Transfusions based upon CPOM orders with parameters

[Bdawley]

Our hospital recently implemented CPOM for physician order entry (which includes Blood Bank ordering). At present we are accustomed to getting orders to transfuse that specifically state, as an example, to "Transfuse 2 units of RBC". We now have an ED physician who would like have the Blood Bank staff automatically send blood components to ED for transfusion based upon written parameters within the order set. In this situation the responsibility would fall upon the Blood Bank to monitor Hgb, Hct, Plt Ct, INR, etc to decide whether an ED patient needed to be transfused. I feel uncomfortable with this arrangement because then it becomes Blood Bank's responsibility to make sure that the patient gets transfused. An example of what such an order would look like is:

Transfuse 2 units of pheresis platelets if platelet count is <50,000/uL (this would be for a bleeding patient in ED)

Is anyone else facing this issue in your hospitals? Opinions are welcome!

[L106]

Personally, I am against this practice. I think it is the physician's responsibility to evaluate the test results, evaluate the patients' condition, and decide exactly what he wants to transfuse.

Frankly, I think most of us experienced blood bankers would do a very good job of monitoring the patient's Hgb, Hct, Plt Count, INR, etc., and order appropriate transfusions. However, it is not our responsibility. Also, we are not in a position to evaluate the patient's clinical condition and we don't have access to the patient's medical history and other factors that might come into play in the transfusion decisions. It's not our decision if the benefits of transfusion exceed the risks.

Would transfusing 2 plateletpheresis be the best course of treatment if it turns out that the patient is going into DIC? (Or does the doc also want us to figure out what the patient's diagnosis is??) (Again, many laboratorians could, but it's not our responsibility.)

Why are some docs trying to do this practice? (Laziness?)

Donna

[Malcolm Needs ☆]

Agree ONE HUNDRED PERCENT with you Donna.

I could not have put it better myself (and I mean that - I would have used expletives!!!!!!!!!!!).

[John C. Staley]

Include me with Donna and Malcolm!!!!!!!!!!! You are skirting with "practicing medicine without a license".

:disbelief

[Bill]

To play devil's advocate--with all our computerization, that order set could be set up in the computer to reflex the transuse order when the criteria of the MD is met. This MIGHT be better patient care as opposed to waiting for the MD to see the result, remember to write the order, wait for the ward secretary to enter the order, have the nurse acknowledge the order, get the product, and start the transfusion. The reflex order would eliminate the first four(4) steps of the process. Also, is this not more fitting with the US CMS stand of using "Standard of Practice" for all situations?

[Bdawley]

To put this in perspective, the order set is specifically for ED patients on anticoagulants who present with a major life threatening bleed. I'm sure the physician is most interested in controlling the bleed as quickly as possible without delays. I still don't feel comfortable with this for reasons stated in your responses but the thought of a reflex order might have some merit. I am taking this discussion to our Blood Utilization Committee meeting in May and your responses will certainly be included as part of that.

[jayinsat]

With every ounce of strength in me I would fight that transferrence of responsibility! Does pharmacy have to monitor clinical values and automatically send drugs when certain criteria are met? If a patients BP drops to below a certain value or Potassium level hits 2.5, the pharmacist doesn't automatically send dopamine and Potassium to the floor. It must be ordered by the physician and requested from the pharmacy. The same goes true for transfusions.

[estiner]

We do not allow such orders - we leave that responsibility up to the physician or the nurse.

[Townsend]

Agreed - this should not be the responsibility of the Blood Bank. However, we do have the ability in our HIS to enter "standing" or "conditional" orders. The practitioner would enter the order to transfuse platelets if under 50,000 (or whatever the trigger). Then if the platelet count was below this, the nurse could "release" the order to transfuse. This is normally used in our ICU or Hem/Onc setting. Not sure if you are able to set something like this up.

Stephanie Townsend, MT(ASCP)SBB

[L106]

At our instituation, all "Reflex Testing" must be approved by our Medical Staff. (ie: It is discussed and voted on during their monthly medical staff meeting.)

(I am familiar with several Laboratory Information Systems that do not have the capability to automatically generate reflex testing based on who the physician is.)

Donna

[Mabel Adams]

Although this might be reasonable under a very specific protocol (brain bleeds, say), it flies in the face of the current "patient blood management" approach where we very much want them to evaluate how the patient is tolerating that low hgb, not just transfuse the numbers. And I wouldn't want to just send blood components to ED. What if they can't get the IV started or the patient is off to CAT scan or they need to admit him before transfusing and no one tells you that and the blood sits down there while you crossmatch more units for the floor? Or then they start sending the blood along with the patient (without a lot of safeguards as to who it is for etc.). Or my great nightmare is that someone assumes that crossmatched A pos blood hanging around in a cooler or fridge is uncrossmatched universal donor blood they asked for 2 hours later and someone hangs the A pos on an emergency patient without really checking ID, cuz "it's universal donor blood so we don't have to check."