Protocols for 'identifying' unidentified trauma patients who need emergency transfusion
A colleague who works in a large trauma hospital reports that they use a "Statpack" number as a 'John Doe' identifier. Every unidentified trauma patient receives an armband giving a Statpack number and medical record number. A given patient might be Statpack 132, #356789.
This system becomes complicated when the patient is subsequently identified, and if known to the hospital, issued the historically correct medical record number. At this time a new armband is placed on the patient's arm and a new addressograph plate placed at the nursing station, and the old armband and addressograph removed. The problem is that the patient may still be using blood. However, the transfusion service cannot issue crossmatched or group specific blood-using information from a sample labeled with a Statpack and old medical record number, when the patient now has a different armband, and the request for blood release comes to the transfusion service with the new identification. The inquiring colleague believes the possible solutions are as follows:
- Obtain a new blood sample with the new (correct) identifiers
- Keep both armbands on for the duration of the bleeding episode.
He wonders, "Are there other approaches?"
The following responses have been received.
ADDENDA Oct. 16, 2003
- The Editor reports that at the Los Angeles County+USC Medical Center (a major urban trauma center) we use a protocol that employs Emergency Identification that consists of an Alias Name (which is not reused more often than once every few years) and unique medical record number (MRUN) which is never reused. An emergency Alias Name is a combination of an arbitrarily assigned first name such as TOM or MARY combined with a last name that is a spelled out 'alpha' number from 'one' to 'ninety-nine'. There are twenty male first names and twenty female first names that are used in our system. Each of the twenty names begins with a different letter and they cycle in alphabetic order. The combination of ninety-nine 'alpha' last names and twenty cycling first names provides 1,980 different male first name/last name alias combinations and 1,980 different female first name/last name alias combinations. Examples include TOM TWENTY-FIVE and MARY THIRTY-THREE.
By using Alias Names that rarely recycle and MRUN numbers that are unique, we can 'identify' patients, even in the absence of their true identity, and avoid using similar sounding names such as JOHN DOE or JANE DOE.
Operationally, a list of male and female alias names with associated unique MRUN numbers is issued to the Emergency Department administration, which creates packets of pre-printed forms and labels (and other items as described below) for critical emergency care of unidentified patients. Each packet is labeled on the outside with the alias name and unique MRUN using red ink for females and black ink for males. The packets consist of a patient identification (I.D.) plate, which includes the MRUN, gender ("M" for male or "F" for female), the assigned first and 'alpha' last names. All documentation for the patient is imprinted with this I.D. plate. Additionally each packet contains a patient chart including all of the following, which are prelabeled using the I.D. plate:
When a patient has been admitted using an emergency packet, the patient continues to use the assigned alias name and MRUN until their true identity is determined. Once their true identity has been determined, their ID band and computer record is updated to reflect the most current name, but the MRUN does NOT change during that admission. In addition, an 'AKA' (also known as) cross-referencing the alias name and the patient's true name is created in the hospital information system (HIS). The blood bank may dispense blood products based on either the assigned alias name/MRUN combination or the the AKA/MRUN, provided the MRUN number is unchanged and the AKA appears in the HIS. When the change from an alias to a real name has been made, the blood bank will add the correct name to the patient tube label, indicating that the original name is now an AKA. (Now both names are on the specimen tube.) We will also include both names on the transfusion slip that is issued with the unit of blood product. This is only done after confirming the change either in the HIS or with the Dept. of Medical Records (DMR). That allows the blood bank to issue blood under either name as often the rebanding of the patient and the update of the HIS are not simultaneous and one process may lag behind the other. This prevents hospital staff from having to redraw the patient specimen and prevents delay in issuing crossmatch compatible blood and prevents having to issue emergency released blood while a newly drawn and labeled specimen is being worked up. If the MRUN is changed during a hospital admission (this occurs only for various reasons) and transfusions are still needed, a new blood sample must be submitted to the blood bank for testing, and if transfusion is absolutely needed, uncrossmatched blood is dispensed until a new sample is received and tested. If it is discovered that the patient actually does have a historical MRUN (prior to the current admission), the two MRUN numbers (historical and current) are cross-referenced by the Department of Medical Records, but blood is issued using the MRUN that was issued upon the current admission. Upon discharge, the charts and MRUN numbers are merged and the MRUN which has the most activity is used.
- Two patient identification arm bands (one for the wrist and the other for the ankle)
- Paper tie-on, identification tags
- Physical exam sheet General consent form
- Four labels for specimen tubes
- Radiology request and record sheet
- Blood bank request sheet
- A colleague in South Florida reports that his transfusion service is located in a 500-bed medical center which has a level 1 trauma service. Currently their trauma patients are given 5 DIFFERENT identifiers, 3 of which will always remain the same and with the patient during their entire hospitalization. Those identifiers are as follows:
In addition, they also use a separate blood bank identification armband, with a totally different set of numbers. All of the numbers have a different number sequence and are printed on a computer-generated specimen label, which is attached to the type & screen sample. The only two identifiers that can change are the name and medical record number. The financial number, "T" number and the "encounter" number do not change. They handle trauma patients as follows, in the event that an old pre-existing medical record number is discovered, after the initial identification of the patient has taken place. According to the responding colleague, once the patient is identified by their true identity, a second computer label is printed, containing the true name and possibly an old medical record number, with the other three identifiers remaining exactly the same as when admitted. This new label is compared to the original label for COMPLETE AGREEMENT OF AT LEAST 3 OF THE 5 ORIGINAL IDENTIFIERS. If there are no identifier number discrepancies, the new label is placed on the original type & screen sample, so that the original label information is still visible. Therefore, there will always be positive identification with at least 3 separate identifies on the type & screen specimen, as well as crossmatch compatibility tags, throughout the entire admission.
- The trauma name
- Medical record number
- A financial number
- A "T" (trauma) number
- An "encounter" number.
- At a facility in Texas they use a blood bank band system (e.g. Typenex®, IdentiBand) for identifying trauma patients, which is also the regular band that is used with every potential transfusion patient. Unidentified patients are initially called JOHN and JANE DOE. However, once the patient's true identify is learned and the right medical record number is assigned, the reporting Texan says that "it is easy for one of the blood bank personnel to talk to a nurse at the beside and make sure the band number is the same and then add the name and medical record to the specimen". She continues, "When the patient is identified, our Medical Records department merges the "John Doe" record with the patient's real name and number. We find that using a special blood bank band gives us an added sense of security when it comes to patient identification."
- A colleague at a level 1 trauma center in New Mexico reports that patients are initially assigned a "Trauma-Alert" ID as the last name and a fictional first name from a pre-designated list. When the patient is re-identified, admitting calls blood bank and gets "approval" to update the ID. Approval is NOT given if the patient is in a location inaccessible to blood bank staff at that time (OR) or is currently being transfused or has imminently pending tests/procedures. Approval will be given later after immediate patient care needs have been met. Blood bank staff facilitate the re-identification by receiving the paperwork from admitting and taking it to the patient bedside and checking the old ID band and replacing it with the new band and giving the new paperwork to the ward clerk. The original specimen is also given additional labeling indicating the patient was re-identified and it is still an acceptable specimen. If the original band is no longer on the patient, the new ID band and paperwork are all left with the ward clerk, no blood bank re-ID is performed and original crossmatch specimen is invalidated and all unused blood removed from crossmatch. They report that the above approach mostly works well for them as they are physically quite close to the intensive care units and lab assistants are trained to perform this process. They have had good cooperation from admitting but it took a while for this to all work smoothly when they first set it up a number of years ago.
- At a facility in Southern California, they report that the medical record number (assigned to the patient as a trauma case) remains with the patient throughout their stay even though it is discovered they have been at the facility before with a different medical records number.
Once the patient is discharged, the medical records numbers are "combined". This hospital has the Cerner computer system for laboratory, radiology, pharmacy, etc. which has the function to "cross-reference" different medical records numbers (such as in the situation described by the inquiring colleague), so that the same historical information is presented no matter which medical records number is accessed. This cross-reference function can be performed before the patient is discharged.
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