8. A medical technologist in Indianapolis, Indiana reports that their transfusion service considers evidence of a hemolytic transfusion reaction and any abnormal delay in providing blood for transfusion or surgery as "critical values". They 'respect' the intent of the CAP checklist item in that in their opinion the aforementioned events are important enough to require immediate notification of the attending physician, who may alter the patient's treatment based on the new information. Their SOP requires both the notification of the physician (or primary caregiver for inpatients) and a call to the pathologist.

9. Dr. Holli M. Mason, Director of Transfusion Medicine and Serology at Harbor UCLA Medical Center in Southern California (attribution used with permission) thinks that the term 'panic value' is a little more difficult to define in the blood bank because the blood bank has so few "values". She thinks that, though a matter of semantics, the spirit of the CAP Checklist item is satisfied with a policy on situations requiring immediate physician attention, and her service has a policy entitled: "Situations in which a physician must be called, AKA "Panic Values" ". Most of these situations require that a pathologist be called (in their case a resident or the transfusion service medical director) but many also require that the primary care physician be notified as well. Strictly speaking, "values" that would initiate physician contact urgently in her practice would be increases in the antibody titer of a pregnant woman, positive direct antiglobulin tests and blood that has been issued uncrossmatched only to be found incompatible upon completing testing. Situations requiring physician notification include: suspected acute or delayed hemolytic reaction, significant delay in providing blood (medical director to be involved if patient's Hgb is below 6), inventory/blood shortages, transfusion requests against established policy, switching Rh negative patients to Rh positive red cells, unable to result Rh of newborn and requests for incompletely tested blood products. Dr. Mason acknowledges that colleagues might wonder why she has specified that she is to be involved in delays in providing blood to patients with a Hgb below 6. As she works at a teaching hospital, she has found that new interns often simply accept the notification that there will be a delay as something they are "stuck with". To ensure good patient care and to make sure to take advantage of a teaching opportunity, she likes to get involved and evaluate patients who may be at serious risk for complications of anemia and educate the interns on the options available to them in such situations.

10. A medical technologist in Long Beach, California reports that her facility feels that transfusion services do have some critical values and includes these on a list that their Department of Pathology provides to the medical staff:

1. incompatible crossmatch
2. unexpected results on transfusion reaction workups (ie, unexplained post transfusion hemolysis, positive post transfusion DAT, different ABO type on post transfusion specimen, etc)

She comments that they do not feel that they are doing the aforemented "just to meet CAP regs", but to assure their physicians that they will be notified of what the transfusion service considers serious situations relating to blood bank test results.

11. A transfusion medicine physician in New York agrees with those who state there are no "critical values" in transfusion medicine. In his view, a critical value is a laboratory determination whose result is not already obvious from clinical findings. He states "This must be a result that is of extremely urgent interest to the patient and their care giver. Examples include severe laboratory abnormalities that may indicate impending clinical crisis but that may be partially or totally asymptomatic. Wildly abnormal potassiums and calciums come to mind, as well as PTs and PTTs that are off the wall. But the finding of a new alloantibody, or positive direct antiglobulin test obviously do not qualify. The workup of a hemolytic transfusion reaction is invariably initiated by the clinical staff, so the results hardly constitute a critical value. I think all laboratories should have procedures for how urgently and when and by/to whom clinically important findings are to be communicated, but I think we've taken this critical value thing to the point of a reductio ad absurdum."

ADDENDA Aug. 6, 2005

12. A Blood Bank Management Consultant is of the opinion that having a "critical values" list is quite appropriate in the transfusion service. She recommends to her clients a list such as one attached (pdf) file which is often termed a "Medical Director Notification Guidelines Policy."

13. A transfusion medicine physician in Cleveland argues that there are situations which qualify as 'critical' and require a transfusion service to urgently notify a patient's physician. For example, when a patient is in urgent need of blood, but all selected donor units are 'incompatible' due to a strong pan-agglutinin. While the aforementioned situation is NOT a TEST VALUE in the traditional sense, it nonetheless represents a lab result, which in her opinion should trigger immediate notification of the clinical service and the physician responsible for the Transfusion Service. In fact, she believes that anytime there is an actual or anticipated delay in availability of blood there should be a communication with the patient's clinician regarding the urgency of the clinical need. She has personal knowledge that lack of proper communication between transfusion service and clinician can result in an unnecessary patient death. Alternatively, there might be a situation in which sufficient blood or components are not available to meet clinical needs due to very low product inventory. In that situation, while there are no lab results to respond to per se, there is certainly a need to notify the appropriate clinical services in a timely manner to help utilize the inventory in a clinically most appropriate manner. She also believes that a blood bank test result suggesting the receipt of a WBIT (wrong blood in tube sample; see posting #2 on prior page) should elicit an immediate notification of the physician responsible for the Transfusion Service. Such notification is vital to prevent a potential mistransfusion by ascertaining whether another patient is also party to a speciman mix-up. She personally feels that cases requiring immediate notification, while possibly "buried" in other policies, need to be culled out into a separate list and supported by a separate policy thereby establishing the vital importance of communication in such circumstances. In her facility, they have a form that their Blood Bank lab utilizes to document calls to the physicans covering their Transfusion Service and Donor Room. She reports that she and her staff are in the process of updating this form and developing a corresponding policy.

14. A technical coordinator at the Chicago hospital reports that they have a "Physician Alert Policy" which defines certain situations that require notification of a physician. They employ an “Alert Value/Situation Log” that blood bank staff must use to document when they notify the Blood Bank Medical Director and/or the patient's physician of an "Alert Value/Situation". Attached is an example of their Log (MS Word).

Their policy requires notification of the Blood Bank Medical Director OR patient’s physician for situations like:

1. Transfusion error or serious transfusion reaction
2. Delayed hemolytic transfusion reaction
3. New hemolytic antibody identified during pregnancy
4. Excess feto-maternal hemorrhage

Examples of log entries include:

• Positive Fetal Maternal Hemorrhage Screen
• New Anti-Jkb and eluate contains Anti-Jkb on a recently transfused patient
• New anti-K1 on a pregnant woman
• Eluate contains Anti-A – Transfusion Reaction work-up
• Anti-D titer = 32, last month was 8
• Transfusion Reaction required intubation with pulmonary edema possible TRALI
• Newborn. 4+ DAT and eluate contains anti-D

The Blood Bank Medical Director reviews each Alert Value/Situation entry in a timely manner to ensure appropriate action has been taken and the appropriate physician has been notified if applicable. The Blood Bank Medical Director documents the review, and any comments as applicable, in the space provided on the Alert Value/Situation Log. Quality Improvement Reports (QIR) related to the Alert value/situation are generated as appropriate.

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