Blood Request Form

[jfdrn]

I am working with one of our hospitals to improve there blood administration practices. One area that needs work is the blood request form that the nurse would send to the blood bank in order to get the unit. Does anyone know of any regulations of what should be on that form? Any ideas of how to make it as simple and easy to fill out as possible? If you have examples I would love to see them. Thanks Julie :cool:

[Liz]

[ATTACH]614[/ATTACH] Lets see if i can post a simple template, you can add to it ofcourse. Yes i did.

[Auntie-D]

We do it that the doctor prescribes the unit on the patient's drugs chart and then the whole patient's notes are takent to the fridge to do the patient checks before release. The units can then be signed out of our blood register. We prefer not to have additional forms as it increases the risk of transcription errors. At least if it is prescribed by the medic then all the checks that the doc would do for drugs are done.

[MAGNUM]

We have a form we call a "pick up" that is basically a duplicate of our blood tag. In addition when the floor comes to pick up the unit they are required to bring the pickup and the physicians order. We have caught many ordering errors that way since we see what the physician actually wrote such as irradiation, cmv negative, etc.

[davidh142]

I am working with one of our hospitals to improve there blood administration practices. One area that needs work is the blood request form that the nurse would send to the blood bank in order to get the unit. Does anyone know of any regulations of what should be on that form? Any ideas of how to make it as simple and easy to fill out as possible? If you have examples I would love to see them. Thanks Julie :cool:

This is our product request order form. Received via air tube and product dispatched via same.

[TABLE=class: MsoNormalTable, align: left]

[TR]

[TD=width: 379]Patient Name / DOB / Hospital or HC number / Ward / Special Requirements

[/TD]

[TD=width: 216, colspan: 2]Product Required

[/TD]

[/TR]

[TR]

[TD=width: 379, bgcolor: transparent]

[/TD]

[TD=width: 216, bgcolor: transparent, colspan: 2]Red Cells

[/TD]

[/TR]

[TR]

[TD=width: 216, bgcolor: transparent, colspan: 2]Fresh Frozen Plasma

[/TD]

[/TR]

[TR]

[TD=width: 216, bgcolor: transparent, colspan: 2]Cryoglobulin

[/TD]

[/TR]

[TR]

[TD=width: 216, bgcolor: transparent, colspan: 2]Platelets

[/TD]

[/TR]

[TR]

[TD=width: 108, bgcolor: transparent]Albumin 4.5%

100ml or 400ml

[/TD]

[TD=width: 108, bgcolor: transparent]Albumin 20%

100ml

[/TD]

[/TR]

[TR]

[TD=width: 216, bgcolor: transparent, colspan: 2]Immunoglobulin (g)

[/TD]

[/TR]

[TR]

[TD=width: 216, bgcolor: transparent, colspan: 2]Other :

please specify

[/TD]

[/TR]

[TR]

[TD=width: 379, bgcolor: transparent](For Lab use only)

Dispatched to (ward) :

By:

Date/Time

[/TD]

[TD=width: 216, bgcolor: transparent, colspan: 2](For Lab use only)

Ward notified :

(record who)

Date/Time

[/TD]

[/TR]

[/TABLE]

[mollyredone]

Our form is like Magnum's, a tear off with all the info about the patient and unit on it. If they don't have one, they can bring a printed demographic label with the patient's blood bank band number hand written on it. We don't get to see the dr's orders-wish we did! Dr's also don't have to justify why they are transfusing, as I've noticed some of the hospitals require. That, too, would be nice!

[carolyn swickard]

About a year ago, we started requiring the pick up person to bring a photocopy of the Dr's orders (page with the blood order on it) and a photocopy of the pt's consent form (with pt's or designee's signature). It has eliminated the floor's failure to obtain a consent before transfusing and does allow us to see some order errors, as mentioned above. We do not get very many "indications" for transfusion from our Drs yet either - we are still trying to fix that with a special Blood Order form designed by our pathologist, but there has been little compliance with the special form. Where the Drs just write in Type and Cross and Transfuse - there are never any indicators. We are just now going to electronic Drs ordering, we have mandated indications there (if they survived the computer folks desires to "get rid of all of those questions that will slow the Docs down!"), but have also had to put in an "Other" category. Experience from one of the regional hospitals trying this shows that the Docs will use "Other" every time they can get away with it. Photocopying does eliminate transcription errors, but has lead to some of the consent forms being misplaced and we have had to send them the copy back up for the chart. We require the same amount of paperwork for each pickup since we don't want to keep track of who we have received what on, etc. There was a lot of opposition to that at first, but things have settled down now and we mostly get what we need. We require the BB ID wristband number to be on the paperwork for all RBCs pickups too. Good Luck

[Auntie-D]

This is our product request order form. Received via air tube and product dispatched via same.

[TABLE=class: MsoNormalTable, align: left]

[TR]

[TD]Patient Name / DOB / Hospital or HC number / Ward / Special Requirements

[/TD]

[TD=width: 216, colspan: 2]Product Required

[/TD]

[/TR]

[TR]

[TD=width: 379, bgcolor: transparent]

[/TD]

[TD=width: 216, bgcolor: transparent, colspan: 2]Red Cells

[/TD]

[/TR]

[TR]

[TD=width: 216, bgcolor: transparent, colspan: 2]Fresh Frozen Plasma

[/TD]

[/TR]

[TR]

[TD=width: 216, bgcolor: transparent, colspan: 2]Cryoglobulin

[/TD]

[/TR]

[TR]

[TD=width: 216, bgcolor: transparent, colspan: 2]Platelets

[/TD]

[/TR]

[TR]

[TD=width: 108, bgcolor: transparent]Albumin 4.5%

100ml or 400ml

[/TD]

[TD=width: 108, bgcolor: transparent]Albumin 20%

100ml

[/TD]

[/TR]

[TR]

[TD=width: 216, bgcolor: transparent, colspan: 2]Immunoglobulin (g)

[/TD]

[/TR]

[TR]

[TD=width: 216, bgcolor: transparent, colspan: 2]Other :

please specify

[/TD]

[/TR]

[TR]

[TD=width: 379, bgcolor: transparent](For Lab use only)

Dispatched to (ward) :

By:

Date/Time

[/TD]

[TD=width: 216, bgcolor: transparent, colspan: 2](For Lab use only)

Ward notified :

(record who)

Date/Time

[/TD]

[/TR]

[/TABLE]

Please tell me you are joking about sending products through the air tube...

[Mabel Adams]

AABB has guidelines for validating issuing blood via a pneumatic tube system. It is widely done in the US.

[Cliff]

Please tell me you are joking about sending products through the air tube...

No joking. We've done a pretty extensive validation of our tube system. We sent empty canisters, room temp products and cold products, each with timers and temperature monitoring devices. We did 20 runs to each location we send products to and we are a very distributed campus. We have four buildings, not near each others that are all connected via the same two systems. One of them is 16 stories high. The amount of human labor we save is tremendous as well as being able to provide products much quicker.

[John C. Staley]

No joking. We've done a pretty extensive validation of our tube system. We sent empty canisters, room temp products and cold products, each with timers and temperature monitoring devices. We did 20 runs to each location we send products to and we are a very distributed campus. We have four buildings, not near each others that are all connected via the same two systems. One of them is 16 stories high. The amount of human labor we save is tremendous as well as being able to provide products much quicker.

Don't you just love the 21st Century!!! Our tube system was even validated for sending up to 4 units of PRBCs in one carrier but we never told the nurses that.

:surrender

[Cliff]

It sure makes it a lot easier. I've been at my current location for 21 years, and we've always sent products through the tube. When we had albumin in the blood bank we used to send that too!

[Brenda K Hutson]

I don't have an example to send you (do not like the one where I work now), but here are some thoughts from pervious Forms I have used (some which I revised when I went somewhere; based on past experience):

1. I like to make it a duplicate Form; 1 copy to go back with the blood and 1 to keep. Why? I recall one time where we sent the blood they requested. The Nurse then hung the blood on the wrong patient. She called us, saying that we sent her the wrong blood and that it was our fault. We had the evidence that we sent who they requested (so she then said her clerk used the incorrect patient addressograph to send for blood and that was not who she wanted; the fact that she had CLEARLY not done any of her required "checks" prior to hanging the blood, seemed to have been a minor point in her mind).

2. Have used a 1/4 sheet (carbon copy). At very top, a place for patient addressograph or sticky label (but if they use a label, must make sure they put it on both copies). Then a place for Location: ____________; then under that, I would make 2 columns; one for type of product and the other for # of that product; i.e.

PRODUCT #

RBCs _______

Platelets _______

etc.

We then time-stamp the slip when we receive it.

Brenda

I am working with one of our hospitals to improve there blood administration practices. One area that needs work is the blood request form that the nurse would send to the blood bank in order to get the unit. Does anyone know of any regulations of what should be on that form? Any ideas of how to make it as simple and easy to fill out as possible? If you have examples I would love to see them. Thanks Julie :cool:

[Auntie-D]

AABB has guidelines for validating issuing blood via a pneumatic tube system. It is widely done in the US.

So how is it guaranteed that cold chain is maintained? How do you know that the blood is not sat in the pod in the basket for a couple of hours? What happens if their is a tube failure and the pod becomes stuck. What happens when the tube system is busy and the pod is sat at a junction waiting its 'turn' to drop? Have you audited the time sent to the time used/returned to the cold chain? And what happens if the blood ruptures in transit - do you have a procedure for decontaminating the whole tube system? Speaking of decontamination - the blood is going to the patient's bedside - do you have designated pods for blood only that get decontaminated on every use and never see a specimen?

Sorry for all the questions but the fact that this is commonly used kinda horrifies me. There is a complete loss of cold chain control and the H&S implications do not bear thinking about...

[Moncada]

Our tube system validation involved measuring the temp of the transported blood products. All were within AABB standards for transport, including platelets at room temp range. We use the "secure send" feature of our system...i.e. a pin# unique to the individual is required to "receive" the tube. If a valid pin is not entered within 2 minutes, the tube returns to the blood bank, again with an alarm and a pin # required. Any tubes sent via secure send take "STAT" priority.The biomed department can track deliveries and provide us with the names of the nurses that remove the products from the system. All products are heat sealed in plastic bags to contain any leaks (which are very very rare). Yes, there is a procedure to "decontaminate" the tube system, but is rarely needed. Our tube system works great with only an occasional lost unit.

Most of your concerns are addressed and solved:D

[Mabel Adams]

And human transporters have been known to take units along on other errands etc. that can disrupt the cold chain in ways that tube systems would never think of doing.

[Mabel Adams]

I am going to resurrect this old thread in hopes of getting a copy of someone else's blood request form with reasons for transfusing on it. If you collect this info in the computer instead of on a blood request form (issue or pickup slip), could you share your indications please? Our new EMR is not going to let us require transfusion indications in CPOE so I will probably try to capture it on issue if I can find a workable way.

[PAWHITTECAR]

Mabel I'm not sure if this helps but we require the patient full name, Medical record number, what product that is requested and the name and signature of the courier (MD or Nurse)

IT is working on an e-form that will auto pull all of the patient info onto the form then they just have to enter their name and sign it. They could probably have it pull H/H, Plt/ PT etc onto the form.

[Mabel Adams]

Below are the sort of indications I am thinking of, but I hope someone has something more succinct.

[TABLE=class: MsoTableGrid]

[TR]

[TD]Red Blood Cells (including autologous)

[/TD]

[/TR]

[TR]

[TD=width: 546, bgcolor: transparent]Hct £ 21% or Hgb £ 7

[/TD]

[/TR]

[TR]

[TD=width: 546, bgcolor: transparent]Active bleeding or procedure with EBL ³20% of total volume or ³750 ml

[/TD]

[/TR]

[TR]

[TD=width: 546, bgcolor: transparent]Hgb £ 8-10 with pre-existing cardiovascular disease: with chest pain, orthostatic hypotension, tachycardia unresponsive to fluid resuscitation, congestive heart failure

[/TD]

[/TR]

[TR]

[TD=width: 546, bgcolor: transparent]Plasma

[/TD]

[/TR]

[TR]

[TD=width: 546, bgcolor: transparent]PT ≥ 19.6 sec. or INR ≥1.7

[/TD]

[/TR]

[TR]

[TD=width: 546, bgcolor: transparent]Bleeding or invasive procedure in a patient with DIC or warfarin therapy and coagulation results not yet available.

[/TD]

[/TR]

[TR]

[TD=width: 546, bgcolor: transparent]Microangiopathic hemolytic anemia such as thrombotic thrombocytopenic purpura (TTP).

[/TD]

[/TR]

[/TABLE]

[tbostock]

Our request form consists of patient demographics at the top, product requested, and the nurse has to sign and date a patient preparation statement (IV started, order verified, consent signed, pre-tx vital signs good, pre-tx meds administered, etc).

We capture the transfusion indications in our EMR. We are just now updating our transfusion criteria. Most of the new studies out in the last few years are leaning toward <7 Hgb, or <8 Hgb with cardiac, etc. in non-actively bleeding patients. We used to be flexible with an 8-10 category, so this should be quite a change for our physicians to grasp.

[Mabel Adams]

If you require pre-tx vitals to be recorded before they send for the product, do they record them on a transfusion slip that comes up with the product or just in their usual EMR for vitals?

[mollyredone]

Mabel, I just emailed you with a couple of samples I've run across. HTH.

Molly

[tbostock]

If you require pre-tx vitals to be recorded before they send for the product, do they record them on a transfusion slip that comes up with the product or just in their usual EMR for vitals?

They enter them in the EMR.