Transfusion medicine informatics for neonatal and pediatric patients: a narrative review

Introduction

Background

In transfusion medicine, clinical informatics has helped blood banks and transfusion services optimize the use of information and technology to enhance patient care, reduce preventable transfusion errors, and improve clinical decision-making processes (1). Clinical Decision Support Systems (CDSS) have been successfully implemented to reduce unnecessary transfusions but may result in alert fatigue (2). Workload reports and blood product inventory dashboards have been created to improve data-driven blood bank operations (3). Electronic crossmatch and remote blood issuing have been implemented to improve safety and increase technologist efficiency (4,5). Implementation of universal barcodes, such as International Society of Blood Transfusion (ISBT) barcode 128, has standardized and improved traceability of blood products and has also allowed utilization of scanners for blood product verification prior to administration (6). Electronic patient identification systems have reduced wrong blood in tube errors which can help decrease the risk of ABO incompatible transfusions (7). Large vein-to-vein research databases, like the Recipient Epidemiology and Donor Evaluation Study-III (REDS-III), have allowed the study of patient outcomes as it relates to blood donor characteristics and the biologic composition and characteristics of blood components (8).

Rationale and knowledge gap

While general transfusion medicine informatics has been reviewed elsewhere (1), little has been published to review clinical informatics and its use in pediatric transfusion medicine.

A 2005 survey of children’s hospitals in the United States revealed that adoption of Health Information Technology (HIT) in children’s hospitals in the United States has been different from adult counterparts and that a significant number of children’s hospitals are not using clinical HIT applications to their fullest (9). Applications like computerized order entry or clinical decision support were used in 40% and 35.8% of responding children’s hospitals, respectively (9). One of the largest barriers identified was vendors’ inability to deliver products or services to satisfaction (9). It was noted that clinical HIT applications used by children’s hospitals need to be able to provide certain functionalities tailored to the specific needs of children (e.g., weight-based dosing) that similar systems in adult acute-care hospitals might lack (9).

There have been advocacy and educational efforts to demonstrate that transfusing pediatric patients is not just transfusing little adults (10). Children are at a higher risk of adverse outcomes from medical errors in blood transfusion practice than adults (10,11). Pediatric transfusion medicine has many unique challenges when it comes to informatics compared to its adult counterpart.

Pediatric patients have different hemoglobin concentrations and oxygen requirements than adults and therefore have different transfusion indications and doses (12). While adult transfusions are typically ordered in whole units, pediatric patients often require weight-based dosing in mL/kg (13). This distinction introduces unique challenges for hospital computer systems, particularly in institutions that serve both adult and pediatric populations. These challenges also often result in complex blood order sets. Errors in ordering special blood product modifications in susceptible pediatric patients can lead to potentially fatal complications such as transfusion-associated graft versus host disease (TA-GVHD) (13). Special blood product modifications, like aliquoting full blood product units into smaller bags or special expiration dates for the neonate population post-irradiation modification, also present unique blood bank computer system challenges.

Management of the pediatric transfusion service blood product inventory can also be challenging. Special requirements in pediatrics, such as cytomegalovirus (CMV) serology status, irradiation, and the age of red cells, can require computer system workarounds or can inadvertently result in wasted blood products (14).

Hospital blood bank computer systems are often different software from the electronic medical record (EMR) software which can make the visibility of blood bank information a challenge for clinical teams. Additionally, limited inter-institutional sharing of blood bank data, including clinically relevant but undetectable alloantibodies, poses a significant risk for patients, especially those with sickle cell disease (15). When care is fragmented across multiple hospitals, false-negative antibody screens may occur, increasing the risk of delayed hemolytic transfusion reactions (DHTRs) (15).

Additionally, advancement of pediatric transfusion practices has been challenged due to lack of robust data and standardized tools to help guide clinical decision-making (16).

Objective

The purpose of this narrative review is to provide the reader with an introduction to the various uses of informatics that have been implemented to improve pediatric transfusion medicine which includes all age ranges of the neonatal and pediatric population. The understanding of these examples can help inform the reader of existing opportunities in their own institutions to improve safety, efficiency, or utilization, as well as help highlight the need for additional studies and publications on the use of informatics in pediatric transfusion medicine. This information is useful to pediatric hospital blood banks and transfusion services.

The objective of this review is to address the following questions

• How have Computerized Physician Order Entry (CPOE) and CDSS been used to improve safety and efficiency in pediatric transfusion medicine?
• What informatics tools have been implemented to enhance blood product inventory management and reduce wastage in pediatric transfusion services?
• How do EMR integrations and antibody registries contribute to improved communication and patient safety in pediatric transfusion practices?
• What role do centralized databases and data analytics play in advancing evidence-based practices in pediatric transfusion medicine?

I present this article in accordance with the Narrative Review reporting checklist (available at https://aob.amegroups.com/article/view/10.21037/aob-25-17/rc).

Methods

Peer-reviewed literature with keywords transfusion, informatics, pediatric, neonatal, and computer system published in English in PubMed from 1990 to April 2025 was reviewed (Table 1). Insights were also derived from the author’s 8 years of directing a pediatric transfusion service. Table 1 summarizes the literature search strategy used to gather information to include in this review.

Findings

The following findings are summarized in Table 2.

CPOE and CDSS

Utilization of a CDSS in a pediatric health system, as described by Orenstein et al., can help decrease blood product order errors for special processing requests, as well as decrease inappropriate transfusion rates (17). They showed that although total blood product safety events from ordering errors, as detected from hospital incident reports and/or surveillance by a transfusion safety specialist, did not change significantly from the baseline period to the intervention period, they did see significant improvements in order errors related to selecting irradiation modification in patients with T-cell dysfunction [from 3.9% to 3.0%; risk ratio: 0.77; 95% confidence interval (CI): 0.66–0.90] and requesting phenotypically similar units for patients with sickle cell disease or thalassemia (from 13.4% to 3.2%; risk ratio: 0.24; 95% CI: 0.18–0.32) (17). They also describe seeing significant improvements in the proportions of transfusions administered faster than the recommended 5 mL/kg/h for non-emergent transfusions, especially for platelets (17).

By utilizing a multidisciplinary multimodal approach to redesigning electronic ordering tools in a pediatric inpatient setting, Stoffel et al. describe reduced red blood cell (RBC) monthly wastage by 77% and improved crossmatch:transfusion ratio (C:T) from 1.79 to 1.38 over a 7-year period (18). Some key interventions included changing Pedipacks to on demand ordering, updating dosing guidance for blood products, nursing release of product and order status visualization, and implementing CDSS (18). They also analyzed the C:T utilization data with changepoint analysis and red cell wastage with causal impact analysis, two types of data analyses that may show continued utility in the future to display transfusion medicine intervention and utilization impacts (18).

Integrating real-time CDSS alerts into CPOE systems can help accelerate the adoption and implementation of evidence-based clinical guidelines (19). Adams et al. showed in their cohort study, that automatically linking the entry of a RBC order to a CDSS tool that evaluates the patient condition (patient’s age, diagnosis, and blood pressure) and relevant laboratory studies (serum hemoglobin level within previous 24 hours) improved adherence to evidence-based recommendations for transfusion thresholds and decreased RBC transfusions by 52% in a pediatric acute care patient population (19).

Baer et al. implemented a pediatric blood management (PBM) program across four neonatal intensive care units in their health system in 2008 that included electronic transfusion ordering with an order screen that displayed the transfusion guidelines as a real-time reminder of the recommendations (20). They demonstrated increased provider compliance with transfusion guidelines from 65% to 90%, which decreased the number of transfusions and showed associated cost savings of $780,074 to the institution within the first year (20).

CPOE can also be used to help streamline complex, multi-step processes with a multidisciplinary team (21). McCrory et al. demonstrated that in a cohort of pediatric intensive care unit patients, CPOE for manual RBC exchange procedures was associated with improved protocol compliance (85% reduction in protocol violations), improved reduction of sickle hemoglobin, and better maintenance of hemoglobin levels in a goal range during prolonged exchanges (21).

Ensuring CPOE and CDSS are user friendly and do not contribute to alert fatigue is a challenge with these types of informatic tools (2). Several studies demonstrated that developing a user-centered design and implementing formative usability testing for pediatric blood product order sets has been shown to further reduce blood order errors compared to a design by expert committee alone (28,29).

Inventory management

Development and implementation of an informatics platform for adult and pediatric hospital blood banks have been used to automate and streamline the blood product inventory assessment and ordering process (22). Tsang et al. describe that their custom-created software showed noninferiority to the previous manual process while saving an estimated 7 hours per week of technologist time (22).

Radio frequency identification (RFID) uses wireless communication between an object (tag) and interrogation device (encoder) to automatically track and identify the tagged object (in the case of a blood bank, this is a blood product bag) (30). da Souza et al. demonstrated that implementation of an RFID tracking system helped decrease RBC units, including pediatric aliquots, expiring on their shelves from 4% (260/6,440) to 0.63% (42/6,635), P<0.001, over a 5-year period (14). They also describe the benefits of being able to decrease technologist time needed to manually reconcile inventory and find special products (e.g., irradiated or antigen-negative units) from 12 to 20 minutes to less than 1 minute (14).

EMR integration and sharing patient blood bank information

Lack of blood bank information integration in the EMR can result in numerous phone calls to the blood bank requesting order status or type and screen availability (23). Chai et al. developed a blood tracker for their adult and pediatric hospital that displays the status of blood products in real time and is easily visible in the EMR (23). After the implementation of the blood tracker, they saw a significant decrease in phone calls by 47% of those technologists who received 21 or more calls per shift (23).

Jones et al. describe their >10-year experience as a US blood center hosting a regional antibody registry for their hospital customers (24). Participation in the Health Insurance Portability and Accountability Act (HIPAA)-compliant registry is voluntary, but 69% (45/65) of their customers utilize the registry almost daily and they report six known instances when failure to check the registry led to DHTRs (24). They also describe the inclusion of patient molecular genotypes in the registry can help prevent redundant genotyping or extended antigen typing and improves efficiency of pre-transfusion testing which can decrease turnaround time for finding compatible blood for patients (24).

Use of national antibody registries and hemovigilance systems, like in Canada, has shown a decrease in acute and DHTRs per 100,000 red cell units transfused from 4.62 to 2.35 and 10.79 to 4.23, respectively (25).

Universal utilization of antibody registries still remains a challenge, either due to financial or security reasons, as does ensuring efficient health information exchange in a rapidly growing digital health record era (31).

Research, data analytics, and calculations

The Recipient Epidemiology and Donor Evaluation Study-IV-Pediatric (REDS-IV-P) program is a 7-year multi-center program (April 2019 to March 2026) that is a new iteration of prior National Heart, Lung, and Blood Institute REDS programs (16). The REDS-IV-P aims to develop a centralized vein-to-vein database across the lifespan with a focus on neonatal and pediatric populations that receive blood transfusions (16). This database links information from blood donors, their donations, the resulting manufactured components, and data extracts from hospital EMRs of transfused and non-transfused patients (16). This system will aid in design of new randomized clinical trials that are necessary to support and guide evidence-based neonatal and pediatric transfusion practices (16).

Several machine learning algorithms have been developed to help predict surgical scenarios with high blood product utilization, mostly in adult transfusion medicine (32-34). Jalali et al. describe the development of a machine-learning model to predict blood product transfusion requirements for individual pediatric patients undergoing craniofacial surgery for craniosynostosis with an area under the receiver operating characteristic curve of 0.87±0.03 (26). They found platelet count, weight, preoperative hematocrit, surgical volume per institution, age, and preoperative hemoglobin as the most influential variables (26).

Hauser et al. describe the creation of free internet-available transfusion medicine equations to aid the clinician with standardized and quick calculations of complex equations (27). Of the twelve they developed, several are applicable to pediatric transfusion medicine including maternal-fetal hemorrhage Rh(D) immune globulin dosage, intrauterine RBC transfusion dosage, neonatal polycythemia partial exchange, and sickle cell RBC exchange volume (27).

Conclusions

This narrative review describes the various uses of informatics that have specifically been implemented in pediatric transfusion medicine. Advancements have been made in pediatric transfusion medicine using informatics tools and techniques especially with utilization of CPOE and CDSS. CPOE and CDSS have been shown to help decrease pediatric blood order errors and inappropriate transfusions, and to aid pediatric PBM programs by improving utilization of blood products and adherence to specific pediatric transfusion guidelines (18-21,28). The addition of of informatics software and technology, like RFID, can help improve inventory management, decrease blood wastage, and decrease manual work (14,22). Implementation of integrated EMRs and electronic antibody registries has helped improve clinician and blood bank visibility to important data to help improve efficiencies and patient safety (23-25). Development of a major pediatric transfusion database will aid in design of randomized clinical trials that are necessary to support and guide evidence-based neonatal and pediatric transfusion practices (16).

This review reflects the perspective and experience of a single author. Although efforts were made to conduct a comprehensive and inclusive literature search, the potential for inadvertent omissions and selection bias cannot be excluded. Several limitations exist for studies described in this review. Many studies are from a single institution and are quality improvement pre-post intervention studies that lack randomization or controls. Improvements observed could also be due to concurrent interventions or other variables. Pre-post intervention study designs can be subject to changes that occur over time unrelated to the intended intervention. In these types of studies, statistical techniques like changepoint analysis, as described by Stoffel et al. in their study (18), can help determine whether an outcome truly coincides with the intended intervention.

Many challenges and potential opportunities for study still exist for informatics in pediatric transfusion medicine. There is paucity of published literature on clinical informatics utilization in some specialized pediatric populations, such as pediatric hematology/oncology, fetuses, those receiving extracorporeal life support, or pediatric trauma. The need still exists for expanded and more robust studies on the potential benefits of clinical informatics in pediatric transfusion medicine. Additional challenges include data security and privacy protection as well as the lack of harmonization of regulations and standards affecting widespread use of some of these clinical informatics tools.

There is potential for improvement on the visibility of blood bank information in the EMR, like historical antibodies or special blood product modification requirements. Other challenges include the need for clear traceability of intrauterine transfusions to unborn fetuses who may not have their own EMR chart, and more widespread access to advanced data analytics and predictive models especially for smaller pediatric transfusion services. Opportunities still exist for vendors of information systems (IS) to take time to understand the unique processes and challenges of a pediatric transfusion service and proactively build appropriate IS solutions for the needs of these patients.

Continuing to pursue the collaboration between information technology and transfusion experts to develop more automated processes will become necessary to ensure the safest and most efficient level of care for one of our most vulnerable patient populations.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Nabiha Huq Saifee) for the series “Neonatal and Pediatric Transfusion” published in Annals of Blood. The article has undergone external peer review.

Reporting Checklist: The author has completed the Narrative Review reporting checklist. Available at https://aob.amegroups.com/article/view/10.21037/aob-25-17/rc

Peer Review File: Available at https://aob.amegroups.com/article/view/10.21037/aob-25-17/prf

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://aob.amegroups.com/article/view/10.21037/aob-25-17/coif). The series “Neonatal and Pediatric Transfusion” was commissioned by the editorial office without any funding or sponsorship. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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