Recognition of patients who need special cellular products that are washed irradiated, leukocyte-reduced and/or CMV negative

Blood bankers in Texas report that their multi-campus Health System is in the process of standardizing their transfusion services. One area for standardization is how to recognize patients who need cellular products that are washed, irradiated, leukocyte reduced and/or CMV negative, etc. At one of their campuses they have relied only on the doctor's orders, so that if a physician orders a patient to receive irradiated products, the patient gets irradiated products. However, if a different physician orders non-irradiated products for the very same patient, the blood bank issues non-irradiated products without any questions being asked. At their second campus, a marker is placed in the computer system in order to notify the technologists when a patient has had special products ordered. If a subsequent blood order does not mention the special product, the patient's nurse and/or physician is called to verify what the patient actually needs. The inquiring blood bankers want to know how other institutions are handling the aforementioned situations.

The following replies were submitted in response to the above:

1. A Canadian blood banker reported that he works at a multi-site transfusion service with a shared computer database. When a patient is admitted with a diagnosis that requires blood products other then standard red cells, an instruction is placed in the patient's file. The blood bank staff follows those instructions unless the medical director approves a change. If a technologist inadvertently prepares red cells in place of irradiated red cells the system flags and warns the technologist that the requirements of the patient are not met.
   
   
2. A blood banker from California wrote that many of the hospitals at which he consults have systems in place similar to the one described at the second campus of the inquiring blood banker. These hospitals maintain an "electronic reminder system" for each patient who previously has required specialized components, so that they will not forget to honor these parameters at the time future units are requested/issued. Some of these hospitals will call any physician whose request does not match the historical precedent (e.g., they will call a physician who does not order CMV-negative RBCs for a patient who previously has required CMV-negative "cellular" components). Others treat the earlier request for specialized blood as a "standing order," and automatically honor the previous parameters at the time of any subsequent requests for the same patient.
   
   
3. A blood banker in Pennsylvania reported that at his facility they irradiate all cellular products for all patients all the time. They reason that they don't want to fail to use irradiated products when they are medically necessary because the consequences of not doing so could be devastating.
   
   
4. A Canadian blood banker who works at a blood center in Alberta reports that the center tracks the patients requiring CMVneg/irradiated products by entering a comment in their computer system. Most of these patients are bone marrow transplant patients. The blood center apparently requires the client hospital that performs these transplants to provide a fact information sheet that includes blood group of donor, recipient, and whether the patient will be needing irradiated/CMV negative blood, and for how long. Subsequently, every time blood products are issued by the center to the hospital for these patients, an effort is made at the blood center to make sure the patient gets the proper product type. The blood center will phone the ordering unit/hospital if a blood product order differs from what they have in their records.
   
   
5. A blood banker at a facility in Northern California reports that they make use of the second option, as reported by the inquiring blood banker. The Northern Californian's facility adds a marker to the Transfusion history indicating the need for that product, the first time a special product such as irradiated or CMV negative is requested. If subsequent orders are received that do not request the special need, they phone the nursing unit or physician notify them that the patient has previously received irradiated or CMV negative products and request a clarification of the current order. If the physician indicates that the patient no longer needs the special product, they remove the marker from their history.
   
   
6. A blood banker from Virginia reports that at a multi-campus Health System, if a physician orders CMV-negative and/or Irradiated products, they put a permanent comment in the patient's file that shows up each time blood is ordered. If they get an order that differs from the original order, they call the floor/or office and let them know that the first physician ordered special products and ask if they want to continue with CMV-negative and/or irradiated products. The patient information is tracked using a Sunquest Computer System, which allows them to view patient data from each site. When they perform their history check on the patients, they can go in under each facility and see if the patient had antibodies, or special orders.
   
   
7. A blood banker from Ohio reports that at a network of 6 hospital transfusion services (2 teaching facilities, and 4 community hospitals, 1 of which supports a bone marrow transplant program), a physician's order to place a patient on leukocyte reduced, CMV negative, irradiated, washed, or volume reduced products is entered as a special instruction in their computer system. The same computer system is installed in all the facilities in the network, and the data is shared between all of the various institutions. Any product ordered on the patient subsequently will have the special instructions honored; they do not contact the ordering physician. Removal of special instructions can only be done at the request of the patient's attending physician.
   
   
8. The blood bank medical director of a centralized transfusion service covering 8 hospitals, reports that they flag special product needs of patients by placing a marker in the LIS data field allotted for antigen restrictions. They also have a master list of all hem/onc physicians, so whenever blood is ordered by any of these physicians, their patient are issued irradiated units, unless otherwise indicated by the medical director, even if the order was for non irradiated blood products (they have an on-site irradiator).

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