Navigating Blood Bank Lookbacks

• Transfusion Medicine – Blood Bank Lookbacks - CPIP case by Melissa George, DO, FCAP
• See all Clinical Pathology Improvement Program cases.

Lisa Tomcko:

Welcome to the latest edition of the College of American Pathologists' CAPcast. I'm Lisa Tomcko, content strategist with the CAP. Safeguards related to blood transfusion are typically proactive to prevent transfusion of unsuitable products. While these safeguards are highly effective, they're not completely infallible. New information may become available regarding a blood donor after they have donated. If an unsuitable blood unit was collected and then unknowingly transfused, the blood bank must undertake a lookback or a process of investigating and identifying prior donations from the same donor.

In this episode, I'm joined by Dr. Alexis Peedin and Dr. Melissa George. Dr. George is a member of the CAP's Clinical Pathology Education Committee, and she recently authored a case for the Clinical Pathology Improvement Program all about blood bank lookbacks. We get to listen in while she and Dr. Peedin discuss the ins and outs of lookbacks, everything from how often these types of events occur, their implications for affected patients and lots more. But before we dive into things, would you like to introduce yourselves?

Dr. Melissa George:

Hi, I'm Dr. Melissa George and I'm the medical director of transfusion medicine at Penn State Health, Hershey Medical Center in beautiful Hershey, Pennsylvania, the sweetest place on earth. And I've been working in the blood bank field for over 14 years.

Lisa Tomcko:

Great. Thank you. And Dr. Peedin?

Dr. Alexis Peedin:

Hi, I am Lexi Peedin. I am the assistant director of apheresis at the Children's Hospital of Philadelphia and also clinically covered the blood bank. I have been in transfusion medicine for about seven years and I'm very excited to interview Dr. George today.

Lisa Tomcko:

Excellent. Well, I'm excited to have you both here with us for this discussion. And with that Dr. Peedin, I'll hand things over to you to get us started.

Dr. Alexis Peedin:

Thanks Lisa. So Dr. George, how often does new post-donation information make a blood product unusable?

Dr. Melissa George:

Thankfully, it's not that common when you think about the millions of blood units collected each year and transfused lookbacks really happen and just a fraction of a percentage of those collected units. But we always have to consider that blood donation is a very human process and there are times where donors might not understand a question, remember a certain risk factor where they might be hesitant to disclose the risk factor. And most of the cases I investigate end up being relatively low risk, thankfully, and I'm able to convey that to the recipient even if I'm still offering testing. And that's a nice feature of being able to communicate that this might be a regular donor who just forgot to mention something or happened to test positive that was something that was cross-reactive and nonspecific.

Dr. Alexis Peedin:

Now, how often do you perform lookbacks in your practice?

Dr. Melissa George:

I would say a true lookback only happens really a few times a year, and most of those are pretty low risk. A lot of times it could be a faithful donor who's like a multi gallon donor and we find out that there's maybe a positive infectious disease test and it's usually a screening test and sometimes either the supplemental testing is unclear or maybe for some reason they can't find the supplemental testing. So a lot of times we are always having to take each case seriously and acting accordingly, but more often than not we'll get information that confirmatory testing's negative and we can be reasonably sure that it was a false positive. Another example, especially in our area in central Pennsylvania, tick-borne illness unfortunately is quite common here. So if someone had babesiosis, tick-borne illness, they may not know they had it, they may have felt fine and they may come up positive and for most recipients, most likely they would also be fine if they have a normal spleen and good immune system. But there could be high-risk recipients like a hem-onc patient who may not clear the infection well. So if that's the case, we certainly have to follow up to make sure that patient can possibly get treated. If they were to test positive.

Dr. Alexis Peedin:

In your practice, does the transfusion medicine team typically contact the recipient or are you communicating more through one of their healthcare providers?

Dr. Melissa George:

As a courtesy, we always reach out to the healthcare provider because we feel that that person has a relationship with that patient. If it was someone's surgeon, they're the ones who actually order the transfusion. So we always like to talk to them first and offer them the option of talking with the patient first. We are always willing to talk with them in a joint teleconference if that makes them more comfortable. We can certainly handle the transfusion piece of it, but we always feel that it's kind of scary for a patient just to hear from a doctor that they don't know out of the blue. So if I feel like I just call them directly, I think it's more disconcerting to the patient. So if it's a team approach, I think that usually works out the best.

Dr. Alexis Peedin:

That's pretty similar to how we handle it here where we usually reach out to the healthcare team first. So once you're notified of a lookback, what in your opinion is the most time consuming part of the lookback process?

Dr. Melissa George:

Unfortunately, I'd say the most time consuming part is sometimes phone tag of notifying the transfusion provider. Sometimes the person doesn't remember the patient. Well, if it was a surgeon who maybe encountered someone as a trauma and suppose it was several months ago, they may not really remember a lot about the process. So sometimes they might need to refresh their memory of the situation through chart review if they don't feel comfortable talking to the patient themselves. Sometimes I end up having to handle the situation entirely or in tandem with them. And sometimes coordinating schedules can be difficult because a lot of times we try to pick a time to try to call the patient together. Then if you can't reach that person, maybe leave a vague voicemail, asking them to call back and trying to coordinate that can be very time intensive. Another challenge is sometimes you can't reach the person by phone at all and you end up having to send kind of a vague certified letter as the first point of contact. I don't like having to do that because it can feel alarming for the recipient. So you always try to be sensitive to the psychological component, realizing that a patient's probably pretty scared when they receive this information. So ideally coordinating that phone call is probably the best way of handling it initially because you can provide reassurance, answer their questions in real time rather than have that letter be received on a Friday and have the person worry about it over the weekend and so they can get in touch with someone.

Dr. Alexis Peedin:

And that's another reason, like you said, to work with their existing healthcare team. Sometimes I've seen if it was one of those trauma surgery cases where we would actually collaborate also with the patient's primary care provider, even though they weren't part of that transfusion event because they have a relationship with the patient. And like you said, for the psychological safety, that conversation can happen more comfortably with a physician that they already have that relationship with.

Dr. Melissa George:

Absolutely. And the same is true for hematology oncology. They often have very long lasting relationships with the patients and can be extremely helpful in partnering in this practice.

Dr. Alexis Peedin:

So when a blood product like this has already been transfused, what are some of the possible implications for the recipient?

Dr. Melissa George:

The worst case scenario would be for the recipient to actually acquire infectious disease from a truly infected product. Thankfully, that's very rare and all the time I've been doing this, I've never actually seen a real case where someone acquired a transfusion transmitted infection. But if that were the case, at least we could offer early testing that could lead to earlier implementation of treatments like whether it be antiretroviral drugs for HIV or drugs that could potentially cure or mitigate hepatitis C. In the case of babesiosis, the patient could be assessed, tested themselves, possibly be offered that short course of antibiotics that would hopefully clear up the infection and basically eliminate the risk. More commonly though, we'll find that the testing gets performed and the donor does not have the infectious disease. So realistically, the testing just provides reassurance. So a couple of days later, everyone finds out they're in the clear can breathe a sigh of relief, and basically it finds out that the sensitive screening tests may have been non-specifically reactive to something completely innocent. The donor might months later be eligible for reentry according to strict criteria. Those are kind of the main scenarios that tend to happen.

Dr. Alexis Peedin:

And so you and I working in academic transfusion medicine come across lookbacks and withdrawals fairly often, but do you have any advice for general pathologists related to performing lookbacks?

Dr. Melissa George:

Well, let's face it, this certainly is not anyone's favorite part of the job. It's actually one of the more stressful pieces of the job I think we both do. I think for a community practice pathologists, the best advice is to have an organized systematic approach, good recordkeeping, good relationships with the other doctors at your hospital to partner with them and handling notifications first, reading the notification from the supplier very carefully because they're going to err on the side of notifying you more often than not. And sometimes there's additional information that may make a notification unnecessary and things we could see additional information, like if there were negative donations after the one that we received, say like a year later, that would make the risk of actual transfusion transmit disease really low for our patient. So it's nice to be able to have that information to communicate low risk or on occasion not have to make a notification at all. And knowing that degree of risk also helps offset anxiety and just having a calm, cool approach to handling the communication, being approachable, knowing that that patient might have additional questions and really indicating an availability to answer those questions to not increase their stress. I think that's really the keys to handling a look back effectively.

Dr. Alexis Peedin:

Well, that is great advice.

Lisa Tomcko:

And before we go, Dr. George, I just wanted to ask you specifically about your CPIP case. Who is the intended audience for this case and what do you hope people will take away from it?

Dr. Melissa George:

The target audience is really going to be the community practice pathologist who doesn't necessarily handle these regularly, going to provide a very broad overview of how to handle things in a very systematic approach. This particular CPIP case features, figures, and flow charts that kind of walk through the process of how to handle these effectively. And the goal is to make the process as simple and smooth as possible. If you approach it mentally the same way each time, it's going to make things a lot easier. Making sure you kind check all the boxes of checking the most up-to-date guidance, handling it very systematically. It makes it a lot less anxiety producing for the medical director because no one ever wants to think about someone possibly getting a transfusion transmitted infection. Thankfully, doesn't happen very often, but this helps us handle it safely and effectively.

Lisa Tomcko:

Definitely, yes. Well, we of course hope that lookbacks aren't a frequent occurrence. It definitely helps to be prepared for them when they do happen or are necessary. So thank you both so much for sharing your insights and experiences on this topic.

Dr. Alexis Peedin:

That's great. Well, thank you so much. I'm looking forward to reading your CPIP. Thank you

Lisa Tomcko:

And thank you all for listening. For anyone interested in learning more about lookbacks, the link to Dr. George's CPIP Case is in the episode show notes. You'll also find the link to the CAP's Clinical Pathology Improvement Program page, where you can check out other CPIP offerings. Stay tuned for future episodes of CAPcast and for more information about the CAP visit cap.org.

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