Blood Consents

A Corporate Compliance/Risk Management individual from a California hospital would like to know what other facilities are currently doing regarding obtaining consent for transfusion. The consent for transfusion is currently included in their general 'Consent to Perform Surgery or Special Procedure'. A copy of the inquiring colleague's hospital consent may be found HERE. The inquiring colleague wants to know if ALL patients who require a Surgery or Special Procedure should sign the blood consent portion of the general consent, even if the chances are slim that blood would be needed during the surgery or procedure (circumcision/ lap chole)? Or should they continue to only obtain a signature for transfusion consent, if there is a likelihood that blood MAY BE GIVEN during surgery and shortly after?

The following comments have been received.

ADDENDA Nov. 15, 2011

1. At a large academic hospital in Massachusetts the following approach to consent for transfusion is noted: Consent for transfusion represents a conversation between the recipient and the healthcare worker in which the risks, expected benefits, and alternatives to transfusion are described and the recipient given a chance to ask questions. Documentation of consent for transfusion can be done with a note in the medical record. Commonly, one of two different hospital forms are used: one form is for non-surgical patients. For patients undergoing surgery or a significant invasive procedure, the consent for procedure form includes consent for transfusion even if transfusion is not likely.
   
   
2. A transfusion medicine physician in Vermont reports that they have overlapping processes to cover transfusion consent:
   1. Similar to the colleague who sent out the inquiry, their Surgical Procedure consent includes the possible risk of requiring a blood transfusion and the risks associated with a transfusion as part of the verbage in the consent form.
   2. All transfusions outside of the OR or ED, such as floor (ward) based orders which are ordered via computerized physician order entry (CPOE) includes a physician attestation box for the physician to document via one of two checkboxes, either: informed consent was obtained, or that informed consent was not obtained due to the emergent nature of the patient's clinical state requiring a blood transfusion. This CPOE requirement for informed consent documentation by physician attestation cannot be bypassed (hard stop) in order to place the transfusion order. The only time this is bypassed is via a phone call to the Blood Bank due to the emergent need for uncrossmatched blood or massive transfusion protocol.
      
      
3. A transfusion medicine physician at a large private practice based medical center in Los Angeles reports that for the medical patient, physicians are required to obtain informed consent once per admission, and document that the risks, benefits and alternatives to allogeneic blood transfusion have been discussed with the patient. The surgical consent has a separate consent for blood transfusion related to the procedure located on the opposite side of the page.

ADDENDA Nov. 17, 2011

4. According to Phillip J. DeChristopher, MD, PhD, the Medical Director, Transfusion Medicine / Blood Bank / Apheresis at Loyola University Health System (attribution used with permission), blood consent at Loyola is separate from the Surgical or Special Procedure consent(s). After detailed discussions with members of our Blood Usage Review committee, they developed and implemented 3 blood consent documents: One to consent to any and all blood components; one with "limitations" (specified by the patient) and a third one for complete refusal. Although this sounds complicated, Dr. DeChristopher believes it isn't because their institution has an electronic medical record (EMR) and the consenting is documented electronically as well as in hard copy form (on the chart). Blood is ordered through a "Blood Navigator" function in the EMR, such that blood orders cannot be completed unless the ordering physician documents the appropriate blood consent has been obtained. In situations where patients totally refuse blood (component or derivative) transfusion, the EMR "red flags" that comment every time anyone logs into that patient's record. Dr. DeChristopher has graciously provided PDF copies of each consent form (see links above), for review by colleagues who might be interested in reading them.

ADDENDA Nov. 29, 2011

5. A transfusion medicine physician in Chicago reports that at his hospital they have a blood consent form and a surgical consent form with the same language included for blood consent. Everyone getting blood is thus giving prior informed consent for transfusion. For inpatients, a new form is needed for each admission. For longterm outpatients, the consent is repeated annually.

ADDENDA Dec. 13, 2011

6. A colleague in Chicago suggests that two recently published editorials by colleagues in Great Britain provide a perspective that is germane to this discussion.
   • Public policy, blood safety and haemovigilance. D. J. Roberts National Health Service Blood and Transplant, John Radcliffe Hospital, Headington, Oxford, UK
   • Patient consent for blood transfusion – recommendations from SaBTO. C. A. Howell1 & J. L. R. Forsythe2 1NHS Blood and Transplant, Oxford Science Park, Oxford, UK, and 2Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK. [SaBTO is an Advisory Committee on the Safety of Blood, Tissues and Organs to all four UK Health Ministers.]

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