Process Flow for 2nd Blood Draw

[Brenda K Hutson]

I know there was another Thread regarding a 2nd blood draw; but it does not provide all of what I am asking for.

We are definitely moving in that direction. One place I previously worked did follow this protocol, but I rarely worked on the bench there (and when I did, it was in Reference) so I do not recall all of their protocol (though I am going to call them to collect more information).

What I am wondering from those of you out there who perform a 2nd blood draw on patients w/o a history:

1. For Inpatients (but not in OR): What is your process for the 1st and 2nd draws (who does them; how far apart; are patients resisting; how much has this increased the workload for both phlebotomy, and your Transfusion Service staff)?

2. For OR: Same questions as above. This one I do recall from where I previously worked (but the process seemed tedious to me). The 2nd specimen was brought to the T.S. by a Courier when they wanted to pick up blood for surgery; the courier waited while the T.S. performed a quick blood type; then the blood was released.

3. Outpatients; do you obtain the 2nd specimen from them when they come for their transfusions (similar to OR; have a Courier bring a 2nd specimen; perform a quick blood type; release blood to Courier)?

4. Since the only testing performed on the 2nd specimen is a blood type; for those of you who log your specimens into the computer (which then assigns an expiration), how do you indicate that the specimen has not had an Antibody Screen so can not be used for subsequent crossmatches? I know our computer system would not allow a crossmatch on a patient specimen without a Type and Screen having been performed on that specimen?

Brenda Hutson, CLS(ASCP)SBB

[Generic]

All of our samples are drawn by people on the floor. When we receive a sample for a type and match, we perform the type and screen and crossmatch, put a sticker on the blood to let us know we need a second sample, then call the patient's nurse to tell them the blood is ready and we'll need a second sample. They'll generally walk the sample down when they're ready to pick up the blood. We'll perform a quick type and order a "Retype" in the computer, then issue the blood - usually one tech will be issuing while another is performing the quick type, and there is no delay in issuing. Even when, for whatever reason, there is only one tech in the blood bank, the delay to issue is minimal - less than 60 seconds usually.

We have no policy regarding who has to draw the 1st and 2nd samples, as long as they properly label them. Some people in the blood bank won't accept two samples received at the same time regardless of the time written on them (sure, sure, they were drawn EXACTLY 5 minutes apart), but some will. When the 2nd sample policy first went into effect there was some push back from nursing, but that has largely disappeared. The areas that transfuse most often - ER, ICUs, and cancer floors - are used to the 2nd sample request and will cut us off with a "Need a 2nd sample?" once they hear our voices. If we come across a nurse who is resistant to drawing the second sample (most will calm down when you tell them you just need a couple drops), informing them we'll need an emergency release signed by the doctor instead will usually get them to send us the sample. OR and outpatients work similarly. In trauma situations in which we don't know the patient's name, everything is issued using an emergency release and an emergency blood sample; once we get a correctly labeled sample to perform a T&S on, we'll use the original sample as the 2nd sample.

The second sample is listed in our system as an ABO confirm, so we know it can't be pulled to crossmatch on without a full type and screen being performed on it.

Our hospital requires a second sample on all patients, regardless of blood type or component being transfused - all except neonates, who get O= blood and AB plasma products.

Edited May 10, 2011 by Generic

[Brenda K Hutson]

Thanks, that was very helpful.

My concern with the scenario of someone saying the specimen had been drawn 5 mins apart is that I would not think I would want the same phlebotomist to draw the patient twice (i.e. stand in their room for a few minutes; then stick them again). Kind of defeats the purpose of catching episodes where an incorrect patient is drawn (Yes, let's draw the wrong patient twice, shall we??). But I will have to check with my phlebotomy dept. Not sure they have more than 1 phlebotomist on the graveyard shift.

Brenda

I know there was another Thread regarding a 2nd blood draw; but it does not provide all of what I am asking for.

We are definitely moving in that direction. One place I previously worked did follow this protocol, but I rarely worked on the bench there (and when I did, it was in Reference) so I do not recall all of their protocol (though I am going to call them to collect more information).

What I am wondering from those of you out there who perform a 2nd blood draw on patients w/o a history:

1. For Inpatients (but not in OR): What is your process for the 1st and 2nd draws (who does them; how far apart; are patients resisting; how much has this increased the workload for both phlebotomy, and your Transfusion Service staff)?

2. For OR: Same questions as above. This one I do recall from where I previously worked (but the process seemed tedious to me). The 2nd specimen was brought to the T.S. by a Courier when they wanted to pick up blood for surgery; the courier waited while the T.S. performed a quick blood type; then the blood was released.

3. Outpatients; do you obtain the 2nd specimen from them when they come for their transfusions (similar to OR; have a Courier bring a 2nd specimen; perform a quick blood type; release blood to Courier)?

4. Since the only testing performed on the 2nd specimen is a blood type; for those of you who log your specimens into the computer (which then assigns an expiration), how do you indicate that the specimen has not had an Antibody Screen so can not be used for subsequent crossmatches? I know our computer system would not allow a crossmatch on a patient specimen without a Type and Screen having been performed on that specimen?

Brenda Hutson, CLS(ASCP)SBB

[Brenda K Hutson]

Now how did I do that?! I could have sworn I clicked to Post Quick Reply to your message; not my own initial posting!!

I think it is one of those days where I should just go back to bed.....

Brenda

All of our samples are drawn by people on the floor. When we receive a sample for a type and match, we perform the type and screen and crossmatch, put a sticker on the blood to let us know we need a second sample, then call the patient's nurse to tell them the blood is ready and we'll need a second sample. They'll generally walk the sample down when they're ready to pick up the blood. We'll perform a quick type and order a "Retype" in the computer, then issue the blood - usually one tech will be issuing while another is performing the quick type, and there is no delay in issuing. Even when, for whatever reason, there is only one tech in the blood bank, the delay to issue is minimal - less than 60 seconds usually.

We have no policy regarding who has to draw the 1st and 2nd samples, as long as they properly label them. Some people in the blood bank won't accept two samples received at the same time regardless of the time written on them (sure, sure, they were drawn EXACTLY 5 minutes apart), but some will. When the 2nd sample policy first went into effect there was some push back from nursing, but that has largely disappeared. The areas that transfuse most often - ER, ICUs, and cancer floors - are used to the 2nd sample request and will cut us off with a "Need a 2nd sample?" once they hear our voices. If we come across a nurse who is resistant to drawing the second sample (most will calm down when you tell them you just need a couple drops), informing them we'll need an emergency release signed by the doctor instead will usually get them to send us the sample. OR and outpatients work similarly. In trauma situations in which we don't know the patient's name, everything is issued using an emergency release and an emergency blood sample; once we get a correctly labeled sample to perform a T&S on, we'll use the original sample as the 2nd sample.

The second sample is listed in our system as an ABO confirm, so we know it can't be pulled to crossmatch on without a full type and screen being performed on it.

Our hospital requires a second sample on all patients, regardless of blood type or component being transfused - all except neonates, who get O= blood and AB plasma products.

[JEMarti]

Getting a second blood draw is very problematic to say the least. You've already pointed out that having 2 draws in close proximity to each other is virtually like having one draw into two tubes. Then there are the issues of what to do for presurgical patients and are you going to require them to come in an additional time for a second blood draw? If you have a NICU are you going to require it for those patients? (At my institution we give Rh POS units to Rh Pos babies so you wouldn't want to be giving it to an Rh NEG baby by accident) Are you going to demand two blood draws for trauma patients and if so are you going to give O Negs until you get them?

And perhaps most disturbing should be the fact that in collecting two specimens you are taking an oficial position that transfusing off of one specimen is not safe and therefore if you allow any exceptions to that rule you are exposing yourself to a large amount of legal liability. You are setting up a possibility of having two standards of treatment and you are making a policy that says that having two specimens is the safer of the two. Even if you do not have a case of mistransfusion any transfusion complication could become an opportunity for a claim of negligence.

I understand the impetus for having a second confirmatory draw, but it is logistically very difficult to implement. I would be very reluctant to set up two standards of care if I could avoid it.

[Generic]

If you have a NICU are you going to require it for those patients? (At my institution we give Rh POS units to Rh Pos babies so you wouldn't want to be giving it to an Rh NEG baby by accident)

I'd just point out here that without a second sample, you wouldn't necessarily know you were giving Rh pos blood to an Rh neg baby in the first place

To be frank, we only get a few 2nd samples a year that are discrepant (although that definitely doesn't mean that the same, correct patient was drawn both times). However when you have a major discrepancy - a type O patient having a type A initial sample, as happened in our pediatric ER several months ago - it makes all involved VERY happy you have the policy in place. That being said, I can't speak to the logistics of implementation at my hospital as the policy began before my time.

[Mary**]

I TOTALLY agree with you JE.

[Brenda K Hutson]

You made some very good points that I had not thought of.

1. As far as pre-surgical patients, the one Institution I worked at that did collect the 2nd blood draw, followed this protocol for those patients: Each evening 1 of the Techs. or Lab Assistants would go through the surgery schedule for the next day and look to see if we had specimens and/or orders on any of the surgeries that might require transfusion. They would then indicate which patients we would need a 2nd specimen on. The list was then sent to OR. When OR wanted to pick up blood on a patient needing a 2nd specimen, the transporter brought the 2nd draw with them at that time (drawn in OR). The transporter waited while the Tech. did a quick type (forward and Rh only). This is similar to what "Generic" above does.

2. We only give O Negative "Dry Packed" RBCs to Neonates (the Donor Center we use produces this product which is CPDA-1 and almost all Plasma is removed; they service a large Medical Center I used to work at with a huge Neonatal population so they do a lot of Boutique Blood Banking as we called it). Anyway, I would be comfortable then with only 1 type; unless of course there was a Directed Donor for the baby that was not O NEG Dry Packed.

3. As far as the legal issue....I am seeing the regulatory agencies "move in the direction of" the 2nd blood draw. Done right (meaning not same phlebotomist staning in room and redrawing a few minutes later), it does seem to be the best system at this time. But your point for "exceptions" is true. However, for me, I would not let that deter me but rather would just give that as the reason why we must have the 2nd draw in all situations (and in the rare situations where they could not draw a 2nd specimen, they would be limited to O NEG, Dry Packed until we could get another specimen; which would have to be soon so we did not waste that supply).

We are also moving towards a different method of patient identification. First, a barcodeable armband. My only problem with that here is that patients are not banded until they are admitted (either for Outpatient Transfusions, or for Surgery; we have had too many issues with patients cutting off their armbands if forced to wear them home). Also, some of the OR Surgeons are stating emphatically that they will cut the armband off for surgery (heart surgeons; nice that we can all "work together" for the safety of the patient, right??; NOT). They are supposed to place them back on the patient at the end of surgery, but we had a recent case where the previous patient's armband was still in the OR when the next patient was brought in! Plus, in my mind, anytime an armband is not placed on the patient at time of draw, you are opening up the system to risk (however great or small that may be) that the wrong armband is placed on the patient when admited (you have to rely on the Nurse following protocol for identification).

A process I am told is in trial at my Hospital is a palm scanner (not sure if that is the correct term). So the person's palm is scanned when their blood is drawn; then again when they are admitted. Not sure if the palm scan at time of draw is in some way then connected to the specimen; but it certainly is a sure-proof way to identify a patient.

Anyway, thanks again for your input; much appreciated!

Brenda

Getting a second blood draw is very problematic to say the least. You've already pointed out that having 2 draws in close proximity to each other is virtually like having one draw into two tubes. Then there are the issues of what to do for presurgical patients and are you going to require them to come in an additional time for a second blood draw? If you have a NICU are you going to require it for those patients? (At my institution we give Rh POS units to Rh Pos babies so you wouldn't want to be giving it to an Rh NEG baby by accident) Are you going to demand two blood draws for trauma patients and if so are you going to give O Negs until you get them?

And perhaps most disturbing should be the fact that in collecting two specimens you are taking an oficial position that transfusing off of one specimen is not safe and therefore if you allow any exceptions to that rule you are exposing yourself to a large amount of legal liability. You are setting up a possibility of having two standards of treatment and you are making a policy that says that having two specimens is the safer of the two. Even if you do not have a case of mistransfusion any transfusion complication could become an opportunity for a claim of negligence.

I understand the impetus for having a second confirmatory draw, but it is logistically very difficult to implement. I would be very reluctant to set up two standards of care if I could avoid it.

[Brenda K Hutson]

All good points!

And even seeing that you get a "few" discrepant times a year sounds an alarm in my head! It makes me wonder how many we have had that have just not been caught. All the more reason to go to the 2nd blood draw in my mind; so I appreciate you sharing that!

I suspect that more difficult than the logistics of when/where/how the 2nd draw will take place, will be convincing Nursing and Physicians that we must do this for patient safety (the Phlebotomy Manager is already on-board with the idea; must to my surprise).

Brenda

I'd just point out here that without a second sample, you wouldn't necessarily know you were giving Rh pos blood to an Rh neg baby in the first place

To be frank, we only get a few 2nd samples a year that are discrepant (although that definitely doesn't mean that the same, correct patient was drawn both times). However when you have a major discrepancy - a type O patient having a type A initial sample, as happened in our pediatric ER several months ago - it makes all involved VERY happy you have the policy in place. That being said, I can't speak to the logistics of implementation at my hospital as the policy began before my time.

[Byfaith]

We have had the 2nd draw policy for about a year and a half - a few things that have helped are;

A previously drawn CBC can be utilized for the re-type. Hematology stores samples for a few days, using a computer storage system that makes it easy to locate them. We verify that the sample is drawn at a different time, by a different phlebotomist (ALL samples are logged in with phlebotomist ID - in theory anyway). This saves many re-sticks.

In an emergency or surgical case, if there is any resistance or an obvious urgent need our policy is to use Type O until a 2nd draw can be obtained. We will give O POS if first type is Rh POS, O NEG if first type is Rh NEG - the goal being to prevent transfusion of ABO incompatible blood.

Our computer generates a seperate order for the retype based on the BB tech answering a question "Retype Needed?" at the time the original TXS order is resulted.

Hope this helps!

[Mabel Adams]

Hmm. How well does a palm scanner work on one of those patients that had meningococcemia and had all hands and feet amputated? There's always something.