A colleague reports that patients treated at her hospital and outpatient clinics who require (for a medical reason) that cellular blood products be irradiated not infrequently have blood orders submitted that do not include a specific order for cellular blood products to be irradiated. This causes many phone calls to the ordering location and calls to the physician to add the irradiation requirement. To prevent wasted effort and to ensure that patients who need irradiated products receive them, the hospital Transfusion Committee recently implemented a policy that if irradiation is ordered for a cellular product, all future orders will be provided as irradiated until a discontinuation order is received. A hospital nurse auditor has recently questioned this strategy. The auditor felt that reimbursement for the products might be denied if the physician did not specifically order irradiated for each order. The auditor thought that a note in the nurse's progress notes might be acceptable. In addition, not every physician will be aware of the need for irradiation. If a bone marrow transplant patient comes in through the emergency department, the ER physician may very well not be aware of the need. This colleague asks:

• How do others handle this?
• Is coverage denied if there is a hospital policy to provide irradiated cellular products without a specific physician order for irradiation with each blood order?

The following responses were received.

1. Dr. Breanndan Moore at the Mayo Clinic (attribution used with permission) reports that his institution has addressed the issue of ensuring irradiation of blood products for appropriate indications, and has implemented a system whereby once a clinician has ordered irradiated products for a patient the blood bank lab enters a computer note which pops up whenever that patient has blood ordered. Dr. Moore comments that in his experience, surgeons or other physicians who are not hematologists and who do not routinely use irradiated products are quite likely to omit a specific request for transfusion of irradiated products for patients who need their transfused cellular products to be irradiated. At the Mayo the Transfusion Medicine residents or Staff physicians question the ordering doctor about the indications for all irradiation orders on patients who are not registered as Hematology or Pediatric Hem/Onc., but in any emergency, they "irradiate first and ask questions later". Dr. Moore says that they recognize that most of the patients who truly need irradiated blood have diseases which are either chronic or likely to involve relapses (leukemia, lymphoma, BMT recipients, GVHD, etc) and that their need for irradiated products is thus likely to be prolonged and episodic. The Mayo blood bankers reasoned that re-admissions or orders for blood coming much later than the original order for irradiation are likely to be related to those relapses or chronic problems (eg GVHD ) and thus these patients, more than likely still need the special attribute of irradiation applied to their blood orders. Dr. Moore states that in their view, this justifies leaving the computer flag in place to irradiate blood products once the flag has been placed. They also recognize that there is a danger that the permanent computer flag may actually cause real delays and additional and unneccessary costs if left in place for babies whose only medical reason for irradiated blood is for an intrauterine or neonatal transfusion and the requirement for irradiation of blood products is temporary. They are trying to come up with a mechanism to delete those notes after a specified period of time.

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