Advice about Emergency Release

[LaraT23]

Situation:

The Ed doc orders emergency release and writes the following:

Emergency release O pos 2 FRBC 2 FFP. The ward clerk who puts the orders in has no medical training and did not question this. My night blood banker asked the clerk who verified that yes that is what he wanted.

HELLO???? So the lucky thing is that the patient was O POS, but if he was an A we would be in deep you know what from the plasma.

So, my question is, do you all have a policy that your emergency release protocol over rides what ever the doc might say? My thought is that I should speak to the ED medical director and make sure that she is on board with us over riding doc orders only in this case. My boss thinks that with AABB, CAP, and CLIA ( what?) we don't have to talk it over with anyone but our medical director.

Suffice to say I told my staff to in the future always release O neg cells ( or O Pos to males in an O Neg shortage) and only AB plasma ever. If there is an issue ask the ED doc to clarify and if there is still an issue call the on call pathologist. :mad:

[Malcolm Needs ☆]

Situation:

The Ed doc orders emergency release and writes the following:

Emergency release O pos 2 FRBC 2 FFP. The ward clerk who puts the orders in has no medical training and did not question this. My night blood banker asked the clerk who verified that yes that is what he wanted.

HELLO???? So the lucky thing is that the patient was O POS, but if he was an A we would be in deep you know what from the plasma.

So, my question is, do you all have a policy that your emergency release protocol over rides what ever the doc might say? My thought is that I should speak to the ED medical director and make sure that she is on board with us over riding doc orders only in this case. My boss thinks that with AABB, CAP, and CLIA ( what?) we don't have to talk it over with anyone but our medical director.

Suffice to say I told my staff to in the future always release O neg cells ( or O Pos to males in an O Neg shortage) and only AB plasma ever. If there is an issue ask the ED doc to clarify and if there is still an issue call the on call pathologist. :mad:

In my own experience in the UK (and my experience working in the hospital environment is limited to about 10 years, and none for the last decade) the person in Blood Bank would issue group O, D Negative blood (again, like you, sometimes group O, D Positive) and AB plasma blood components whatever the requesting doctor says, with the full backing of their own Pathologist, without contacting their own Pathologist, and, if there are any arguments to be had, these would take place later, with the presumption that the Laboratory was correct unless proven otherwise.

And Lord help any doctor who tries to prove otherwise!

:)

[clmergen]

Our emergency release protocol overrides anything the doctor may actually order.

[L106]

Our emergency release protocol overrides anything the doctor may actually order.

Ditto for us. I tell my staff that the physician has 2 choices: Crossmatched or Uncrossmatched. If he orders uncrossmatched, we make the choice whether we issue O Neg or Group-specific units (based on whether we have a sample from the patient, how far along we are on the testing, our inventory, etc.)

[Bill]

Ditto here other than we need pathologist approval to give any Rh + to an Rh = patient. We also will do a quick front type (30-50 sec) to give Group specific whenever we can to save on O Neg

[Eagle Eye]

Same for us. We decide what blood type is compatible for patient. Emergency release, no specimen available...O pos or O neg RBC and AB plasma. If specimen is available and have time to type the patient we can give type specific RBC & Plasma. Our system would not allow us to release O plasma(or non O RBC) to patient who doesn't have blood type in the system. Basically our LIS stops us from issuing ABO incompatible plasma.

[jcdayaz]

NEVER would I advocate giving type O plasma to a patient if you have no history. If a physician requests emergency release blood/plasma we would automatically give O neg blood(considering supply, of course) and AB plasma regardless of what type they asked for.

These DR's have very limited Blood Bank training. It is up to us to provide safe products to our patients.

[LaraT23]

To be honest, I just wanted to make sure you were all on the same page I am! After I was revived yesterday after having passed out seeing O POS emergency released plasma.... I sent a nice message to the ED nursing staff and to my staff that they should always stick to our protocol and that our medical director welcomes calls if any doc wants to give them a hard time about it.

The doc in question is really a good guy, he was just a bit nervous dealing with a drunk with a fatal head injury who was still in his twenties. Sad.

[tbostock]

We also don't allow physicians to tell us what blood type to give. We had one insist on O Neg uncrossmatched when we had two A Pos type specific units already crossmatched for the patient. Another one insisted on giving the patient the blood type that was on his dog tags from WWII (A Pos), even though we were repeatedly typing him as O Pos. The patient was adamantly refusing the type O cells, and the doctor wanted to make him happy. We decided alive was better than happy...he didn't receive any blood.

We follow our policies, and anything outside that has to be approved by our Medical Director.

[ovrwkd]

Well done on the refusal to issue. Do you have a chart of emergency compatable types which may be posted in the ER or in a protocol book?

[tbostock]

We have our internal Blood Bank policies for blood type compatibility. We also have which types are used as part of our Massive Transfusion Protocol which the medical staff agrees to. Other than that, no, nothing posted in the ED...we're trying to get them to label Blood Bank tubes correctly and let us worry about the blood types.

[L106]

Well done on the refusal to issue. Do you have a chart of emergency compatable types which may be posted in the ER or in a protocol book?

A couple years ago we added charts for compatible types for red cell products and plasma products to the nursing procedure for Blood Administration (per nursing's request.) (I doubt that anyone actually ever reads or refers to the information.)

We, too, have a huge problem with nursing personnel not labeling Blood Bank specimens properly with the required information. (Come on.......this isn't rocket science!!)

[LAS]

We always determine what blood type is issued, never the physician. In my hospital, we do not post any type of compatible blood product guidelines in our E.D. since they do not order transfusion by blood type. If someone is interested, we can chat with them or refer them to various users' guides, but typically it is handled on a case by case basis on the rare occassion that someone has a question about differing blood types. Fortunately they either order a crossmatch or ask for an emergency release unit, and then let us do our jobs.

They want no part of this decision and are more than happy to leave that part up to us

[adiescast]

A couple years ago we added charts for compatible types for red cell products and plasma products to the nursing procedure for Blood Administration (per nursing's request.) (I doubt that anyone actually ever reads or refers to the information.)

I think it is important for nurses who transfuse to know what type of blood is compatible with what type of recipient. They need to be convinced that they are the last line of defense in case of error. One hospital I inspected convinced their nurses that it was very important to check all of the data before they transfuse "in case the lab made a mistake." I guess we get to be the fall guy for just about everything!

[Malcolm Needs ☆]

One hospital I inspected convinced their nurses that it was very important to check all of the data before they transfuse "in case the lab made a mistake." I guess we get to be the fall guy for just about everything!

Well, nobody is perfect. The difference is that most people that work in blood transfusion are prepared to admit it (unlike some other health professionals - and I use the term "professionals" in its loosest sense here).

:(:(

[Joseph78]

I had this experience a few months ago... wherein the ED doc ordered for an emergency release of "O" pos packed cells. We released "O" negative packed cells per protocol BUT the ED doc returned the units and insisted of getting an "O" pos. Luckily, the patient was "O" pos. The ED doc told me why question his request. I asked our Laboratory Director to talk to that ED doc to follow protocol since we are under strict regulation and unless the patient was already typed for the current stay then we can give type-specific regardless of previous ABORh history.

[Malcolm Needs ☆]

I had this experience a few months ago... wherein the ED doc ordered for an emergency release of "O" pos packed cells. We released "O" negative packed cells per protocol BUT the ED doc returned the units and insisted of getting an "O" pos. Luckily, the patient was "O" pos. The ED doc told me why question his request. I asked our Laboratory Director to talk to that ED doc to follow protocol since we are under strict regulation and unless the patient was already typed for the current stay then we can give type-specific regardless of previous ABORh history.

I hope that the ED doc was thoroughly ashamed; but I have my doubts!

:(

[AMcCord]

We once had an anesthesiologist in the ER on a trauma case insisting on O neg, even though we had the patient typed and crossmatched with type specific red cells. He kept telling us that O neg was 'safer' with multiple patients. We pointed out to him that the patient's had armbands for a reason - so that they could be sure which patient they were dealing with. That seemed to be too difficult a concept. Our medical director finally had to adjust the thought processes with a STAT visit to the ER.

Our worst problem is pediatricians - all babies must get O neg cause that's what they learned when they were residents. I called and chatted with one of them about why that order did not apply in all cases (like Mom has anti-c or Mom and baby are both A Pos) and he kept insisting that there was a good reason why all babies should get O neg - 'some antibody thing' he thought. Why would he have been taught to give O neg if the 'antibody thing' wasn't correct. I didn't have the heart to tell him that his mentor didn't know much more about Blood Bank than he did. We override their orders, too, if O neg is not indicated/appropriate.

[Antrita]

Our policy is to provide type compatible, which overrides what the doctor orders. This came after a death in the OR many many years ago. We use to have to ask the ordering MDs permission to change from type specific to type compatible blood (very stupid policy, I don't recommend it). The patient was A positive. When we ran out of A positive and A negative the tech wanted to switch to O positive. The anesthesiologist said no. Of course it was in the middle of the night. The tech had the pathologist over the phone talk to him but he would not change his mind. The patient died in the OR. Our policy very quickly changed.

Antrita

[L106]

Oh, what an awful, senseless, situation. That's too bad.

[Antrita]

We have had the same situation as Malcolm, trying to explain that the "universal donor" isn't really universal is not so easy.

[jcdayaz]

We have had the same situation as Malcolm, trying to explain that the "universal donor" isn't really universal is not so easy.

We have the same "issues" here in the US. "Just give them O negs" is a common statement among ER physicians when there is an antibody issue.

SCARY! As a previous post said, they probably get @ 3 hours of blood bank training in Med School/ Residency. Kinda hard to figure it out in that amount of time, I would say!!

[Marilyn Plett]

Years ago when I lectured medical students, they got 2 hours of blood banking. I doubt if that number has improved. The rest is passing on incumbent habits during residency. In my experience, many medical students specialize in pathology because they like anatomical pathology; clinical pathology including blood banking is just a necessary evil. When I tell residents that part of their job is to talk to clinicians, I frequently get some horrified looks. My pet peeve is that they don't seem to learn the difference between a direct and indirect Coombs (antiglobulin) test.

[Malcolm Needs ☆]

My pet peeve is that they don't seem to learn the difference between a direct and indirect Coombs (antiglobulin) test.

Believe me Marilyn, this situation has not changed one iota!

:eek::eek:

[jcdayaz]

Our policy is to provide type compatible, which overrides what the doctor orders. This came after a death in the OR many many years ago. We use to have to ask the ordering MDs permission to change from type specific to type compatible blood (very stupid policy, I don't recommend it). The patient was A positive. When we ran out of A positive and A negative the tech wanted to switch to O positive. The anesthesiologist said no. Of course it was in the middle of the night. The tech had the pathologist over the phone talk to him but he would not change his mind. The patient died in the OR. Our policy very quickly changed.

Antrita

I agree with your "Very stupid Policy" statement. That is not only stupid....it is absurd!!!!

I would have just overridden that ridiculous anesthesiologist's demand. I would have packed up O pos blood and sent it in a cooler to the OR. I hope that particular anesthesiologist is no longer practicing medicine!!