A Nurse Educator at a small rural hospital in Wisconsin reports that her hospital currently gives post-transfusion discharge instructions to all of their outpatients, but she is also wondering whether these same instructions should also be given to inpatients. She wants to know if there are any standards of practice that address this? She has been told that JCAHO requires all inpatients who are discharged within 24 hours of a transfusion to receive written instructions, but she has not been able to pinpoint such a standard. She would appreciate any input on this issue. Is any colleague aware of JCAHO and AABB standards that might pertain?

The following responses have been received.

1. A transfusion medicine physician in Los Angeles who is quite knowledgeable about JCAHO and AABB Standards reported that she is not aware of any JCAHO standard that specifically mentions written instructions for inpatients discharged within 24 hours of the transfusion. However, she is aware of a more genertic JCAHO standard under the "Education" section (as follows): "Standard PC.6.10 - The patient receives education and training specific to the patient's needs and as appropriate to the care, treatment, and services provided. The rationale for PC.6.10 is that patients must be given sufficient information to make decisions and to take responsibility for self-management activities related to their needs. Patients and, as appropriate, their families are educated to improve individual outcomes by promoting healthy behavior and appropriately involving patients in their care, treatment, and service decisions."

The Los Angeles physician adds that the AABB's Transfusion Services Accreditation Program Unit (TS- APU) has revised the Transfusion Service Assessment tool to include the following requirement for accreditation. The revision was to be discussed at the 2004 AABB Annual Meeting, but she is not certain if it was actually approved:

"5.19.8 - Specific instructions concerning possible adverse events shall be provided to the patient or a responsible caregiver when direct medical observation or monitoring of the patient will not be available after transfusion."

2. A colleague in Bethesda, Maryland also refers to the above Standard from the 22nd edition of the AABB Standards, and adds: "This standard implies that if an inpatient receives a transfusion and then is discharged within a time-frame during which a transfusion reaction might occur, they should receive the same instructions as an outpatient who comes in to the facility for a transfusion and then goes home."

3. Editor's comment: Please note that the AABB Standard 5.19.8 does not impose a time limit on how long before discharge an inpatient has received a transfusion. Rather, the standard addresses the lack of direct medical observation or monitoring of a discharged inpatient after having received a transfusion.)

ADDENDA Nov. 12, 2004

4. A colleague at a hospital within a community owned, not-for-profit health system based in the Heartland of America reports that at his facility, because of the decreased length of stay of post-operative patients, many receive a red blood cell transfusion shortly before discharge, including the day before or even the day of discharge. In order to assure that their patients understand what to look for in regard to a possible transfusion reaction, both inpatients and outpatients are given a Blood Transfusion Patient Information Booklet at the same time they sign the Consent Form for blood transfusion. The signs and symptoms of a transfusion reaction are listed in this booklet along with the risks and benefits of blood transfusion. The booklet states: If any signs or symptoms listed below occur after your transfusion, please contact your physician immediately.

• fever or chills
• shortness of breath or difficulty breathing
• chest or back pain (not present before transfusion)
• hives or itching
• yellowish skin or eyes (may appear up to 3-6 months after the transfusion)
• red or dark colored urine (may appear up to 3-6 months after transfusion)

They believe that the distribution of this booklet when patients sign the consent for transfusion satisfies the requirement in the above AABB Standard 5.19.8.

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