months pre-intervention, there were a total of 8,673 transfusions in our health system. 23 cases were sent to pathology, 15 of which were found to be consistent with transfusion reactions. The BPA did not demonstrate increase in the number of cases reported to pathology or the number of transfusion reactions identified. Post-Intervention, there were a total of 6,552 transfusions. 14 cases were sent to pathology, 10 of which were found to be consistent with transfusion reactions.

Conclusions: Identification of transfusion reactions is important to reduce morbidity and mortality in patients. Studies have also shown that reactions are typically under-reported. Unfortunately, our study did not show an increase in identification of ATRs when using BPA through the electronic medical records. Possible reasons explored included over-firing of the BPA, alarm fatigue and need for continued education with bedside providers.