On July 30th, a member of the e-Network asked for input on the practical problem of documenting the time of blood administration to a patient. According to the member, one of the on-going quality indicators for their transfusion service is to review all transfusion records for "start and stop" times of each transfused unit. Documentation of unit start and stop times is generally not a problem except in the Operating Rooms where documentation is frequently lacking. The anesthesiologists have responded that the clinical situation sometimes precludes documenting the start and stop time of each individual administered unit. The inquiring member's transfusion service believes that the AABB standards require documentation of unit start and stop time, regardless of where the blood is administered. The inquiring member wanted to know from other transfusion services how they interpret the AABB Standards with regard to unit start and stop times. If a hospital requires that unit start and stop times must always be documented, how is this accomplished? If a hospital does not always require that unit start and stop times must always be documented, is a retrospective note on the transfusion record by an anesthesiologist (or other physician) documenting the urgency of the situation satisfactory in meeting the standards?

As part of this discussion, the Editor noted that AABB Standard J8.120 states that: "A clinical transfusion record shall be kept including the donor unit or pool identification number, the date and time of transfusion, pre- and post-transfusion vital signs, the amount transfused, the identification of the transfusionist, and whether a transfusion reaction occurred." The Technical Manual states that records for transfusion include: A signed statement that the information on the container label and the compatibility record has been matched with the wristband or other identification of intended recipient, item by item; documentation of vital signs; and transfusionist’s identification and date/time of transfusion. Neither the Standards nor the Technical Manual specifically state that a start and stop time for the transfusion must be recorded on a specific form. The Editor is aware of situations where a patient required multiple units of blood and components within minutes, during treatment of massive hemorrhage. In such situations, it was probably better that the nurses and doctors who were administering the blood prioritized their efforts to assure that the correct units were administered, rather than worry about the exact minute a specific unit of blood was started and stopped.

Here is what members of the e-Network had to say:

1. This issue of documentation has already come up in our Transfusion committee. At our Medical Center, Our QI team has been working on compliance with blood administration documentation. We are revising our transfusion record to include a "check - box" that says "Administered in OR, see anesthesia record/cell saver record/perfusion record". We are also planning to reeducate the nursing staff to complete all portions of our "vital signs" section. When the new transfusion record is implemented, we plan to audit for compliance with documentation. Our hospital QA department staff is currently keeping track of "lapses" in documentation when they perform our transfused blood product audit. They report at our Transfusion Committee. This committee is multidisciplinary and includes nursing and medical staff from perioperative services.

2. At the institutions that I have worked for, the recording of the start and stop times of the transfusion allowed the blood bank reviewer to determine that the unit of blood had been given within the requisite 4 hours. If any of the required data was not on the form it was sent through the hospital incident report system to be investigated and documented. If any unit took longer than 4 hours for administration that also was reported as an incident. The data of these reports was monitored by the Blood Utilization Committee as part of the on-going quality program. In situations such as OR, it was considered acceptable to document the approximate time of start and stop. Since the whole point was to prevent the 4-hour limit being exceeded this was adequate documentation in such a situation where blood is being pumped in 2 units at a time. When inadequate documentation was received in the blood bank in such a situation, the form was returned with the request that approximate times be entered and the note "late entry documentation" added.

3. The STANDARDS rule! While a nice idea and helpful regarding transfusion reactions and medico-legal issues, I don't think it is necessary to record the start and stop times of a transfusion. The TECHNICAL MANUAL provides guidance but does not replace or overule any standard.

4. At our hospital we monitor start and stop times in a Performance Improvement indicator ONLY for the purpose of detecting units that were allowed to hang over 4 hours. Units allowed to hang over 4 hours had been a problem in the past and reporting this indicator has greatly improved this situation. If the start and stop times are not recorded, we have no way of telling how long the unit was allowed to hang. Therefore, we report any missing times that should have been recorded to nursing management.

5. This is one of the problems I have encountered at my 300-bed military medical center where I have been the Medical Director for approximately one year. Our anesthesiologists are very good about documentation on the anesthesia record, so I have requested they send us a copy of the completed record to attach to our transfusion document. Their document numbers the unit, puts it on their timeline and then in the margin they write the complete unit number with the code they used on their document. This gives a start time but no finish time. I think it is a workable plan. However I've often had to track down the paperwork in the medical record in order to get the documentation.

6. Our hospital's transfusion administration policy states that the start and stop time should be documented. A recent audit of charts, however, showed that compliance is poor. Not only is the time poorly documented, but often the unit number is missing from the documentation. This problem of documentation causes great difficulty in evaluating reports of possible transfusion reactions, because the Transfusion Service physician is often unable to identify when a unit was given in relation to the onset of patient symptoms, or even which unit was associated with the symptoms. As a physician who reviews many transfusion reaction reports, I feel it is essential to document the unit numbers and start and stop times of transfusion for each unit, whenever possible. When multiple units are given within a short period, a list of the units given and the time period over which they were infused should be adequate.

7. We also have poor documentation compliance from the OR as well as the ER. We have negotiated with them that except in trauma situations, they would document both infusion data (who and when) and vital signs on the Transfusion Records. For trauma and massive transfusions we have created a sticker which lists # of units given, transfusion "event" start and stop times, a statement indicating the patient showed no signs/symptoms of a transfusion reaction and signature of RN. The sticker is applied to the first lab copy of the stack of Transfusion Records. In these situations, vital signs are recorded in the chart.

ADDENDUM Sept. 12, 2000

8. My comment is that documenting the limit of 4 hours is the most important. In fact the start time is immaterial in this regard, because the 4 hours is the time after leaving the blood bank refrigerator, not the "hang time". The blood bank issue time is then the start of the 4 hours. The start time for the blood infusion is however important for comparison with measurements of vital signs, both to understand the dynamic of a transfusion reaction and compliance.

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