Special needs units

[pbaker]

What is your protocol for giving patients units with special needs, specifically CMV seroneg and irradiated? Do you have a set type of patient that gets the product (ex. BMT) or does the doctor order specifically what he/she wants? Do you have specific patients that DO NOT get special units (ex. solid organ transplant)? Do you request the CMV status of the patient when asked for CMV seronegative units?

I know this is a lot of questions. We currently give a lot of special products for which we do not get reimbursed based on the diagnosis and which the patient probably doesn't really need. This is all based on past "protocols" and I am trying to improve or discard them. I know that once the patients are identified, they must always be identified as needing special things. I just want to make sure that we are identifying the correct patients with the correct products.

[David Saikin]

The pt's MD has to order the "special" products. Once we have these identified it takes an order in writing to remove these "special" needs (except in emergent situations). My staff is all generalists so we are definitely NOT making any calls on what type of pt has special needs.

[L106]

Once a physician has ordered a special need for a patient, we document that on our Patient Record File in Blood Bank and all future blood products that we provide for the patient should comply with that special requirement. Sometimes this system works well, other times, not so well.

Sometimes the physician waives the special requirement if the urgency of the situation overrides the time delay to procure special units. Sometimes we get conflicting info from different docs who cover for each other. (ie: One says the special need is required; a different doc covering for the weekend says it's not necessary, etc.) Of course, the Emergency Dept. docs are almost never aware of a patient's special needs history, so our record in Blood Bank is very good in this situation (ie: we call & tell the ED doc of the pt's history, and he decides whether to honor it or transfuse regular units promptly.)

We in Blood Bank have written procedures explaining when special needs are appropriate, but we do not dictate to the physicians the criteria for ordering the special need products, and I am sure than sometimes the docs (especially during weekend coverage, etc.) don't always know the patient's history well enough to order the correct type of product. (This is where you get into requests for special needs that probably are not warranted.)

So, I haven't really given you any useful information, have I, pbaker? I think the bottom line lies with your Pathologist in charge of the Transfusion Service. It depends on how knowledgable he/she is, how willing he/she to be involved and provide consultation to the physicians, etc.

[Townsend]

We assign patient protocols (CMV neg, Irrad, LR, Sickle neg) based on the patient's diagnosis or procedure. These protocols were approved by the TS Medical Director in conjuction with the medical staff of the appropriate areas (transplant, HemOnc) and the Transfusion Committee when needed. BB staff look at the patient's past and current diagnosis and place them on proper protocol as defined in our SOPs whenever a sample is tested. I tried to attach those charts and special feature SOP, hopefully that worked.

Once the patient is on a certian protocol, it is placed in the computer file for future transfusions. Only if the TS Medical Director okays would they be removed from protocol (CN, irrad, etc).

This does place a lot of the responsibility on the BB techs, but we are lucky to have dedicated blood bankers rather than generalists. We also find that the ordering physician (who may be a rotating resident) often has no idea what protocol would be required for their patient. (what is irradiation? everyone should get cmv neg, etc)

Stephanie Towsend, MT(ASCP)SBB

Compat 1.0.doc

HO special features.xls

OTHER special features2.xls

ECMO special features.xls

OHSblood.xls

[LaraT23]

We just go with the physician order. I had an order from a cardiologist just the other day for a split washed unit. The internist ordered just regular banked units the next day. So much for physician communication right?

[Malcolm Needs ☆]

We just go with the physician order. I had an order from a cardiologist just the other day for a split washed unit. The internist ordered just regular banked units the next day. So much for physician communication right?

Perhaps they think they are psychic as well as incapable of making a mistake (not all by any means, but a goodly number).

[adiescast]

You mean they aren't?

[tbostock]

Our criteria for irradiated:

1. Patients with leukemia, Hodgkin’s, or non-Hodgkin’s lymphoma during chemotherapy treatment.

2. Patients with severe congenital immunodeficiency syndromes.

3. Patients who have recently received or will be undergoing allogeneic or autogeneic bone marrow or stem cell transplants.

4. Neonates and fetuses receiving intrauterine transfusions.

5. Patients receiving HLA matched platelets.

6. Patients receiving blood donated from any blood relative.

Our criteria for CMV Neg:

1. Leukocyte reduction is effective in greatly reducing CMV transmission. For patients at highest risk for CMV transmission and disease (premature/low-birthweight neonates, stem cell or bone marrow recipients, solid organ transplant recipients), CMV sero-negative red cells or platelets may be requested by the physician and ordered from the blood supplier.

We haven't had luck getting all physicians on board with this. Some physicians want ALL of their patients to have irradiated (one because he says it prevents alloantibodies...) so we are trying to do some education; until then, we honor what they order.

[lkalko]

We require the physician to order any special needs initially. Once they are identified, we can place a patient instruction in our blood bank system for fiurther orders. We do require that the patient be tested for CMV status and will remove the CMV neg request if they are CMVpositive. If we get special needs requests that don't really seem to make sense then we can take this to our medical director and have her speak to the ordering physician. Most of our requests for Irradiated and/or CMV neg come from our Heme/Oncology docs.