Irradiated orders

[bmarotto]

We have a multi-tiered mechanism for identifying patients who require irradiated blood. Once identified, we issue only irradiated products even if the order is written for "red blood cells" or "platelets". Our experience is "irradiated" is seldom specified when needed. There are many reasons...heme/onc docs know we will issue irradiated products once we are alerted the first time, the patient may come in under a different service that has no knowledge of the need for irradiated products, or simply the MD "forgets". Our compliance folks think we should contact the ordering MD and have them cancel the red cell order and re-order irradiated red cells. I see this as causing unnecessary delays. Tracking down the ordering physician is not always an easy thing. My proposal is to have the Medical Practice Committee approve the list of indications for irradiated blood, allowing the blood bank to modify an order as needed. We meet with compliance on Friday. How are others handling this?

[Malcolm Needs ☆]

We have a multi-tiered mechanism for identifying patients who require irradiated blood. Once identified, we issue only irradiated products even if the order is written for "red blood cells" or "platelets". Our experience is "irradiated" is seldom specified when needed. There are many reasons...heme/onc docs know we will issue irradiated products once we are alerted the first time, the patient may come in under a different service that has no knowledge of the need for irradiated products, or simply the MD "forgets". Our compliance folks think we should contact the ordering MD and have them cancel the red cell order and re-order irradiated red cells. I see this as causing unnecessary delays. Tracking down the ordering physician is not always an easy thing. My proposal is to have the Medical Practice Committee approve the list of indications for irradiated blood, allowing the blood bank to modify an order as needed. We meet with compliance on Friday. How are others handling this?

I completely agree with what you are proposing, but on the other hand, you are then taking on a lot of responsibility, and who will get it in the neck (and quite possibly sued) if someone in the Blood Bank forgets.

The point is, it should be the responsibility of the ordering physician, and then they get it in the neck (and quite possibly sued) if they forget. They get paid for taking this responsibility; but, of course, there is a patient on the end.

:cool::cool::cool:

[L106]

I agree with you in theory, Malcolm, but bmarotto is living in the real world, and I'm there too, in exactly the same place. In addition to the reasons she listed for failure to specifically order "Irradiated" blood products, we also have to deal with nurses and unit secretaries who may enter the order into the computer from a verbal order from the physician.

If you have a Blood Bank computer system where you can enter "Special Needs" requirements it can alert the Blood Bank tech every time they open that patient's file, which can be a huge help to manage this scenario.

[bmarotto]

I agree, Malcolm. But I am referring to patients that we KNOW need irradiated products. Our computer system does everything short of grabbing a non-irradiated unit out of the tech's hand to restrict issue to only irradiated products. For patients we do not know about, that initial request has to come from the physician. We do have several supplmental mechanisms to pick-up ones they forget to alert us about, but these can be "after the fact". If the patient got non-irradiated products before our other systems identify the need, it is the physician that is held responsible. They know that and are thankful that we have some systems in place. Believe me, we DO pick up patients that way. Thankfully, most of the time it is before a transfusion has taken place.

[JOANBALONE]

I don't know if our transfusion service has any sort of agreement with the hospital regarding giving attributes not indicated in an order. We do have standing orders for certain floors (NICU) and outpatient facilities regarding irradiated, leukoreduced products etc. However, once the patient is flagged for an attribute in our LIS we will continue to give that attribute, even if it is not written in the order. We do not call the physician requesting a corrected order.

The opposite is true if the patient and orders are not flagged for any attribute and then the physician verbally requests special products such as irradiated or leukoreduced. We require a corrected order with attribute requested.

JB

Edited November 9, 2009 by JOANBALONE
spelling error again

[Malcolm Needs ☆]

Honestly, I do agree with both of you (as I said, there is a patient on the end of the order), and putting it on the computer as a special need is what we do too.

It's just that I see no reason why others should just be allowed abdicate their responsibilities.

:(

[LAS]

We are a smaller facility and have only 3 physicians who order irradiated products. We do tag the patients in our system, but still require that the orders specify irradiated products. If they do not, we have the luxury of being able to contact one of those three doctors and clarify the orders. Were we to decide to take ownership of that process, it would be necessary for us to have some sort of formal written agreement approved by our medical director and our medical executive team. It is not something we would take on ourselves, but now that I have read the posts I can see how helpful that would be in some situations. As always, thanks to all the posters out there. You guys are great!

[eric1980]

I believe the responsibility of order specially processed blood products should fall into the hands of the physician. (They are the highly paid people!)

But we BBers should help out by informing the physician about the special needs if we see it in the BBsoftware.

[Kashmira patel]

We have a multi-tiered mechanism for identifying patients who require irradiated blood. Once identified, we issue only irradiated products even if the order is written for "red blood cells" or "platelets". Our experience is "irradiated" is seldom specified when needed. There are many reasons...heme/onc docs know we will issue irradiated products once we are alerted the first time, the patient may come in under a different service that has no knowledge of the need for irradiated products, or simply the MD "forgets". Our compliance folks think we should contact the ordering MD and have them cancel the red cell order and re-order irradiated red cells. I see this as causing unnecessary delays. Tracking down the ordering physician is not always an easy thing. My proposal is to have the Medical Practice Committee approve the list of indications for irradiated blood, allowing the blood bank to modify an order as needed. We meet with compliance on Friday. How are others handling this?

We have similar expirience as you with regards to Irradiated Blood and Blood Products. We are a teaching hospital and a lot of blood products orders are placed by residents or unit clerks on behalf of the physicians. Our transfusion Committe has aggreed to a list of indications which require irradiated blood and it is a part of the blood transfusion guideline provided to the physicians and is a part of our SOP. Once a patient is identified from the list as requiring irradiated blood products, we get a corrected order from the care giver which may be the patient's nurse,who in turn contacts the appropriate physician.

[bbbirder]

We have the same problems as everyone else. In addition, we get patients who reside locally but have a hematologist/oncologist 'in the city'. The local doctor may take over their day-to-day transfusion needs and may not order the irradiated, even though the hem/onc wants it.

Or a different doc (internal medicine, maybe) is providing weekend coverage for one of the hem/oncs.

Once we get orders for Irradiated, we flag that patient in the computer (a marker in Meditech) and keep that marker 'forever'. In my opinion, only a hematologist/oncologist should revoke the irradiation request, and then it should be a formal request of some sort. (Except for emergeny situations.)

Linda Frederick

[kate murphy]

BB keeps patient's restrictions and requirements in the BB computer. We do not require our physicians to replace orders specifying irradiation, same as we do not require them to specify antigen negative, sickle negative, leukoreduced, washed, CMV neg or any other requirement for the blood products. These restrictions are either diagnosis driven, or patient history driven.

As far as taking on the responsibility in the BB, why irradiation any different from anything else in providing safe blood? This is our responsibility - just as giving K neg for patients with anti-K.

[Malcolm Needs ☆]

BB keeps patient's restrictions and requirements in the BB computer. We do not require our physicians to replace orders specifying irradiation, same as we do not require them to specify antigen negative, sickle negative, leukoreduced, washed, CMV neg or any other requirement for the blood products. These restrictions are either diagnosis driven, or patient history driven.

As far as taking on the responsibility in the BB, why irradiation any different from anything else in providing safe blood? This is our responsibility - just as giving K neg for patients with anti-K.

Hmm, thinking about it, it is difficult to argue with what you say.

[L106]

But the patients' needs for CMV Negative and/or Irradiated blood products change, whereas the need to give donor units that are K Neg to patients with Anti-K does not change.

[Malcolm Needs ☆]

But the patients' needs for CMV Negative and/or Irradiated blood products change, whereas the need to give donor units that are K Neg to patients with Anti-K does not change.

True, but antibody profiles change too.

You may identify an anti-Fya (for example) in the present sample, that was not identified in the previous sample, and you wouldn't give Fy(a+) blood on the grounds that the physician did not order K-, Fy(a-) blood.

If the situation changes the other way (the patient does not, after all need CMV- blood, for example) then, fair enough, the physician should let you know, and you can take this requirement off your computer records (assuming, of course, that the computer programme will let you!).

I must admit that Kate Murphy's post has made me think long and hard, and I may be changing my opinion (some may say this is a unique situation, I might add)!

:confused:

[bmarotto]

I attended a Blood Bank workgroup meeting with our EMR vendor yesterday (we are in the early implementation phase). There were representatives from multiple hospital services working together to make decisions on how the Blood Bank worksflow will be in the EMR. On the EMR end, they recommend generic product orders of Red Blood Cells, Plasma, Platelets, and Cryoprecipitate. They will accept back any product type within that generic product code. The reason for the generic order is they will not allow the Blood Bank to cancel and reorder the "correct" product code. This would create a new order which does not have the electronic signature of the ordering physician. This is going to create some problems on our end since our system will alert the user if the selected product code does not match the ordered product code. Using the 80% rule, I will make the generic order code RL (keukoreduced red cells) and change the translation to Red Blood Cells. Since RL is defined as a Main Product Code in our system, they will still get the translation for the individual product being sent.

It seems like this issue worked out after all. We will still have our "indications for irradiated products" list approved by Medical Practice to keep the compliance folks happy. Thank you Kate for your insight.

[kate murphy]

Malcolm - you're changing your mind?! What's next - cats and dogs living together!?

Bev - glad this could help - for our EMR, we kept physician orders as generic as possible - specifically for the reasons you cite. Platelet pools vs pheresis plts, LR rbc vs deglyced, etc... To the physician, a red cell is a red cell.

[Malcolm Needs ☆]

Malcolm - you're changing your mind?! What's next - cats and dogs living together!?

Bev - glad this could help - for our EMR, we kept physician orders as generic as possible - specifically for the reasons you cite. Platelet pools vs pheresis plts, LR rbc vs deglyced, etc... To the physician, a red cell is a red cell.

Cheek! You've been talking to Rashmi (RR1) haven't you!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

:D:D:D:D