What would you do? Transfer patient....

[swede]

We are the main hospital in the system. We have a small, limited service hospital that is about 10 miles away. They send all the lab work to us that they are unable to perform at their place. They can type/screen and crossmatch, but they do not perform antibody ID. They keep a limited supply of blood because the hospital only has 4 inpatient beds, it is mostly ED and outpatient services.

They use the same computer system (meditech client server), but it is set up by site for testing purposes.

They had a patient that needed to be transfused before being transferred to our main hospital, then the patient was sent to our place for further transfusion. Should we retype type and screen the patient? We did repeat the type on a tube that was sent with the patient (proper ID, the identifying number is the same within the system). We used the screen results that were entered at the other hospital.....we can't add to the specimen because it is a different site, but we can look up the result and it is in the patient's EMR.

We didn't want to delay further transfusion by redoing the antibody screen, but we are thinking we should have done so.

Any suggestions?

THis is all new to us since the small hospital just opened in March and this was their first transfusion and our first transfer in the middle of transfuson.

[Bill]

Does each lab/blood bank operated under the same CLIA number? If so, you would not need to redo the antibody screen. If the CLIA numbers are different, then everything should have been retested at the main hospital.

[swede]

I'll have to check the CLIA number, I can't remember off hand how it was set up, I know they are different CAP numbers. Thank you!

[Eagle Eye]

my opinion is same as Bill. Personally I would not accept the specimen drawn by other facility. If there is an emregency I would give type O...yes it would help to know patient's history..if pt has antibody I will honor the antibody.

[clmergen]

I am part of a system that shares a computer system and we frequently get transfers from the smaller hospitals. We redraw all patients upon admission to our hospital, which is generally through the ER. We also do history search all of hospitals records to make sure that we get a clear blood bank history.

[Sheila]

Remember that old TV commercial, the one with the underwear and the old lady underwear inspector who says, "It doesn't say Hanes until I say it says Hanes"?

That's how our blood bank is; it doesn't say A Pos until I say it's A Pos, etc. I would get a new specimen or give type O until I got a new specimen, and did the T&S myself.

[dgibaud]

Does the patient get a new medical record number when admitted to the larger facility? Doesn't this then cause an armband mismatch, or the possibility of one? We always get a new sample. Do the blood bank records (abo/rh, transfusion history, etc) transfer also? Something to think about when you have one computer system sharing a database with multiple sites.

[swede]

The MR number does not change between sites. We have a system for matching/verifying MR numbers, etc. The type and screen information goes into a shared history file. We don't have a problem with checking history, etc.

We have decided that the policy is to retype and rescreen the patient on arrival.

Thank you!

[Malcolm Needs ☆]

As a Reference Laboratory, we do not have the luxury of being able to draw our own samples, but we always start by performing a full ABO and D type (and usually Rh and K phenotype), DAT and antibody investigation of our own, and never believe the findings of the hospital, however good their reputation (and history of being correct) may be.

However good they may be, everyone makes mistakes sometimes (and that certainly includes us).

:fear:

[John C. Staley]

I have never met a blood banker who trusts the work of anyone else. "If I didn't do the testing it is suspect!"

[Malcolm Needs ☆]

Not quite true.

We do trust the results from the International Blood Group Reference Laboratory.

Whether they trust ours, on the other hand...........

[kemo]

In my last job, the trust had 5 hospital sites with 3 transfusion labs. There were often occasions when patients were transferred between various sites. The labs shared the same IT system, had the same equipement & policies in place and the patient's hospital ID numbers would be the same. Since everyone was working to the same quality standards (allegedly) we could theoretically electronically issue blood for the patient, provided that there had been 2 separate group & screen samples sent and that the other standard pre-transfusion history requirements were okay. I think in this case, it would depend on how satisfied your lab is with the smaller labs proceedures- e.g. is the grouping /antibody screening automated, etc.

[LAS]

We would have redrawn the patient upon admission to our facility. We do not accept specimens for pre-transfusion testing drawn outside our facility. In an emergent situation, O neg would be issued until testing could be completed.

[adiescast]

We are also dealing with this issue. We are a hospital system with one large hospital that does the workups and three smaller hospitals that do routine blood bank. We all have the same computer system. We are all under different CLIA numbers, but had been under one umbrella for everything else (AABB, CAP, JC). I say "had been" because of the recent changes at JC that do not allow system accreditations. Ours will change in the next round, since we were surveyed this year as a system.

We have been moving the results to allow the blood to be issued from the hosptial the patient is transferred to. Part of the reason we do this is that when we do the antibody ID and send blood to them, they take that crossmatch. The requirement is that the performing lab has to be part of the record, not that the test has to be performed at your hospital. At least that is how I read it.

Part of how we look at it is that hospitals in our system are "us" and not "them." We don't accept results from outside locations (except reference labs that we have selected as suppliers). If I am trusting these people to work on "my" patients (I am responsible for blood banks throughout the system), then I should be able to trust their work for the patients in any of our hospitals. If I can't, then they shouldn't be working for me!

[Malcolm Needs ☆]

We are also dealing with this issue. We are a hospital system with one large hospital that does the workups and three smaller hospitals that do routine blood bank. We all have the same computer system. We are all under different CLIA numbers, but had been under one umbrella for everything else (AABB, CAP, JC). I say "had been" because of the recent changes at JC that do not allow system accreditations. Ours will change in the next round, since we were surveyed this year as a system.

We have been moving the results to allow the blood to be issued from the hosptial the patient is transferred to. Part of the reason we do this is that when we do the antibody ID and send blood to them, they take that crossmatch. The requirement is that the performing lab has to be part of the record, not that the test has to be performed at your hospital. At least that is how I read it.

Part of how we look at it is that hospitals in our system are "us" and not "them." We don't accept results from outside locations (except reference labs that we have selected as suppliers). If I am trusting these people to work on "my" patients (I am responsible for blood banks throughout the system), then I should be able to trust their work for the patients in any of our hospitals. If I can't, then they shouldn't be working for me!

Well put!

I have got one question though. If a desperately ill patient has to be moved from one hospital to another hospital (not in the same group), is there ever an occasion in the USA when cross-matched blood would be transported at the same time (such as in an ambulance or in a hospital helicopter/airplane), in case the patient requires transfusion in transit, or has such a rare antibody that only a few units are available (say an anti-HrB) and so would have to be shipped with the patient? (sorry, very long question!). If this does ever happen, how do the various ruling bodies cover this?

:confused::confused:

Over here, by the way, when such a rare event occurs, we have to have a written medical concession.

[adiescast]

If the units were not transfused during transport, we would probably emergency release any special units to the patient in dire need while we repeated the testing. The units not hanging would have to be checked for appropriate transport conditions, accepted into inventory, and released from the blood bank. If the patient was that bad, I don't expect that we would even deal with it. They would be hanging any units they had as fast as they could and we might not ever know the units came in.

I don't think the regulatory bodies say too much about who does the work, except that there has to be a record of who did it. I think we just don't trust anybody else's work, in part because of the possibility of error that you have already pointed out, and in part as a CYA move in case there is a lawsuit.

[Malcolm Needs ☆]

If the units were not transfused during transport, we would probably emergency release any special units to the patient in dire need while we repeated the testing. The units not hanging would have to be checked for appropriate transport conditions, accepted into inventory, and released from the blood bank. If the patient was that bad, I don't expect that we would even deal with it. They would be hanging any units they had as fast as they could and we might not ever know the units came in.

I don't think the regulatory bodies say too much about who does the work, except that there has to be a record of who did it. I think we just don't trust anybody else's work, in part because of the possibility of error that you have already pointed out, and in part as a CYA move in case there is a lawsuit.

Thank you for that prompt and full explanation.

I do wish we still had the "Thanks" button!

:)

[John C. Staley]

If the units were not transfused during transport, we would probably emergency release any special units to the patient in dire need while we repeated the testing. The units not hanging would have to be checked for appropriate transport conditions, accepted into inventory, and released from the blood bank. If the patient was that bad, I don't expect that we would even deal with it. They would be hanging any units they had as fast as they could and we might not ever know the units came in.

I don't think the regulatory bodies say too much about who does the work, except that there has to be a record of who did it. I think we just don't trust anybody else's work, in part because of the possibility of error that you have already pointed out, and in part as a CYA move in case there is a lawsuit.

Our theory worked the same as yours. The weak link was the ER and Transport personell. Far too often the blood arriving with the patient stayed with the patient and the blood bank new noting about it for up to 2 or 3 days when some nurse would call down wanting to know what to do with the box of blood that was setting under her work station!!!

As long as the blood was infused enroute, no problem, if it arrived with the patient unopened we wanted it brought to the blood bank and would issue emergency release blood in needed.

:handshake

[AP44924]

Reference laboratories as a rule of thummb perform all the tesing i.e ABO/Rh and AB screen. I previously oworked at a facility where the labs had different CLIA license number, but same umbrella institution. Since, we did not want to double bill our patients, we repeated Type and screens, but did not charge the patients. there was a addendum out witht he results that the testing was performed at our lab and there was no associated charge. The only charges wer for Antibody ID, screen units nad performing XM's. The general laboratory had charges build in for specimen transfer and such.

[Malcolm Needs ☆]

Our theory worked the same as yours. The weak link was the ER and Transport personell. Far too often the blood arriving with the patient stayed with the patient and the blood bank new noting about it for up to 2 or 3 days when some nurse would call down wanting to know what to do with the box of blood that was setting under her work station!!!

As long as the blood was infused enroute, no problem, if it arrived with the patient unopened we wanted it brought to the blood bank and would issue emergency release blood in needed.

:handshake

The bit about the Blood Bank knowing nothing about transferred units of blood seems to be a ubiquitous problem John. Sadly, anyone in the UK would recognize the scenario instantly.

Now I'm going to be a real pain (nothing new there then).

What if the patient was known to have an anti-HrB, came with Rhnull units, and needed an immediate transfusion? Emergency release blood would not be compatible, and it would be known not to be compatible (I am thinking of a genuine case - not being a pain for the sake of being a pain - for once!!!!!!!!!)?

[John C. Staley]

Life is a gamble!! You pay your money and take your chances.

Not much benefit in worrying about the 1 in a 1,000,000 for every time we see a patient.

Could it happen, obviously, but the time and expense of worrying about it everyday all day is just not there.

A patient like you describe had better come with instructions from the sending facility and I would expect a call from them letting me know this "special" patient is coming. There is always the exception to every rule but I had better be notified when that exception is coming!!!!

:pointandl:lonely:

[L106]

What if the patient was known to have an anti-HrB, came with Rhnull units, and needed an immediate transfusion? Emergency release blood would not be compatible, and it would be known not to be compatible (I am thinking of a genuine case - not being a pain for the sake of being a pain - for once!!!!!!!!!)?

/QUOTE]

If I understand the scenario and question that you are presenting:

In this situation I would communicate with the facility that shipped the blood product with the patient (to make sure I had all the correct history of the patient and special donor unit.) If the info all made sense, I would get the approval from our Pathologist, then issue that special shipped unit (rather than an uncrossmatched unit from our regular inventory.)

Your scenario strikes all-too-close to home..... Several years ago we had a patient who had Anti-HrB (along with a couple other antibodies thrown to make it a little more exciting!) She's still around (YIKES!), but hasn't had any medical problems for many years (thank goodness!)

[Malcolm Needs ☆]

Life is a gamble!! You pay your money and take your chances.

Not much benefit in worrying about the 1 in a 1,000,000 for every time we see a patient.

Could it happen, obviously, but the time and expense of worrying about it everyday all day is just not there.

A patient like you describe had better come with instructions from the sending facility and I would expect a call from them letting me know this "special" patient is coming. There is always the exception to every rule but I had better be notified when that exception is coming!!!!

:pointandl:lonely:

True, true.

I agree that communication is everything.

[Malcolm Needs ☆]

What if the patient was known to have an anti-HrB, came with Rhnull units, and needed an immediate transfusion? Emergency release blood would not be compatible, and it would be known not to be compatible (I am thinking of a genuine case - not being a pain for the sake of being a pain - for once!!!!!!!!!)?

/QUOTE]

If I understand the scenario and question that you are presenting:

In this situation I would communicate with the facility that shipped the blood product with the patient (to make sure I had all the correct history of the patient and special donor unit.) If the info all made sense, I would get the approval from our Pathologist, then issue that special shipped unit (rather than an uncrossmatched unit from our regular inventory.)

Your scenario strikes all-too-close to home..... Several years ago we had a patient who had Anti-HrB (along with a couple other antibodies thrown to make it a little more exciting!) She's still around (YIKES!), but hasn't had any medical problems for many years (thank goodness!)

Yes, you have understood it perfectly, and, like I said in my reply to John, communication is everything.

Your case sounds good fun! This is what serologists live for (NOT!!!!!); although you do get a sort of warm feeling afterwards if everything goes well (if you will excuse the phrasing, usually just before you change your underwear after the shock)!

:eek:

[MAGNUM]

It is my understanding that if a facility is separated from the main facility by 5 miles, then the second facility must have its own CLIA number and CAP number. With that said, I would not accept the specimen or their results although I may know them very well and trust that they are good techs. But in the end, whose name and quality is being afixed to that work. I would not trust the other even if my mother did the work, I would repeat it. To facilitate fast transfusion, in the interum I would transfuse the patient with O Neg PC until I could get my own results.