Emergency Release

[Karen Olsen]

We had an unusual occurance the other night and I was wondering if anyone would be willing to share what their policy would be in this situation. A patient requiring emergency release blood due to incomplete testing was refered(passing the buck) to another physician (at home) who requested that we give one unit at 11:30 PM and he would sign the emergency release slip in the morning when he came in. We had never had this happen where the actual physician requesting Emergency Release was not on site. In the end the testing was completed prior to transfusion, but we were still left with the question of whether we would have insisted that he come in to sign the request prior to transfusion.

[lef5501]

We will let the RN or a designee sign the awareness release form with a verbal order from the Dr. if the physician is too busy, etc.at the moment. The physician is still required to sign the release once everything has calmed down. I'm not sure if an RN would be willing to sign athe form without the physician even seeing the patient, however.

[MJDrew]

We would likely have the blood bank director (me) follow up on this when the physician actually taking care of the patient was not in the thick of the situation; probably the next day. The 1-minute discourse on why this signature was necessary would be given, and sincere thanks extended for their time in completing this necessary task. I like to point out that we are not trying to make their lives more difficult; we are trying to ensure patient safety by maintaining proper transfusion documentation that is required by law.

Physicians need to understand these forms are legal documents. There is NO WAY a physician not on the scene at the time of the transfusion should be signing these forms ex post facto!! Can you picture a plaintiff attorney's line of questioning if there was an adverse outcome in this patient's case??

My view is that it's your best policy to obtain signatures on these forms only from MDs who were actually involved in the care of the patient. Next day is fine. Your medical director might be useful in providing the follow up, peer to peer.

[Eagle Eye]

we had a case where patient was very critical and pick up person didn't bring the emergency release, we issued the blood and sent ER with the units. we didn't get ER back after we made several phone calls. Once they told me that patient expired, I went to the floor myself and got physician's signature.

In your case I would definitely talk to the physician to see what kind of emergency they have. At our institution we have resident available 24/7 so attending can authorize the resident to sign the ER. Many time when they are told to sign the form the order becomes non-emergency.

I would contact my medical director if physician wants to sign the form in the morning and he is off site.

[labgirl153]

This can be a very tough situation in small hospitals where hospitalists or residents aren't available. Physicians and medical staffs in smaller institutions are less likely to follow protocol since there's rarely any muscle behind the lab, i.e. the pathologist(s) rarely back up policy. I know, because have worked in several smaller facilities over the years and it's very frustrating.

In larger facilities, such as where I now work, the resident or the house resident can sign after they've spoken with the off-site attending for least-incompatible blood and incomplete testing so that settles it. Occasionally, a trauma form will come to us unsigned, but we don't withhold blood (now THAT would be a lawsuit!). The form is however, promptly signed once the blood is issued. In the past, at smaller facilities, have made my way down to OR, ER etc. to physically find the M.D. or even an anesthesiologist and have that individual sign it right there. An RN's signature is not kosher, so an M.D.'s signature is essential within an hour or two of emergency release and the doc must be on-site. Hopefully at your facility, the pathologist has by now had a little pow-wow with the chief of staff over getting a protocol together so that you and your co-workers won't have to contend with this legal nightmare.

[Sandy Jo]

The responsible physician's signature is not required before the transfusion, and the AABB TM recommends it is obtained "only after the emergency is over, typically within 24 hours." We include this in our SOP's. See current AABB TM, pages 510-511.

We have a form on which all the Emergency Issued products are listed for an event and the physician needs to only sign that one form, as opposed to each of the cards attached to the units. The form includes a statement to the effect that the clinical situation required release of the product prior to completion of compatibility testing, to comply with Standard 5.18.4.

Sandy R.

South Bay Hospital

Sun City Center, FL

[labgirl153]

Thanks for the Standards clarification Sandy. The problem is actually more along the line of losing track of the M.D. unless you can get them to sign within a few hrs. of the crisis. I've experienced the phenomenon more than a few times of docs passing the buck ...such as the lines: "I'm not really the attending...Dr. so and so is taking over and I didn't really want that emergency-released blood", blah, blah etc. because several M.D.s might be on the case and no one wants to assume responsibility. Then, when the attending is pressed, he'll claim he never ordered the units. Have even seen M.D.s cross out certain lines of text on the release form thinking it would absolve them of responsibility in court. Policy might be in stone, but human nature isn't quite so responsible.

[Eagle Eye]

I agree with labgirl. Once emergency is over, some of the docs give hard time. On the other hand our trauma docs are very good they cooperate with us. I usually like to complete that form ASAP. The patient I mentioned in my earlier post the resident said, "pt expired do you still need my signature?" I had to convince him that it was very important to complete that document for regulatory purpose.