At your institution do the physicians have to order a transfusion reaction before you do a workup or is the workup generated when nursing recognizes certain criteria and notifies your blood bank department?

The latter.

As a general rule, the nurse is supposed stop the transfusion at the first sign of problems. Then, they are to alert the physician of the problem and the physician determines if a transfusion reaction investigation is warranted. At least that's what is supposed to happen. Most of the time they call us and we tell them to call the physician if it is something that should be considered a transfusion reaction.

The Nurse calls a reaction at the first sign of symptoms, stops the unit, calls transfusion service, and then calls the physician to let them know. Now, does that mean it never happens that the Nurse calls the physician and the physician tells the Nurse to medicate and keep the transfusion going- I doubt it!

The nurse is supposed to call the physician at the first sign of a reaction and then the blood bank. We have certain criteria that make a workup mandatory but the physician can request a workup for any symptoms.

Our nursing policy require to notify physician immediately and then notify blood bank. They must fill out the transfusion reaction form and send the specimen to blood bank. They do not need to wait for the physician order. They were not sending specimen before because the physician did not want to investigate and nurses had to listen to their docs. They were not able to tell physician that they needed to send the specimen so we clarified that in policy that they must send specimen to blood bank.

If physician wants to override the sign and symptoms the physiciant need to sign the form to continue the transfusion.----but the RN need to send the specimen to the blood bank.

(they can continue transfusion for mild reaction such as hives but need to notify the physician and document in the chart that pt had this symptoms and pt was medicated with benedryal....also they need to notify the blood bank but no need to send specimen).

We also had physician's saying to continue transfusions without reaction workups. We finally changed the protocol so we have to do ID checks and DAT and retype on post specimen before they continue (except for hives, which they merely document, treat and continue). The hospital and lab felt that there was too much liability if a transfusion was continued without any workup. Pretty indefensible to continue an incompatible transfusion until the symptoms are overwhelming. My favorite line from doctors was for an autologous transfusion--"How could it be a reaction? It's his own blood!" They have such faith that no one ever hangs the wrong blood and bacteria don't grow in auto blood!

Thank you all for your help. We currently do workups only if ordered by a physician. We haven't done a workup in months. Yet when I review transfusion cards later (days or weeks later when they finally are returned) I notice anywhere from 2 to 10 cards with documented signs of a possible reaction. Most are mild febrile - but some as much as 4 degree temp rise! I appreciate that our docs trust us so much, but I fear that with staffing shortage and such that we need to be a bit more proactive in the interests of our patients. I plan to share your answers with my Lab Director today. I have addressed this issue repeatedly with our Medical Director and he does not agree with me. He feels that our current policy is just fine.

How often is the physician even notified? My guess is where you need to start is with some extensive re-education of the nursing staff as to what consitiutes a transfusion reaction and their responsibilities in managing the patient and notifying the physician and the transfusion service. A physician can't call it a transfusion reaction if they are not notified of the symptoms.

our doctors have to order the workup.

I have a Powerpoint presentation on transfusion reactions that I give to nurses. I will share it with anyone who wants it. It is somewhat specific for my institution, but still might be adaptable for another institution. Just give me an email address to send it to.

BC

Our nursing service initiates any transfusion reaction workup. They are to stop the transfusion and notify the blood bank to initiate the workup, which includes a full clerical check of all paperwork and wristbands, pre- and post- ABO/RH of the patient and the unit, and a pre- and post- DAT. The nurse then calls the physician to let them know what's going on. Any suspected urticarial reactions (hives, etc.) can be continued with a physician's order without the blood bank being involved. Once the workup is complete, the nurse gives the results to the physician and the physician decides whether or not to continue the transfusion or order more testing (blood cultures, urine, gram stain, etc.)

I'd be concerned about a policy which could possibly allow a transfusion reaction slip through the cracks without being addressed immediately. Sure, your docs may trust you, but see what happens if you end up in litigation regarding a transfusion reaction. You may see just how far that trust goes. You-know-what rolls downhill, and the lab is usually at the bottom.

It may be worth your while to consider switching to leuko-reduced PRBC's. We've seen a drop in the number of reactions since switching over three years ago. We transfuse a large number of chemo / dialysis patients and the docs won't ever switch back. The units may cost more, but they seem to have cut down on our febrile non-hemolytics.

You might want to share FDA regulation 21 CFR 606.170(a) with your medical director. You are responsible for thoroughly investigating ANY reports of adverse reactions, regardless of the source or whether an order has been placed by a physician. "Well, they didn't order it" won't cut it with the FDA.

BC

i'm with john. if a nurse suspects a reaction she/he may or may not call us to let us know about possibly needing a workup done. i'd say 90% of the time they don't call us until the doctor says he wants the workup ordered/done. otherwise, we have nurses that would call a reaction if a patient sneezed while being transfused.

otherwise, we have nurses that would call a reaction if a patient sneezed while being transfused.

We have the opposite problem, nurses will call the docs and the docs will say, "Don't report it, it's not a reaction". Later, QA finds it and that it really did fit the criteria for a reaction and should have been worked up. And then it is a little late.

I worked in a small 255 bed hospital once, and there was a nurse that could talk a dead person into admitting to back pain so she could call a transfusion reaction. Whenever she would come to pick up a unit for transfusion, the techs would say it wasn't ready yet so that someone else would end up transfusing it.

BC

I would love to see what you have for your educational power point. My e-mail address is Karen.Olsen@mmhhs.com

Thank you

I have a Powerpoint presentation on transfusion reactions that I give to nurses. I will share it with anyone who wants it. It is somewhat specific for my institution, but still might be adaptable for another institution. Just give me an email address to send it to.

BC

Since my last visit I've been made lab manager - but I am also still BB Supervisor. The good part about this - sort of- is that I currently am updating the hospital transfusion policy (at home this wekend:( ). Once I've made the appropriate changes it will take some time to educate our nursing staff. If you have a powerpoint I would very much like to see it. I can use all the help I can get! The double hat role is a bit too big for my puny head.

caj1018@sbcglobal.net