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Implications of legalized recreational marijuana on the United States blood supply

moved our POC machines from the operating room to the blood bank, where integration with the blood supply chain (e.g., component distribution) could be preserved. These tests—the ROTEM and platelet (PLT) function panel—are frequently requested by the primary medical or surgical team ordering blood components, either via phone or during rounds. In other cases, consulting services (such as hematology, gastroenterology, or stroke service) will request these POC tests as part of hypercoagulability or hypocoagulability “work-ups.” Not infrequently, however, real-time pathology review of requests for coagulation testing and/or blood component therapy uncovers inappropriate or unusual orders, thus triggering involvement by our TM specialists. We have found that this integration of POC coagulation into the blood bank has been extremely successful. Through this approach, we have reduced component usage by 15% to 30% overall. Most of the decrease in component usage is from red blood cells and fresh-frozen plasma. However, PLT usage has also been reduced successfully for two reasons. First, in frequent cases of mild PLT dysfunction as quantified by rapid PLT function testing, we recommend DDAVP instead of PLT transfusions; our colleagues in anesthesia, surgery, or surgical ICU readily accept this recommendation. Second, the appropriate replenishment of functional fibrinogen has, in practice, served to be PLT sparing. Like many other medical centers implementing ROTEM, we have seen a dramatic increase in fibrinogen-related product use, which for our hospital, consists of cryoprecipitate. Admittedly, there is no noticeable cost savings in using a pool of cryoprecipitate in place of a unit of apheresis PLTs. We would argue, however, that transfusion with appropriate components (and subsequently preventing infusion of inappropriate products) can lead to reductions in significant morbidity and eventual decrease in hospital costs. This reduction is equivalent to that seen with the perioperative use of these tests, but the reduction from our implementation is for the overall hospital. We have an ongoing study to investigate improvements in patient care by examining mortality risk and bleeding complications in our hospital. We plan to publish our study data after its completion. We believe that this approach is also beneficial for pathology training. Like in Model 1 from Drs Tormey and Smith, our TM specialists, residents, and fellows provide a written note with interpretation and recommendations that appears in the electronic medical record. In providing consultation and education to clinicians as soon as POC results are available, the TM specialists can also advise and guide clinicians toward ordering a more appropriate transfusion regimen. Similar to their Model 2, we also engage in rounding on patients that we have consulted on, increasing our visibility and gaining a clinical perspective on these cases. Because pathology trainees actively participate in this clinical service, this rotation is seen as personally rewarding as they are able to directly impact patient care with frequently favorable outcomes. In summary, we present here our experience of integrating coagulation consultation into our TM practice. We have successfully extended the proven benefits from perioperative integration of coagulation testing to coagulopathic patients throughout the hospital, with the TM specialists and trainees leading significant improvements in patient care.