(P-ED-3) Acute Management and Reporting of Pulmonary Transfusion Reactions: A Quality Improvement Project

Transfusion reactions presenting with respiratory involvement (e.g., transfusion-associated circulatory overload, transfusion-related acute lung injury) are associated with significant morbidity and mortality. Ensuring that learners can properly diagnose and manage these challenging reactions represents an educational opportunity. At present, there is no standardized curriculum or process to guide learners faced with pulmonary transfusion reactions at our institution. We sought to improve the accuracy and level of comfort of pathology residents in dealing with the acute management and appropriate adjudication of pulmonary transfusion reactions as part of a quality improvement (QI) project.

Study

Design/Methods:

This study was exempt from IRB review using our institutional QI IRB wizard tool. The DMAIC framework (Define, Measure, Analyze, Intervene, Control) was used. Baseline data on the self-reported comfort and performance on an objective measure (i.e., exam) of pathology residents in diagnosing and managing pulmonary transfusion reactions was collected. A root cause analysis was performed that identified the lack of a quick reference aid as a key opportunity for improvement. Flowcharts to assist with diagnosis (Figure A) and management were created. After a three-month washout period, the questionnaire and exam were readministered to residents in conjunction with the flowcharts. The same baseline questions were used, and questions exploring the utility of the flowcharts created were included.

Results/Findings:

Six of fifteen eligible pathology residents completed our baseline and follow-up exam and questionnaire. Using the diagnostic and management flowcharts, the average exam score increased by 22.4%, meeting the goal of a 20% increase post-intervention. The average self-reported comfort with pulmonary transfusion reactions showed modest improvement, increasing from an average score of 3.6 to 3.8 on a 5-point Likert scale, falling short of the goal of reaching 4.5/5 post-intervention. Notably, most residents said that they found the diagnostic flowchart useful (average score 4.0/5) and the management flowchart useful/extremely useful (average score 4.4/5).

Conclusions:

Even experienced transfusion medicine physicians struggle with appropriately distinguishing and managing pulmonary transfusion reactions. Flowcharts were developed to assist in the diagnosis and management of these reactions. These quick reference aids have been well received and improved the accuracy of residents in diagnosing and managing pulmonary transfusion reactions on an objective measure. Certain aspects of the management flowchart are unique to our institution, but the diagnostic flowchart is based on CDC Hemovigilance criteria and is thus more generalizable to practice in the US.