New Retype Policy Pitch To Administration - How Does It Look?

[jhaig]

I'll be proposing my retype policy change to transfusion committee and hospital administration in a couple of weeks and just wanted to have a few more sets of eyes look at it.

Proposal: Any patient requiring transfusion of packed red blood cells that does not have a previous ABO/Rh history on file will have a re-draw done at a different time to confirm the ABO/Rh. The blood bank tech can use a previously-drawn specimen from hematology if it available. If transfusion is needed before the patient's ABO/Rh is confirmed, the patient will be issued group O negative packed cells. This policy change will increase patient safety in receiving a red cell transfusion and will further limit the possibility of a mistransfusion.

Most of our patients either have a previous history, have already had a CBC tube drawn prior to blood bank orders being placed, or do not fall into the emergency transfusion situation. The amount of actual re-draws that will need to be done should be kept at a minimum. Any emergency orders would still receive uncrossmatched O-neg.

This is the easiest and most cost-effective way we've come up with to meet CAP standards. We are not a trauma center and most of our transfusions fall into the non-emergent category (routine inpatient, OP dialysis, etc.), so there shouldn't be much of a reason not to get a re-draw if needed.

Any other ideas of ways to enhance or edit this proposal would be greatly appreciated.

[Packer Banker]

We recently instituted a policy similar to this. Ours applies only to draws that were not done by a member of our lab staff. For us, this might be off-site dialysis, drawn by a nurse. Like yours, it was done for safety reasons.

I guess it depends on how many patients your "few" are, and how many O neg you'd be taking out of the supply? Do you have any allowances for males and females over 55 (is that old enough these days?? ) able to receive Rh positive blood if so typed?

Good luck with your proposal...

[gksapp]

We went to a similar policy a couple of years ago. Several nurses and physicans concluded that we meant to draw two samples every time a patient received red cells. Based on that experience, I'd make sure they know that this is not the case.

The other commonly asked question that we received was concerning neonates. If this is an issue at your institution, you may need to point out that neonates are exempted because they get O red cells.

[estiner]

Our policy matches your proposal with one exception. If the specimen we have types as Rh positive, we give O Pos rather than use O Neg if not indicated.

[Mabel Adams]

Some define the retypes as forward only and others do a full retype. I validated (because the typing sera insert was vague) using blue top tubes for blood types. I like that I am not ruining the specimen for add-on tests like I do the CBC tube. We have done it so far due to our new requirement to have a blood type for the current admission for FFP transfusion. We are still trying to decide on a retype policy. I think we would match the Rh so as not to deplete the Rh neg pool.

I liked the suggestion of sending out a marked retype tube so no one is drawing two tubes the first time and sending the second one for the redraw.

[DHarts]

You may want to add that you will use a previously drawn hematology specimen ONLY if it follows Transfusion labeling protocol. (Identifiers, time, date, initials, etc)

[jhaig]

I should have added that the heme tube should be labeled correctly. I also am waiting on our blood supplier to approve my request to ship me a few more O neg units.

I'm still a little fuzzy on the Rh issue. If the current specimen is Rh positive, how can I give O Pos if it hasn't been verified? Am I being too careful, if that's possible? Would this only apply to females of child-bearing age? I'd rather give O Pos because of obvious potential inventory problems, but at the same time I don't want to have patients create Anti-D if not necessary.

We don't have a maternity unit here, so the neonatal issue isn't a problem.

[Mabel Adams]

The Rh decision should be based on FMEA ideas--how likely is it that the wrong Rh will be given and how bad are the consequences. Compared to ABO, the consequences are significantly less (hemolytic reaction and possible death vs. sensitization). Odds of being wrong are based on the facts that 1) we usually have it right on the first specimen, 2) 85 percent of the wrong patients will still be Rh pos and 3) we are much less likely to transfuse females with childbearing potential than older folks or young male traumas. If I am doing the statistics right, the risk, if you are issuing non-O blood but the patient type turns out to be wrong, would be ~55% if you issue A, ~80% if you issue B and ~96% if you issue AB. Those are all quite a bit higher than the Rh risk percentage of ~15%.

If we wanted to do it perfectly we would genetically type all patients and donors and only give phenotypically matched units for all antigens--after we have confirmed ID via DNA -- but we have to do what is cost-effective and currently reasonable.

Avoiding killing people with mistranfusion is the main goal at this point. Thankfully it is a rare error, but the consequences are so dire, it is worth a great deal of effort to prevent it.

Let me know if I overlooked anything.

[CPSHAN56]

We are currently moving in the same direction. I will be presenting to Transfusion committee in May. Question for the group - Does anyone specifically require the second specimen to be collected by a different phlebotomist, nurse, etc.?

[gksapp]

We require the second sample to be drawn by a different person at a different time. We do not have a minimum time interval specified, although I did consider that.

My reasoning is that, if someone is going to draw a sample without properly identifying the patient once, they are likely to do so again.

[BBK710]

We have a similar policy that has been in use for about 2 years. We transfuse O neg if we do not have a second specimen. I think we have only had to do that once. Our policy states that the second sample should be drawn by a different tech at a different time if possible. In some cases it isn't possible to have a different person draw the sample. The only problem we have had is that the ER staff has figured out how to get around it by drawing 2 specimens at the same time and labeling them with different times. So I agree that the special tube for second types is the way to go. Now if I can just find the time to write up that new protocol......

[jhaig]

To quote Ferris Bueller's Day Off - "They bought it!":cool:

I got my retype policy through transfusion committee with little problem. The only question that medical exec. had was along the corporate compliance route (of course). Does a re-draw for confirmation of ABO typing require a physician's order?

[estiner]

Not at my facility because it is our policy per our pathologist to verify the blood type - Blood Bank orders it and charges for it.

[gksapp]

Our SOP is considered the order. It was approved by our medical director, and is reviewed every year. We do not charge for it however.

[Elizabeth Gillis]

We are a small hospital also. We do a retyping on all patients, techs were too confused to be more selective on patients. On our type and screens, I have an automatic default for a confirmation test with a comment attached that a confirmation by ABO/Rh needs to drawn before the patient is transfused. All pre-op patients without a previous ABO/Rh are automatically drawn by our phelebotomist the day of surgery and the nurses now call from ODS to double check to see if we need a confirmation. All in patients, we wait until the next draw unless it is necessary the patient will get transfused, then we will redraw for the confirmation. We do use purple (CBC) or blue (COAG). All outpatients the confirmation is cancelled. In an emergency we follow the protocol for emergency transfusions by giving O neg. We did have reluctance with nurses and doctors at first, not anymore. The policy works very smoothly.

[elm72]

We just implemented the exact same policy 2 months ago throughout our healthcare system. What you propose looks good. One thing though, we cannot charge for the second group and rh. We created a test code that carries no charge and can only be ordered in blood bank

[jhaig]

As it turns out, the second type falls under our reflex testing policy as is a 'no-charge' test and is ordered automatically. It is my understanding that we cannot charge for testing not ordered by a physician.

[REW]

Hi,

Regarding the redraw. I've been now drawing blood for almost 30 years. Still patient ID is a problem, and miss labeling.

Can we still relay on a second ABO/Rh draw? How do we really know the second draw is the right patient?

It's just not with Blood Bank, but with Hema, Chem, and all of the clinical lab draws.

I fully realize the need for proper patient ID, but there is a break down somewhere.

Some of the postings have similar a theme they are all short staffed. The med techs, the phlebotomist, and most of allied health.

The test that is run is only as good as the sample that is obtained. It all starts with the correct patient ID which includes: MR# DOB Last Name, First Name and Middle initial if there is one ALL MUST MATCH.

That brings us back to proper ID where does it all begin. We have all seen it cascade into a huge mess and it still continues. When physicians can't wait, and there is not enough staff to do the task properly, mistakes happen.

So again if drawing a second ABO/Rh is the standard, how do we know the second draw is any better than the original? and for that matter why don't we repeat the other clinical lab draws as well....this is just a thought.

Respectfully,

REW

[jhaig]

We still have to rely on phlebotomy to do the right draw on the right patient the first time. Ideally, a re-draw would be done by a different phlebotomist at a different time, thereby giving you a greater level of confidence that the correct patient was drawn. As long as humans are involved, human error is still going to exist. Blood bank is just as critical as any other department when it comes to patient ID. You can make a fatal mistake by reporting out a 40 glucose instead of a 400 or a protime of 12.0 instead of 120.0.

In the vast majority of blood draws, the correct patient is drawn the first time. Add to that a second draw at a second time and the odds that both of the draws are incorrect are next to zero. The closer to zero errors, the better.