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A California blood banker would like to know what information is routinely available to blood bank laboratories when blood products are requested for transfusion. Her facility's computer generated blood product request displays basic demographic patient information along with the blood product requested, the number of units needed and the date of transfusion and/or surgery. The requisition does not include the indications for the transfusion nor does it provide information such as hemoglobin/hematocrit, PT, PTT and platelet count. The CLSs at her facility have been "instructed to challenge" the nursing unit about blood product orders and inquire why a transfusion is ordered, and upon learning the lab results, to advise the nursing unit whenever lab results are "above the transfusion guidelines". Many times the response that a CLS gets is that "the physician wants the patient transfused", or on some occasions, even if a nurse agrees that the patient does not need a transfusion, the CLS is told that they are interfering with patient care. Sometimes a CLS encounters hostility from the nursing units. On a rare occasion, it is discovered that the transfusion order was placed for the wrong patient or that the laboratory results were misread! The inquiring blood banker would like to know what is the practice at other facilities. The following comments have been received. ADDENDA June 26, 2007 1. The Medical Director of a Blood Bank and Transfusion Service in New York reports that there are several concerns with dispensing blood products merely because "the physician wants the patient transfused" including issues with Joint Commission and AABB requirements for monitoring of transfusions, liability to the hospital and blood bank director, and cost of unnecessary transfusions (see CAP Today article from May 2007, Taking a harder line on blood transfusions). As a blood bank director, he has encountered a number of situations whereby inappropriate product (e.g., cryoprecipitate for warfarin anticoagulation reversal) or wrong product dose (e.g., lack of understanding that 1 unit of apheresis platelets is an equivalent dose of 4-6 units of random-donor platelets) was requested and, in some cases, transfused causing harm to the patient. In his institution, blood bank technologists are trained to obtain the indication (including supporting lab values) for the transfusion and refer requests (excluding emergencies) not meeting hospital transfusion guidelines to a blood bank physician (i.e., blood bank director, clinical pathology resident) for approval. Most of the referred cases involve non-red cell products, but on occasion requests for red cells are referred when deemed excessive (e.g., when Hgb>10 g/dL or multiple units requested for non-bleeding patient with Hgb>8 g/dL). On occasion, clinicians have transfused against the recommendation of the blood bank physician, and these cases are presented to the Transfusion Committee (usually a letter is sent to the involved clinician and/or clinical departmental QI Committee in follow up). Finally, another concern arising out of product transfusion without provision of patient information is inability of the blood bank staff to screen for patients who may require specially-prepared/tested products, such as blood irradiation for patients at risk for graft-vs.-host disease or Hgb-S-negative blood for sickle-cell patients. To the California blood banker who initiated this discussion, he asks how many of those nurses, who accuse the blood bank of interfering with patient care, would want to be the patient who gets an unnecessary blood transfusion? ADDENDA July 17, 2007 2. A colleague in the Pacific Northwest reports that her hospital's transfusion committee created a blood transfusion order form which lists their local indications for all of the blood products that they use. When the physician orders blood for transfusion he/she is required to check the appropriate indication box. The unit secretaries enter that indication into the computer when the order is placed. The blood bank technologist enters the transfusion indication in a prospective review log so that there is a record of all patients with original orders to transfuse and the indication for that transfusion. The technologists calls the physician if there is no justification for the transfusion. In a bleeding patient red cells are never denied, but they always require the lab results for the issuance of FFP, platelets and cryoprecipitate. In some cases (i.e. life threatening bleeding), the blood sample is collected but results are not complete at the time of transfusion…so review is retrospective. The prospective review log is reviewed by the technical specialist monthly. Any transfusions that are not justified are flagged, the charts are reviewed by the technical specialist. If there is no indication on the chart then the case is forwarded to one of the transfusion committee physicians for review. Education letters are sent to the physician if peer review shows no justification. Between 200 and 300 transfusions per month are reviewed prospectively. Peers review 5-10 cases per month. They send about 15 letters per quarter to physicians when the justification for a transfusion is not apparent after the foregoing review process. They are still working to achieve 100% use of the transfusion order form which became mandatory about 2 years ago. If chart review shows the form was not used, then the physician gets a reminder letter to use the form. The form went out with lots of publicity and they take every opportunity to educate about the form. Their medical staff office has been very supportive. In the next year or so, their physicians will enter all blood orders directly into the computer and be required to include the medical indication. Orders will not generate without the indication. |
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Please submit comments to the e-Network Forum. Ira A. Shulman, MD W. Tait Stevens, MD |
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