Should laboratory assistants and other non-medical technologists be permitted to dispense blood products for transfusion?

A colleague in California reports that her hospital's current policy is that ONLY a Clinical Laboratory Scientist (i.e., Medical Technologist) is permitted to dispense a blood product for transfusion. This policy specifically prohibits laboratory assistants from dispensing blood products. However, a check of other hospitals in the community reveals that some institutions DO permit their lab assistants to dispense blood products. The fact that some hospitals allow their lab assistants to dispense blood products has become an issue for the inquiring colleague's hospital, because some of the senior Clinical Laboratory Scientists have expressed the opinion that when they are very busy, it would be helpful if the laboratory assistants could also dispense blood products. The inquiring colleague states that the Medical Director of their laboratory is willing to make a policy change to allow laboratory assistants to dispense blood products, and the laboratory management is always interested in ways to decrease the budget. The inquiring colleague wants to know what others think about such a policy change, including how one would assure that such a practice complies with federal, state and local regulations and accreditation standards, and remains safe for patients.

The following responses have been received.

ADDENDA May 16, 2003

1. A colleague in New Mexico reports that at her hospital, one of the primary duties of their lab assistants is dispensing blood and components. According to her (verbatim) "Units are dispensed through the computer, which doesn't allow issue of incompatible types." She adds that since they are a busy trauma center and have a busy OR, the medical technologists (but NOT the lab assistants) "crossmatch" blood using an electronic crossmatch procedure. The "crossmatched" blood with its attached paperwork is stored in a "crossmatch refrigerator" until it is needed for transfusion, which can often be immediately. It is then dispensed using a different computer function. They also have lab assistants prepare plasma, platelets and cryo for patients. Again, the computer system will not allow incompatible types to be set up or dispensed.
   
   
2. A medical technologist in Minnesota who works at an academic hospital and clinic is of the opinion that for a laboratory or medical assistant to be allowed to dispense blood products for transfusion, they must first go through an appropriate training experience and competence assessment. Specifically, the Minnesotan was of the opinion that one of the more senior medical technologists should watch over the lab assistant to be sure that the job could be done properly before allowing her/him to do the job independently.
   
   
3. A colleague who works at a hospital in Los Angeles reports that they use their computer to issue all blood products. Their lab assistants have been trained to prepare components and to issue blood products. This practice has been in place for more than ten years at the reporting facility.
   
   
4. Another colleague in Los Angeles wonders what backup plans are in place at facilities that rely on a computer systems to justify using lab assistants to dispense blood. Since the use of the computer system seems to justify the safe use of these personnel for dispensing blood products, are lab assistants prohibited from dispensing blood products during computer downtimes? In addition, how do these institutions prevent the dispensing of the wrong product for transfusion in spite of the correct product being "issued" in the computer. It is not unheard of for a blood product to be issued in the computer, yet a different product is dispensed to a patient.

ADDENDA May 19, 2003

5. In response to the question about backup posed by respondent #4, one of the colleagues who reported that they use lab assistants to dispense blood (since they believe this practice to be safe when using a blood bank computer) reports that in her experience lengthy unscheduled computer downtimes are extremely rare and backup procedures are used at those times. She adds (verbatim) "For the short scheduled downtimes, we discourage blood dispensing unless it is an emergency. During other downtimes, technologists must do serologic crossmatching (no electronic crossmatching can be done) and fill out manual paperwork to attach to units. The dispense procedure is the same whether performed by a technologist or a lab assistant. If SOPs are followed, it is no more likely that a lab assistant will make a mistake than a technologist, as all units ready to be dispensed have a slip attached with the patient name and medical record number, donor unit number, patient and donor blood types, and crossmatch results, even during computer downtime. We require the requesting location to bring a completed request slip when picking up blood. This slip must contain patient name and medical record # as they appear on the patient's ID band, component requested and location of patient. We plan to add a place for the name of the requesting physician but at this time have not made that change. Info on the request slip is compared to the info in the computer and to the info on the slip attached to the unit and to the info on the unit label. Discrepancies must be resolved before blood can be dispensed. (Kind of like going to the bank to withdraw $ - wrong info gets you no $.) In emergencies, group O uncrossmatched red cell units can be dispensed if the time necessary to resolve discrepancies may endanger the life of the patient. We rely heavily on the use of barcode readers. When a crossmatched unit is to be dispensed, the donor number from the label on the bag is barcoded into the dispense function. This will bring up the patient's name and medical record # (we don't do any double crossmatching). If the name and medical record # on the slip on the unit do not match the info in the computer and on the request slip, we do not dispense until the problem is resolved. During downtime, the donor number is handwritten on the request slip and all info that we would normally enter into the computer is written on that slip for later rebuild. Techs are always available, so lab assistants are not abandoned and expected to figure out problems on their own. There is no guarantee that everyone will follow all SOPs 100% of the time. SOPs depend on computer system used, how that system was set up, how people are trained and what kinds of flags are in place to catch errors, etc."

ADDENDA May 20, 2003

6. A colleague from Spain is of the opinion that blood products can be dispensed by non-medical staff, provided they are given sufficient training and that their competence is strictly evaluated. At the responding colleague's hospitals, non-medical technologists have dispensed blood products for years without problems. The responding colleague points out that (in his opinion) transfusion in Europe is less regulated than the US, and that blood banks and hospitals are less worried about budget than American institutions. In the Spanish colleague's experience, the range of products that is dispensed is narrow (i.e. red cells, platelets, FFP, cryo) and the main problems are compatibility and traceability. In his opinion, compatibility is not difficult to understand and train, and traceability is not a medical matter. Therefore, he concludes that if one implements a properly validated computer system and trains one's personnel, then technical staff can be used for more complicated matters, and non-technical staff can perform routine functions, such as dispensing blood products.

ADDENDA May 22, 2003

7. A colleague in California whose laboratory allows lab assistants to dispense blood products wishes to respond to #4's comments (Verbatim):
   
   "We train both technologists and lab assistants dispensing blood products to follow our SOPs. We also perform a daily audit to check if blood products are "allocated" (MiSys terminology) but are not physically present in inventory, and use expired product reports to check our physical inventory. We also have a Blood Issue slip that must be brought to the Blood Bank by the messenger. Any blood bank staff issuing blood products is required to carefully check all information on that slip against the computer and product before issuing products. The blood bank lab assistant or messenger is also required to initial the Blood Issue slip. We can back-track to those slips and to copies of the transfusion record that are returned to our department to resolve any product issuing problems. Our staff knows, because of education and training, that this is a high priority process that must be performed carefully. They know that we audit the issuing process, document any deviations, and report to the QA committees of both our lab and hospital."

Submit comments to the e-Network Forum at enetworkforum@cbbsweb.org

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

W. Tait Stevens, MD
CBBS e-Network Forum Editor & Moderator

Elizabeth M. St. Lezin, MD
CBBS e-Network Forum Associate Editor & Moderator