Failure to complete Type and Screen testing until surgery has started

A colleague wrote that a longstanding problem at her institution has been that the doctors fail to order Type & Screen (T&S) blood orders on patients going to surgery. Her institution did an in-house study and found that 24% of T&S were being completed AFTER the start of surgery and 30% of the blood used in the OR was set up after the start of surgery. They are working with administrators, surgical chiefs, OR staff, and the preadmission screening clinic to improve this situation. They want to know what helped correct this problem at other institutions? At present, they use a preadmission antibody screen that is good for 7 days for patients who have not been transfused or pregnant in the last 3 months. They are working on extending the time-frame for the preadmission antibody screen to 30 days, and would appreciate any input from institutions who have used a longer than 7-day time period, especially a 30-day time period.

Editor's Note - The following links may be worth reviewing, as you consider your response to the above query:

• Blood pressure: New Q-Probe looks at types and screens for scheduled surgeries
• Type and screen for scheduled elective surgical cases
• Preoperative Antibody Screens - How to Ensure Timely Receipt Consistently?
• Does your hospital have a problem with STAT pre-transfusion testing orders for elective scheduled surgery?
• Use of Type and Screen versus NO pre-operative blood orders for a patient who has a scheduled elective surgical procedure with a low likelihood of requiring blood transfusion

The following responses were received.

ADDENDA Jan. 14 2003

1. The institution that raised this most recent discussion provides additional information. The problem that they are trying to correct is that their doctors fail to order Pre-Operative Type & Screens (T&S) in a timely fashion, according to their local policy. The doctors wait to place blood orders on patients going to surgery until the morning of surgery, routinely when the patient is already in the operating room. The protocol at their hospital clearly states that T&S and blood orders should be received in the lab by 2:00 pm the day before surgery.
   
   
2. A Lab Supervisor at a hospital in Washington state reports that she read with interest the comments suggesting drawing samples up to 30 days pre-op on patients who have not been pregnant or transfused within the last 3 months. The Washington blood banker is concerned that while this would be very convenient for the patient, she is unclear as to how all these specimens are stored and recovered when needed. In her experience, transfusion services have very limited refrigerated storage space as it is. She continues by asking a more serious question for those "30 day" facilities - How do they insure patient identification of the original sample? Her facility in Washington uses a specific blood bank armband (Typenex) applied at the time of the phlebotomy. The armband is used to link the specimen to the patient. The patient is require to wear the armband until the units are given or released. In her group's experience, the armbands are only legible for about 5 days, a little more if inserted into a protective plastic sleeve. Their goal is to have the pre-op patients drawn between 1 and 3 days pre-op so that the armband will still be legible on the date of surgery. It is not uncommon to redraw and repeat testing on a patient due to an illegible armband. She concludes with the opinion that she would rather have a stat type and screen than a mislabeled specimen or illegible armband.

ADDENDA Jan. 27, 2003

3. A colleague from Virginia writes to reassure the colleague from the state of Washington (reply #2) that at the Virginian's hospital, they have a system which allows them to hold samples safely for 30 days. The Virginian reports that their system requires only two additional racks with the front of each row labeled with a number 1 through 31 to correspond to the day of the month. After the preadmission sample is received and tested, it is placed in the row that corresponds to the sample expiration date. This should take up no more than one-half shelf in the refrigerator. According to the Virginian, insuring patient identification would be no different for a 30-day sample than for a 3-day sample. Their requirement is to verify the identification of each patient by viewing the patient's wristband name and social security number prior to sample collection to the patient's name and social security number on the order. By doing so the phlebotomist confirms that this is the correct patient. A label must be attached to the tube of blood before the phlebotomist leaves the patient's bedside. The label must include the following: the first and last name and complete social security number of the patient from whom the sample was collected; legible first and last name of the person collecting the sample; and the date and time the sample was collected with a computer-generated label or clearly legible handwritten label. The mechanism to identify the phlebotomist will be the placing of their full first and last names on the label which is adhered to the tube of blood. They do not use a specific blood bank armband (such as Typenex), because they believe that their identification system is sufficient. Unfortunately, a stat type and screen is not an option for their hospital unless it is an emergency 'add-on' to surgery. The Virginian reports that they are staffed with only one technologist in the blood bank. If the patient has an antibody, there may or may not be extra technologists to help complete the antibody work-up AND to set-up blood for other critically ill patients in the hospital. This situation happened just last week at their hospital. It is SO important to have procedures in place and followed so that the lab is not always scrambling at the last minute to provide blood for ROUTINE surgery. A luxury of the past was having extra staff to get ROUTINE work done on a STAT basis because busy doctors failed to place blood orders ahead of time. The Virginian adds that at their hospital, their doctors are willing to try and improve this age old problem. It takes a lot of extra work initially (like emailing individual physicians when they fail to place orders or send samples), but they are already seeing it pay off. The Virginian concludes with a plea that "Let's educate the rest of the hospital about what the blood bank really does and how long it takes!"

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