Jean Stanley at Stanford asked for input from members of the CBBS e-network, so that she could share our input with the AABB. Here are the questions and the answers that Jean compiled. Neither the questions nor the answers necessarily reflect CBBS opinion or policy.

Question 1: Should there be an upper limit for auditing red cell transfusions?

This hospital has a lower Hb limit for transfusing rbc. A physician at this hospital says that in addition, there should be an upper limit. The pathologist is leery of this, and feels that this would not be appropriate, and should be dealt with based on the patient's clinical diagnosis and need.

Question 2: How can we increase Compliance with the Paul Gann Act?

The transfusion service is looking for ways to increase compliance with the Paul Gann Safety Act, and making sure that physicians have documented and obtained consent from patients prior to transfusion. An audit indicates that they are not consistent. Any ideas from other hospitals on how they are meeting this requirement?

(Also, see previous responses to this question on this forum in 1998 and 1999.)

The following responses were received to Question #1.

1. An upper limit on hemoglobin determinations to monitor appropriateness of transfusion is problematic. At this hospital it has never been an issue. However, there are times when a clinician might want to maintain a higher hematocrit than normally expected in patients who have compromised cardiovascular or cerebrovascular systems. It may be clinically efficacious to transfuse these patients prior to a procedure in which a massive blood loss is likely. Although there may be some value to this exercise, I believe the time would be better spent in other areas.

2. Another hospital agreed with the asking pathologist, that an upper hemoglobin limit would not be warranted for the same reasons stated.

The following responses were received to Question #2.

1. Currently, through our Tissue and Transfusion committee, a chart audit is performed by Perioperative Services when the patient arrives in the holding area for surgery. Since we do a number of invasive surgeries, we started with this audit. We are now expanding the audit to be included in our chart review that is performed by Medical Records and QA personnel. We are also probably going to form a QIP team to look at a number of compliance issues in chart review (we are having a JCAHO inspection in 9/2000 and this is an issue), the Paul Gann documentation is one of the issues. I am also looking forward to other responses to this question since it is difficult to make sure that this document is signed prior to any procedure requiring blood products.

2. Paul Gann, strictly speaking is not the responsibility of the transfusion service. The Paul Gann pamphlet should be given to patients well in advance of their admission to the hospital in order to give autologous and directed donors enough time to donate. A monitor should be done on the physicians' offices and/or have the physician supply the formal documentation of prior Paul Gann notification on the patients' admission to the hospital.

3. We have an excellent program at our hospital. A form was developed for the doctors that goes right into the chart. The doctors were in-serviced on their requirements to comply. The QA department audits the patient's chart with a variety of other options available to insure the
process is working and complete.

Jean Stanley, MT(ASCP)SBB
Director of Technical Services
Stanford Medical School Blood Center
800 Welch Road
Palo Alto, CA 94304
Phone: 650-725-3978
Fax: 650-725-4470
email: jstanley@stanford.edu

Please submit comments to the e-Network Forum.

Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator