Jump to content

ED type and screens


pbaker

Recommended Posts

Does anybody have any data regarding how many of the type and screens ordered by the ED actually get blood products?  Those products could be given in the ED or on the floor after admission.

One of my ED docs is trying to determine if they are requesting type and screens appropriately.  I did a 3 month retrospective review of data and only 28% of the type and screens ordered by ED actually got transfused from that specimen.  Doc wants to know if that is good or if they are ordering too many type and screens.

 

Thanks,

Link to comment
Share on other sites

Back in the day, when I was working in a hospital laboratory (when Karl Landsteiner was a little boy, and we did all of our testing manually!), I never used to mind getting type and screen samples from the Accident and Emergency Department, even if the patient was not transfused in that department, or, indeed, we not transfused at all during that particular stay in hospital.  The reason for this was the (approximately) 2% of people who had an atypical antibody in their circulation from a previous transfusion, a pregnancy, or both.  This allowed for a bit of time to identify the specificity of any antibody/antibodies and, if necessary, ordering in a sufficient amount of antigen negative blood and blood components.

Just my opinion.

Link to comment
Share on other sites

19 hours ago, pbaker said:

Does anybody have any data regarding how many of the type and screens ordered by the ED actually get blood products?  Those products could be given in the ED or on the floor after admission.

One of my ED docs is trying to determine if they are requesting type and screens appropriately.  I did a 3 month retrospective review of data and only 28% of the type and screens ordered by ED actually got transfused from that specimen.  Doc wants to know if that is good or if they are ordering too many type and screens.

 

Thanks,

This is a very interesting question. I suspect that many, many, many tests requested by the ED (A & E) could be categorized as "unnecessary" during analysis in the quiet time after "The Storm", i.e., the results had no relevance to the patients' treatment. But, in the moment (especially, during trauma), the medics have very little idea of what clinical data is important at that time. A "shotgun" approach seems to be appropriate. I'm not sure there is a way to meter or control this process (other than having extremely savvy ED staff). It seems to be a necessary evil - the need for rapid turn around overweighs the concern of "over-ordering" tests.

And, as Malcolm says, a little extra time for the BB to do its work is always appreciated.

Link to comment
Share on other sites

We don't actually see many T&S orders from the ED. Those are usually patients who may be surgical candidates (like broken hips, bowel obstruction, etc.) and unless they are anemic, usually not transfused. There are more orders for 1 unit and transfuse, almost 100% look appropriate when reviewed. Instead we saw a pattern of ED providers ordering blood types in order to have a Blood Bank specimen available. We've persuaded them to use a BB Hold order instead of charging a patient for a blood type that was rarely needed - a specimen is collected but nothing done until they order a Prepare/T&S. We do use some discretion with the BB Hold orders. If the H&H is low or the patient is a really active GI bleed or it's a trauma case that looks bad, we put the specimen on the Echo just to get a head start. Nothing is reported until we get an order but it can definitely help the TAT. I've never actually looked at stats on ED orders, but I've wanted to (in my abundant spare time :rolleyes:). 

Another project I've wanted to tackle is to look at our emergency releases (especially on medical, rather than trauma, patients) and MTP orders to see what % of our patients we are actually transfusing or MTPs that only use a unit or two (or none), to see if we have any interesting provider ordering patterns. Also, how many times we ship blood with transfer patients vs how many times they are actually transfused in route or the unit(s) wasted. I would like to compare that information with the score ED assigns to the trauma patients to see if we are correlating well. 

 

Link to comment
Share on other sites

1 hour ago, AMcCord said:

We don't actually see many T&S orders from the ED. Those are usually patients who may be surgical candidates (like broken hips, bowel obstruction, etc.) and unless they are anemic, usually not transfused. There are more orders for 1 unit and transfuse, almost 100% look appropriate when reviewed. Instead we saw a pattern of ED providers ordering blood types in order to have a Blood Bank specimen available. We've persuaded them to use a BB Hold order instead of charging a patient for a blood type that was rarely needed - a specimen is collected but nothing done until they order a Prepare/T&S. We do use some discretion with the BB Hold orders. If the H&H is low or the patient is a really active GI bleed or it's a trauma case that looks bad, we put the specimen on the Echo just to get a head start. Nothing is reported until we get an order but it can definitely help the TAT. I've never actually looked at stats on ED orders, but I've wanted to (in my abundant spare time :rolleyes:). 

Another project I've wanted to tackle is to look at our emergency releases (especially on medical, rather than trauma, patients) and MTP orders to see what % of our patients we are actually transfusing or MTPs that only use a unit or two (or none), to see if we have any interesting provider ordering patterns. Also, how many times we ship blood with transfer patients vs how many times they are actually transfused in route or the unit(s) wasted. I would like to compare that information with the score ED assigns to the trauma patients to see if we are correlating well. 

 

Excellent use of your "abundant spare time" !:lol:

On a more serious note, analysis of this kind of data could lead to modifications in typical practice and result in efficiencies of time and money (and, ultimately, patient care/outcome). However, if the ultra-bean counters get hold of this issue, there's a very good chance that they will find, and put administrative restrictions on all kinds of "unnecessary testing". I appreciate that medicine evolves, but sometimes the appropriate approach has already been identified.

Link to comment
Share on other sites

I started doing this kind of data dig before COVID, looking at appropriateness of transfusions in the ED. Similar to you, it's usually 1 unit transfusions, often in emergent settings but not MTP. I agree with @exlimey that the shotgun approach is usually what happens, and our retrospective looking is not comparable to the ED's initial read of the patient. Most often the dreaded "hypotension" is the reason for pushing products, regardless of H/H or active bleeding. We've done education to this point with our ED, and that includes our trauma patients, that a onesy-twosy red cell transfusion for low blood pressure is not appropriate. We haven't tracked the number of TYSCs ordered, but in our concurrent reviews, these are typically ordered for patients who may be pre-surgical, or to be admitted. I feel like they order TYSCs better than blood products at this point! :) 

Link to comment
Share on other sites

On 8/4/2022 at 11:19 AM, pbaker said:

Does anybody have any data regarding how many of the type and screens ordered by the ED actually get blood products?  Those products could be given in the ED or on the floor after admission.

One of my ED docs is trying to determine if they are requesting type and screens appropriately.  I did a 3 month retrospective review of data and only 28% of the type and screens ordered by ED actually got transfused from that specimen.  Doc wants to know if that is good or if they are ordering too many type and screens.

 

Thanks,

28% sounds good to me, allows units to be blood type specific and gives time for antibody identification. I remember the frustration waiting for samples.  I suggest asking the Dr how/if the question incorporates risk assessment for patient care and/or is it just financial. 

Link to comment
Share on other sites

Thank you for the responses.  Let me add an additional question.

About 30-40% of the patients with type and screens are discharged home from the ED.  Since there is really no diagnostic value to a TS, is this overuse?

Some of those come to us as "trauma" and end up not being as bad as expected, so I get those.  That still leaves about 25% being discharged to home.  The others have an registration diagnosis of things like: altered mental status, abd pain, shaky/dizzy, shoulder pain, ETOH, N/V/D, etc..

Link to comment
Share on other sites

I'm curious, can those 25% that appear to be "order abuse" be linked to specific docs or is it random through out the ED?  With current computer technology this should be discoverable.  Over the years of my career I realized that not all ED docs are created equal and some have a much lower threshold for CYA than others.  Just a random thought.

:coffeecup:

Link to comment
Share on other sites

1 hour ago, John C. Staley said:

I'm curious, can those 25% that appear to be "order abuse" be linked to specific docs or is it random through out the ED?  With current computer technology this should be discoverable.  Over the years of my career I realized that not all ED docs are created equal and some have a much lower threshold for CYA than others.  Just a random thought.

:coffeecup:

And we see this in surgeons as well.

Link to comment
Share on other sites

Those 25% that appear order abuse or CYA could just be physicians erring on the side of caution.
Alternatively many ER departments have check-list protocols; when curtain symptom boxes are ticked orders are automatically generated (or required). It may be worth while seeing if this is the case.

Link to comment
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now
  • Recently Browsing   0 members

    • No registered users viewing this page.
  • Advertisement

×
×
  • Create New...

Important Information

We have placed cookies on your device to help make this website better. You can adjust your cookie settings, otherwise we'll assume you're okay to continue.