Blood Ordering Policy

[BB1956]

How does your hospital handle physician orders for blood? My specific question --if a patient requires special units such as irradiated, CMV neg, Sickle neg--does the physician have a written order specifiying these requirements or is it the responsibility of the Blood Bank to recognize the need and give appropriate units. We have run into some seroius discussions with the orders matching the products. Most of our docs order PC period. It is often the Blood Bank who calls and questions or recommends. Would like your thoughts and input.

[butlermom]

We are a 525-bed hospital with a NICU, a Pedi-ICU and Pedi-oncology. The physicians order specifically what they want--irradiated, CMV-neg, etc. and we require a copy of the physician's written order for all patients younger than 18 years of age. We enter these "Special Needs" into our computer system in the patient's record. The computer will not allow any units to be crossmatched or issued that do not meet the patient's Special Needs.

[adiescast]

Generally our physicians order the special requirements. We then put them in the patient's file in blood bank and supply them until the order is cancelled by a doctor. We sometimes have to call on babies in NICU if they don't give us the birth weight because we irradiate by standing order based on birth weight (regardless of the current weight).

We do have a problem with people on the floors ordering more special requirements than the doctor ordered. We have to call and question those. For example, we have been doing leukodepleted blood for a patient and suddenly get an order for irradiated in addition. Sometimes these orders are right, but most of the time someone got overly enthusiastic.

[L106]

This topic has been a little bit of a problem for us. Our physicians order the special requirements and we then write a note on the patient's Blood Bank Record Card. From then on, nurses and physicians usually just order "Packed Red Cells" or "Plateletphereses" and the Blood Bank tech respects the patient's special needs that are noted on the patient's BB card.

Once in a while the physician will urgently transfuse a "regular" blood products if he/she decides that a patient can't wait for us to procure a special product. (I understand and don't have a problem with that.)

The problem is that BB sometimes gets conflicting orders when the oncologists cover for each other. Example: If a patient always get CMV Neg products, then the weekend doc on call comes along and orders "CMV Neg and Irradiated" red cells. Now the BB tech doesn't know if the patient's future CMV Neg products must also be irradiated. (Anyone have a solution?)

Donna

[mcgouc]

No solution for you. My main one is when a covering physician orders irradiated and then the regular physician returns and has no idea we are giving irradiated. We review the original order when they first order something special because our order entry personnel kept checking off the special needs with no orders. Once we add a need, it can only be removed by physician order. So, if a physician orders irradiated, the patient gets irradiated until a physician writes an order that irradiated is not required. However, if the regular physician doesn't realize we are giving irradiated, he doesn't know to stop the order. If we think a patient's diagnosis doesn't require irradiated products, we can take the info to the pathologist to double check the orders.

[David Saikin]

Once we get a special order it becomes attached to the patient record card and we follow it until we receive "written" cancellation from a physician. There are occasions (emergencies) when these are ignored.

[Lcsmrz]

We have CPOE, and phsycians enter special needs as comments. The BB tech enters the requirement into the patient's historical record when verifying the request, and I verify the marker was placed the following day in my daily audit.

Our Blood Bank is responsible for complying with all historical requirements at crossmatch time. Obviously, if this is a first-time patient and the physicians fails to notify us of a special need, then we are absolved from responsibilty -- until CAP and AABB make mind-reading a personnel standard for BB techs.

Occasionally, a HemOnc patient will come into ER for an unrelated event. The historical requirements for the patient still stand, unless the physician specifically waives the special need.

[mdcbk]

I would suggest you get your medical director involved in a dialog with hospital physicians if that is a possibility. We used to have a lot of problems with special needs, mostly with the needs changing back and forth, depending on which physician ordered the blood. Since we're a teaching hospital, this was especially an issue with new residents. Our medical director spent many months helping to define detailed protocols for all the different services, and then getting all the various services to sign off on them. We have neonatal, hematology, BMT, cardiac, and transplant services, so it was a huge amount of effort on his part, but the results have been fantastic. The techs now have documentation to stand behind when a physician requests something not in the protocol, and there are far fewer phone calls to physicians and path residents. This source of stress for the techs has almost disappeared. In addition, our usage and wastage of CMV neg products has dropped dramatically.

[cmelloh]

Our physicians order the volume they want and if the patient needs volume reduction of platelets due to volume issues. All of our products are irradiated, leukoreduced, and tested for CMV status due to our patients being oncology patients. The Blood Bank determines the patient type and CMV requirements based on testing, diagnosis, and cytogenetic data. With our sickle cell patients, the orders for RBCs are for C, E, K and Sickle negative. We perform phenotyping on these patients at admission and then give products based on the information. The Blood Bank makes the decision as to whether a patient will get CMV negative products or not.

[Mary**]

:clap::ignore:Great job! That is the way it should be!!

[mollyredone]

Thought I would add my 2 cents. When we get an order for IRR or CMV- units, we add that to the patient's history in the computer and it pops up whenever we bring that patient up. Our problem recently has been the oncologists getting lazy and not ordering for the patient's specific needs. So we phone the office and require that they either tell us if the requirement is no longer needed or to fax over a correct order for the specified products. If you get audited and are giving IRR products that aren't on the original order, that spells trouble, and of course on the other hand, you are endangering the patient if you don't give IRR. So we are adamant about correct orders. If it is an ER visit or other doctor, we notify them that the patient needs specific products and take it from there.

[AMcCord]

Generally our physicians order the special requirements. We then put them in the patient's file in blood bank and supply them until the order is cancelled by a doctor. We sometimes have to call on babies in NICU if they don't give us the birth weight because we irradiate by standing order based on birth weight (regardless of the current weight).

We do have a problem with people on the floors ordering more special requirements than the doctor ordered. We have to call and question those. For example, we have been doing leukodepleted blood for a patient and suddenly get an order for irradiated in addition. Sometimes these orders are right, but most of the time someone got overly enthusiastic.

 

This is what we do. Once the special requirement goes on the patient record, that's what they get until that requirement is cancelled by the physician who put it there or if he/she is gone, then the physician who took over that patient's care (same specialty - transplant, heme/onc, etc.).

 

If the ortho folks decide to order a transfusion post-op on an Onc patient or a transplant patient, they are not going to order irradiated, etc. because they don't have any idea that they should do so (or why they should do so  ). We are going to protect the patient's wellbeing. If the physician order does not have the special requirement, we also call the floor (or office for outpatients) and notfiy them that the patient has special needs and that we will be providing the appropriate product. We document the call.

Edited August 14, 2013 by AMcCord

[3cardmoe]

_{If we receive an order that has special attributes that is not currently in the patients permanent demographic then we follow up with a phone call to confirm that this is in fact what they need. Once we get confirmation we add that attribute to the patients demographics so that each time an order is placed (maybe by a physician who doesn't know the patient needs irr, cmv etc) it will flag that we need to give the patient special units. These attributes can be taken out at the request of the physician as well.}