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Preparation is Key for Pediatric Blood Draws

8/16/2017

Pediatric patientEach day, phlebotomists are tasked with putting patients at ease during a blood draw. This can be especially challenging when it comes to pediatric patients.  

Sue McAnany, MT, phlebotomy education coordinator at URMC, says her trainees are instructed to give special care to younger patients and involve the parents and caregivers to make the draw go as smoothly as possible.

McAnany oversees the 12-week training for all newly hired phlebotomists at URMC. During this time, the employees must perform a minimum of 50 venipunctures (and members of the inpatient vascular access team must perform twice that many). Within the first few weeks of training, phlebotomists perform draws on pediatric patients of different ages. 

Sue McAnany“It’s very important that they feel comfortable with the procedure on adults before we move on to pediatrics,” she said.

The University of Rochester Medical Center and Golisano Children’s Hospital have adapted concepts from the Poke and Procedure Program  which was originally developed at the University of Michigan Health System. This plan outlines specific ways parents and caregivers can be helpful during pediatric blood draws – asking them to fill out a form describing their child’s experiences with needle-stick procedures and what type of distraction techniques or comfort positions they prefer.  

Communication is vitally important in each step of the process, explains McAnany. When the patient arrives for treatment, it’s important for the phlebotomist performing the draw to clearly delegate responsibility to the adults present. This helps minimize potential anxiety for the child.

“If you have more than one person trying to hold the patient, it’s very overwhelming for the child to have everybody talking at the same time,” she said. “One person in the room should be the speaker.”
Sometimes, if there is just one phlebotomist on site and a caregiver is not present in the room, he or she must hold the patient while making the draw.

Most lab locations that frequently have pediatric patients are stocked with photos, bubbles, and other distraction tools that can help divert the child’s attention before or during the needle stick. These tools often include a “Buzzy,” which is a small cold pack shaped like a bumblebee that can vibrate and help numb the area. No matter what tools a phlebotomist chooses, communication is an important part of any draw. 

“For a patient who’s never had blood drawn, you need to explain what’s going to happen (saying, It’s going to be a little bit of a pinch),” said McAnany. “If you distract them just by asking the patient about themselves, they won’t concentrate on the blood draw.”

Each patient is different when it comes to pain or discomfort, and having your blood drawn differs from getting a shot or vaccine because it is drawing the specimen out of the body rather than injecting something into the body. Still, some of the bravest patients often shed tears during or after the “pinch,” but phlebotomists are trained to give words of encouragement and praise.
 
“I always tell them that it’s OK to cry, but really try to hold still,” said McAnany. “You really have to get a good rapport with them and be soft-spoken.”

At the end of the day, she says the quality of these interactions will shape a patient’s overall experience. While needle-sticks can be challenging for patients at any age, following the right protocol and tuning in to the patient’s needs is absolutely essential.

Establishing a good relationship with a patient often results in them asking for a certain phlebotomist for future visits, even when it means waiting longer.

“Even some adults follow the tech from site to site just because they’ve had a good experience,” said McAnany.

Read more on this topic: CAP Today: Helping phlebotomists ease pediatric patient anxiety

Gene Study Points Researchers toward New Pathway for Leukemia

5/8/2017

Leukemia is one of the hardest cancers to treat, but scientists have discovered a new, targetable pathway in one of the worst subtypes of the disease.leukemia cells

The study, although only relevant in mice and human cell cultures at this point, is important because researchers found that an existing drug, known as creatine kinases inhibitor, is effective at attacking acute myeloid leukemia (AML) in the laboratory.

University of Rochester Medical Center and Wilmot Cancer Institute scientists Archibald Perkins, M.D., Ph.D., and Yi “Stanley” Zhang, Ph.D., teamed up with researchers at Harvard University and the Massachusetts Institute of Technology to study a particular gene, EVI1. When this gene is active, certain types of leukemia and some solid tumors, such as ovarian cancer and some breast cancers, are virtually untreatable.

Their study recently was published in the high-impact journal Nature Medicine. The group showed that when EVI1 is abundant in leukemia, it changes the metabolism of immature blood cells as they progress toward becoming cancer—but also leaves EVI1-positive cancers vulnerable to treatments that can strike down that pathway.

The Perkins/Zhang laboratory in the Department of Pathology and Laboratory Medicine has been investigating the EVI1 gene for several years, resulting in a solid track record of publications on the topic. Their goal is to discover new treatments that will target the underlying pathways involved in EVI1-positive cancers. The Perkins/Zhang data supported Harvard’s and MIT’s investigation of what drives the EVI1 gene.

Leukemia is a type of blood cancer in which abnormal blood cells crowd out the healthy white blood cells responsible for fighting infection. More than 10 different major subgroups of leukemia exist. Many types of leukemia are resistant to treatment, although some patients with AML and other blood cancers can achieve long-term remission if they qualify for a stem cell transplant. Wilmot’s Blood and Marrow Transplant Program is the only program in the Finger Lakes region to offer that therapy.

The Nature study was recently highlighted by the American Association of Cancer Research. Perkins and Zhang are working on other leukemia studies as well, supported in part by Wilmot seed funds and by the URMC Clinical & Translational Science Institute.

Alumni Spotlight: Dr. Ben Fialkow of the American Red Cross

11/17/2016

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Name: Lawrence (Ben) Fialkow, D.O.

Hometown; Originally from Columbia, S. Carolina and now lives in Brighton

Family; Wife, Alice Rutkowski, son, Duncan, 8

Occupation; He is Medical Director of Blood Services (East Division) for the American Red Cross. This coverage area spans seven states in the Northeast including NY and PA.

Education; He earned his D.O. degree from Des Moines University and began post-graduate training in Internal Medicine at Maimonides Medical Center and at the University of Louisville. He spent the first year of his pathology and laboratory medicine residency at the University of Pittsburgh and finished at the University of Rochester. He later did a fellowship in Transfusion Medicine at Emory University Hospital.

Connection to UR; He was a resident in Pathology and Laboratory Medicine from 2004-08. He now serves as faculty for the Transfusion Medicine Fellowship at UR and is a regular judge for Pathology Research Day.

What first brought you to Rochester?

I had never heard of Rochester before I came here for residency and my wife. She’s a tenured professor at SUNY Geneseo, but even before she got tenure we knew we wanted to stay in the area. I targeted this Red Cross job after my training and it’s worked out very well.

Describe a typical day for you at the Red Cross.

I am part of a team of three physicians located in the Upstate NY, Boston, MA and Farmington, CT, who are responsible for all the Red Cross issues in NY, PA, Massachusetts, Maine, Connecticut, Vermont and New Hampshire. Basically, I’m responsible for any donor issues, blood product issues, or any issues with blood products being transfused at the hospital. During the day I get numerous questions about donors – if they’re okay to donate or how to handle some sort of reaction to a donation. I spend a lot of time on the phone with hospitals giving them recommendations. I’m not necessarily in the office a lot

Why did you choose blood banking?

I was actually trained in internal medicine. I wanted to pick something that would allow me to stay as close to patient care as possible. With transfusion medicine, you’re essentially involved with patient care all the time, and that’s why I went in this direction.

What’s something people may not know about your job?

As a medical director at the Red Cross, I’m one step removed from patient care. A lot of times when I’m discussing issues over the phone, it’s hard for people to understand that I don’t have an office where I see patients on a daily basis. I’m almost more of a manager where I oversee the laboratory and the blood products, but it’s more of a managerial role with a little bit of patient care. I don’t fit into the mainstream of what most consider a physician to be.

What advice can you give medical students or trainees?

If you’re not already decided on a field in medicine, when you go out and do your different rotations, pay attention. I went into internal medicine because I liked the lifestyle and the attitude of internal medicine docs, and was turned off of other careers because I didn’t necessarily see myself as that type of individual.

It’s the same thing with pathology. When you’re going through your pathology residency, think about whether you want to be a clinical pathologist because you like the laboratory side of things versus the anatomical side. Really pay attention to what you what you see yourself being in 10 or 10 years because, ideally, this is the job you are going to keep for the rest of your working life. Make sure you’re happy.

Do you have any professional goals for the future?

I did a lot of research when I was in training, and I’d like to get back more into the research field and maybe publish more.

Do you have any hobbies?

I am an avid runner. In the rain or snow, I am out there running every day. Otherwise, I love reading cheap science fiction and horror novels. The rest of my time is spent being a fulltime dad. It keeps me busy but it’s very rewarding. 

Alum Blood Banker, Dr. Triulzi, a Leader in Transfusion Safety

9/16/2016

Dr. Darrell Triulzi, M.D., gets excited when thinking about the direct impact his work has on patients.

The former URMC Pathology resident (1986-1990) now serves as the director of Transfusion Medicine at the University of Pittsburgh Medical Center Department of Pathology and medical director of the Institute for Transfusion Medicine.

Triulzi MDHe originally intended to work in internal medicine but switched to pathology during his second year of residency. After a rotation in the Blood Bank, Triulzi says he found his calling. 

“I immediately fell in love with the Blood Bank because it combined clinical medicine and pathology," he said. "It was one of those niches where you could do both clinical and laboratory medicine, and there aren’t many places where you can do both.”

After residency, he completed a fellowship at Johns Hopkins University and later joined the faculty at University of Pittsburgh, where he's worked for the last 25 years. His driving inspiration is finding ways to improve patient care and safety in transfusions, and a practical way to do that is by participating in clinical research. 

He has taken part in a number of multi-institutional NIH-funded clinical trials since the 1990s. These studies have addressed such questions as: Will HIV patients who receive transfusions progress to AIDS more quickly? The findings said no. Or, a study published in The New England Journal of Medicine asked, what’s the proper platelet dosing strategy for cancer patients? What about the storage duration of blood in cardiac surgery patients?

A follow up study published in Blood questioned whether it made a difference if platelets are apheresis or pooled, fresh or stored or ABO matched. When results showed that it did not, a number of providers responded positively, saying this information helped them strategically manage platelet inventory. Triulzi most recently began working on an NIH study examining the use of an antifibrinolytic agent to reduce bleeding in cancer patients.

He is co-chair of a multidisciplinary health system-wide patient blood management (PBM) committee at UPMC alongside fellow co-chairs, an anesthesiologist and a trauma surgeon. Like many PBM groups across the U.S. the committee has worked to promote restrictive transfusion practices in clinical settings.

While blood transfusions can be life-saving, there are safety risks linked to using them. Physicians are therefore encouraged to only administer transfusions when absolutely necessary for the patient. Triulzi says this effort is having a real impact in recent years as UPMC has reduced total transfusions by more than 30 percent. 

“I’ve always enjoyed taking care of patients and the clinical side of medicine,” said Triulzi. “I think one of the reasons I chose blood banking is because it’s a consultative service to the clinicians that’s not so much looking at slides like most pathologists do. There is a more outward focus.” He added, “Most physicians at the hospital think that I’m a hematologist as opposed to a pathologist, and I take that as a compliment.”

Triulzi has fond memories of his time in Rochester, where he met his wife Mary, a dietician. He continues to keep in contact with longtime mentor, Dr. Neil Blumberg, director of Clinical Pathology, and credits Blumberg with triggering his interest in academic pursuit within his career.

An Albany area native, he and his wife have three children, Leah, 23, Ben, 20, and Sam, 15. In his free time Triulzi enjoys studying American and European history, attending University of Pittsburgh football and basketball games, and playing fantasy football. 

 

 

The Lifesaving Work of the Blood Bank and Transfusion Medicine Unit

7/13/2016

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Have you ever wondered what happens to blood donations when they are taken to a hospital?     

According to the American Red Cross, 6.8 million Americans give blood each year. The Blood Bank and Transfusion Medicine Unit at Strong Memorial Hospital receives and stores these blood products to be ready for patients around the clock. 

We spoke with Debra Masel, Blood Bank chief supervisor, and Aimee Kievitt, lab supervisor, to learn more.

Where do blood products stored in the Blood Bank come from?

The vast majority of our blood comes directly from the American Red Cross located on John Street in Henrietta.

There is also a small donor room located off the main lobby at SMH where patients scheduled for surgery, and who qualify to donate their own blood, can have a unit of blood collected. This blood is then stored in the Blood Bank specifically for them if a transfusion is needed during their surgery.

What are the main functions of the Blood Bank?

We do testing to make sure that the blood received from the American Red Cross is compatible with patients who need it. If a patient has any type of transfusion issue, we need to identify and resolve the problem to ensure that the blood is truly compatible and that we’re not causing more harm by transfusing them.

Our attending physicians, nurses, residents and fellow provide clinical consultation on effective and safe use of blood transfusions, and evaluate transfusion reactions.

How much blood does the Blood Bank receive each day?

We transfuse about 100 units a day. During the blood collection process, approximately 500 milliliters of whole blood is collected which is then separated into red cell, plasma and platelet products. A unit of red cells has a volume of approximately 400 milliliters, which includes a preservative solution to increase the shelf life of the product.

What’s the difference between a blood sample and a blood product?

A blood sample is drawn directly from the patient and is used to complete pretransfusion testing to ensure compatibility with the intended blood product. Blood products are collected from volunteer donors.

A donation is separated into its component parts – plasma (55%), red blood cells (45%), and white blood cells and platelets (less than 1%) – which are each stored and used separately to help multiple patients.

What happens when there’s a trauma patient in the Emergency Department who needs blood products?

The Blood Bank has a trauma pager so when a Level 1 trauma patient is being transported to the hospital, the technologists are notified. They then prepare the trauma cooler with four units of O Negative (O-) uncrossmatched red blood cells, commonly known as the “universal donor.” When a staff member from the ED comes to pick up the blood, he or she will bring a patient blood sample for testing to be performed.

It is important to switch the patient to blood products identically matched to their own blood type as soon as possible, since our research at SMH shows that ABO identical transfusions are safer than use of “universal donor” red cells or plasma.

BloodbanktestWhat kind of testing does Blood Bank perform?

The Blood Bank processes about 120 patient samples a day, many of which are outpatient samples for pre-operative and prenatal testing. About 90 percent of our transfusions are given to inpatients and the remaining 10 percent are transfusions received by outpatients.

What happens if a patient with very rare blood type needs a transfusion?

Sometimes there are other complications besides a patient’s blood type. If a patient has multiple antibodies, for example, finding compatible donors in the available blood inventory may not be possible.

In that case, we contact the Rare Donor Registry via the American Red Cross and a national search is initiated to identify a compatible donor. If we request something that’s available in the registry, they send it to us. We have gotten products from Florida, California, and other states.

What if the Red Cross can’t find what you’re looking for?

If we have a need for a rare unit and the American Red Cross has nothing in inventory, they can search their database to find a donor who matches the patient’s needs. They contact the donor and let them know that they are a rare match for a patient in need and request that they come to a center to donate.

How does a critical shortage in blood donations affect the work of the Blood Bank and Transfusion Medicine Unit?

In the event of a critical shortage (and it would have to be very dramatic) hospital administration and our attending physician and resident on call are notified. Our physicians and technologists will triage requests so that only clinically urgent transfusions are performed during the shortage.

The hospital chief medical officer may ask surgeons to reschedule elective surgeries so that the available blood supply can be conserved for urgent needs.

Thankfully, the community response to blood shortages has been good in bolstering the blood supply so that the drastic measure of rescheduling surgeries hasn’t happened in many years.

What’s a more common type of shortage you encounter?

When there’s a shortage of O- blood and the Red Cross can’t provide our normal inventory levels, we may need to evaluate every requested transfusion for clinical necessity and urgency.

It’s very important to obtain a patient sample as quickly as possible so that trauma patients receive products identical to their blood type instead of group O- blood. In those cases, it requires a higher level of communication and coordination between Blood Bank and the ED or Operating Room so we can appropriately supply their needs.

The same is true for platelet shortages. Our physicians, nurse and technologists evaluate each request for necessity and urgency. We discuss orders with providers to hold off on transfusion or reevaluate whether a transfusion is absolutely necessary when the necessity or urgency are not clear from the order.

Bloodbank3When do you have the greatest need for blood donations?

Summers (around the Fourth of July) and December tend to be the two times when supplies are running lowest. Schools, which hold many blood drives, are closed, and people are on vacation so they are not available to donate blood.

What have been the biggest changes in blood banking within the last decade?

There has been a national push for restrictive transfusion practices, and this is a good thing. Blood transfusion can be lifesaving in certain situations but it’s not the cure-all. A transfusion is like a liquid transplant. If a patient doesn’t have a specific need to be transfused, they shouldn’t be.

Research performed here has led to substantial changes in transfusion practices to render them safer for the recipient, such as use of ABO identical transfusions, leukoreduced transfusions for all patients and washed transfusions for select patient groups. This has led to many fewer complications of blood transfusion and increased survival in some instances.

How has your role in patient care changed over time? 

In the last decade, our staff has started to interact more directly with nurses and ordering providers to discuss patient cases; their underlying diagnosis, signs, symptoms, and whether transfusion is the most appropriate course of action. There have been more of those types of collaborative and educational discussions. 

In photos: 

Top: The Blood Bank at URMC stores all blood products in a cooler where staff can pull units needed for patients. 

Middle: Lisa Hughes, a medical technologist, performs a test to determine the blood type of a patient who has received a bone marrow transplant.

Bottom: Medical technologist, Kim Bastian, releases a blood product to a patient for a transfusion. In this case, the patient has had transfusion reactions, so the product has been "washed" with saline to help prevent further reactions from occurring.

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