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Time limit for type and screens on outpatients


jerriemc

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We used to extend the specimens out 7 days but we discontinued it.  Now specimens are good for 3 days, just like inpatient specimens.  If a patient comes in preadmission blood work earlier, they still draw a specimen so that we can test to see if there is anything going on antibody wise (and if it needs to go to the reference lab).  In those cases, the patients type and screen is redrawn the morning of surgery.   Some of the reasons we discontinued our extended PAT (pre admission testing) program were 1) for continuity - we have 4 sites with techs rotating and there was confusion.  We also experienced a lot of confusion from nurses and physicians who did not understand why inpatients were different from outpatients etc. 2) we found that enough of our patients were unreliable historians of thier transfusion history (elderly usually) that we were concerned 3) We had a few instances where antibody screens had changed within the 7 days with a supposed "negative" transfusion and pregnancy history.    

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We stick to the 3 day rule for outpatients.  We are a small rural hospital and figure no one is traveling hundreds of miles to come here for surgery!  The surgeons write "get TS day before surgery", but we get our share of draws on the day of surgery as well.  We have the ability to extend when the patient is inhouse if negative for pregnancy, transfusions and history of antibodies, but seldom do that.

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We have a long standing policy of up to seven days in advance for outpt surgeries with a negative history.  The history is recorded on the tube by the RN drawing the preop work after questioning the pt.  (Understandable that that information source may not always be perfect, but it has done well for years.  If they were transfused here, we catch it on prior records.)  If used, the specimen still has 7 days storage post transfusion because I have room for 18 days of storage racks.) 

 

We also occasionally extend inpts too, we ask the RN if the pt is "awake and aware" and is capable of answering transfusion history questions before extending.  The answer is documented on the pt's records.  If the information comes from the pt in both instances, it should be equally valid.  Though we did just have a case where we had a newly developed anti-E and when pheontyping the pt, showed a mixed field phenotyping for E.  The pt and the family both said he had not been transfused with RBCs (we did have a history of Plts and FFP), but I have not yet figured out how he could have a mixed field phenotyping and a new antibody without getting units somewhere - anybody else know?

 

Sometimes the RN forgets why they are asking for history and we get a request for an extended specimen with a positive history recorded - on those we run the specimen anyway, but do not charge for it and then redraw date of surgery, at least knowing about possible problems and having units on site if needed.

 

This whole procedure is getting a little harder to maintain as the RNs and the Physicians turnover more and more and we have almost all rotating generalists in the Blood Bank here.  It is hard for them to keep perfect track of the usable specimens and the specimens that need redrawing.  That need is in fact, the only reason we still have a card file, we have not yet figured out how to get all of the "negative hx, surg date, ok to use until such a date data" in an easiley accessable place in our Meditech 5.6.6 system. If anybody has a nicely functional system going in their Meditech system, could you share it?

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We have a pre-op clinic where the patient comes in about a week to a month prior to surgery and has all pre-op testing done which usually includes:

CBC, Basic metabolic panel, PT, PTT, ABO/Rh type and antibody screen (no banding). Other tests that may be included are a urinalysis, and x-rays. 

 

It takes only one incident of a crossmatch drawn on the day of surgery, comes out positive, and time /$$$ wasted for our MD's to learn to order these pre-op antibody screens in advance. When the pt. comes in on the day of surgery, the type and screen gets repeated (with banding) and there are no surprises. I know it involves repeat testing but as long as the MD's code it correctly it is usually covered by insurance.

 

We average about one positive (pre-op) antibody screen 2-4 times/year. When this happens, the pt will come in a day before surgery and get redawn, banded for surgery the next day, and the blood bank will have already identified the antibody on the pre-op testing and will have units ready for crossmatch. It's been working well ..... we used to do it on the day of surgery but like I said it took one incident of a big open heart surgery to change all that. 

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We used to do almost all our surgical orders as PATs (pre-admission testing). Now we do about 98% of our surgical orders 35 minutes before they roll back into the OR. We used to get first crack at the patient so it was 50 minutes prior to Surg, but that has gone by the wayside cause the stuff that the nurses do is 'more important'. PATs are only done by one Ortho and he does a small minority of the Ortho cases here. The reason that the others have dropped PAT testing?.......they tell us it's 'inconvenient' for the patient. Never mind that 75% of those same patients are here in this building for Xrays, EKGs etc in the week prior to surgery. :confuse:

 

There is a movement afoot, however, to change that. There is talk of having a pre-op clinic in which one of the hospitalists sees every patient preop for a physical. Hopefully we would be able to get Blood Bank orders included in the labs drawn for those visits.

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We have a long standing policy of up to seven days in advance for outpt surgeries with a negative history.  The history is recorded on the tube by the RN drawing the preop work after questioning the pt.  (Understandable that that information source may not always be perfect, but it has done well for years.  If they were transfused here, we catch it on prior records.)  If used, the specimen still has 7 days storage post transfusion because I have room for 18 days of storage racks.) 

 

We also occasionally extend inpts too, we ask the RN if the pt is "awake and aware" and is capable of answering transfusion history questions before extending.  The answer is documented on the pt's records.  If the information comes from the pt in both instances, it should be equally valid.  Though we did just have a case where we had a newly developed anti-E and when pheontyping the pt, showed a mixed field phenotyping for E.  The pt and the family both said he had not been transfused with RBCs (we did have a history of Plts and FFP), but I have not yet figured out how he could have a mixed field phenotyping and a new antibody without getting units somewhere - anybody else know?

 

Sometimes the RN forgets why they are asking for history and we get a request for an extended specimen with a positive history recorded - on those we run the specimen anyway, but do not charge for it and then redraw date of surgery, at least knowing about possible problems and having units on site if needed.

 

This whole procedure is getting a little harder to maintain as the RNs and the Physicians turnover more and more and we have almost all rotating generalists in the Blood Bank here.  It is hard for them to keep perfect track of the usable specimens and the specimens that need redrawing.  That need is in fact, the only reason we still have a card file, we have not yet figured out how to get all of the "negative hx, surg date, ok to use until such a date data" in an easiley accessable place in our Meditech 5.6.6 system. If anybody has a nicely functional system going in their Meditech system, could you share it?

Besides the actual type and screen, our regular type and screen "G" test battery includes the following nonreportable tests:

1. ABOV - has the ABO been verified by a second typing? (result: yes or no)

2. CPR - check of previous results (result: previous results checked)

 

In addition to the above, our preop type and screen "G" test battery has:

1. PTX - pregnant or transfused in last 3 months (result: yes, no, uncertain)

2. DOS - date of surgery (result free texted).

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To add to the above (and yes, there are many versions of the 'Extensions') ...

Our 'extension' is 5 days, that works for us.

If a patient is being drawn earlier than 5 days or refuses to wear the BB Band, Antibody Screen is ordered and a notation is made in the chart to draw a Pretransfusion sample the morning of surgery.  The result of the Antibody Screen gives us the information we need to be ready for the surgical date.

 

BTW: We locate our specimens by the date drawn ... placed in dated racks.  The computer displays the draw date so they are easy to find when needed.

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For all of you that are drawing samples more than 3 days before surgery, how do you document that the patient has been neither pregnant nor transfused in the prior 3 months?  Has anyone found a way to do this electronically rather than on paper?  If on paper, do you require the patient's signature?  Does this signature become part of the patient's chart?

 

We have a form that has the patient's name, SS# if they'll give it, birthdate and MR# at the top (below our institutions header). We ask the questions 'have you been transfused in the last 3 months' and 'have you been pregnant in the last 3 months' and ask the patient to circle either YES or NO. The patient signs and dates the form and that signature is witnessed by the phlebotomist collecting the specimen. The phleb signs and date. The patient is given an PAT ID card that he/she is instructed to bring back on the day of surgery. The patient's preop nurse is supposed to notify us when the patient presents with the card. 

 

We use a separate Blood Bank armband here. An armband is prepared for the patient at the time of the PAT visit. One sticker from the tail is placed on the PAT form and one is placed on the PAT ID card that the patient is given. The armband is clipped to the PAT form - that comes to Blood Bank along with the specimen and order. Once we are notified that the patient has arrived/presented the ID card, someone goes to Preop to ID and band the patient. We follow our standard patient ID process plus verify that the info on the PAT form, ID card and Blood Bank band match the hospital band and the patient's stated name and BD, MR#, etc. At this point, the patient is asked to sign the PAT card and he/she is banded with the armband that was prepared at the PAT visit. The signature on the PAT form and ID card are compared as the last step of verification. The card is stapled to the PAT form, which is kept in Blood Bank for 10 years in paper form. We haven't really discussed putting it into the patient's EMR, but that would probably be a good idea. We could scan it into the lab section the same way we do reference lab results.

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Can anyone tell me where I can find references about extending the crossmatch? I think it could be a good thing for us to look in to but I honestly didn't think it was permissible.

 

The only restriction on T&S or xm is if the patient has been transfused or pregnant in the 3 months prior.  ABB Std 5.14.3.2.  The same concept is in the CFR -you can look it up if you really need to.

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For all of you that are drawing samples more than 3 days before surgery, how do you document that the patient has been neither pregnant nor transfused in the prior 3 months?  Has anyone found a way to do this electronically rather than on paper?  If on paper, do you require the patient's signature?  Does this signature become part of the patient's chart?

 

We have a Transfusion History card with 2 questions that they must answer, "Have you been transfused in the past three months? and "Have you been pregnant in the past three months?"  It also has a statement that "I understand that removal of the Blood Bank arm band will result in having to have my blood redrawn".  They answer the questions and sign the card at time of specimen collection and the card accompanies specimen to the blood bank.  We also verify transfuion history in our BB LIS.  We will extend the sample up to 10 days.  We have an orderable test "Transfusion History" that we use to document that the patient qualifies and has signed the Transfusion History card.  The test Transfusion History has an alpha response result that equates to no preganacies/transfusions in the preceeding 3 months. 

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  • 3 months later...

Resurrecting an old thread. We've been extending Type and Screens for patients who come in through preadmission testing up to 7 days in advance of their day of surgey for a number of years. We have a new chairperson for Anesthesia and they've requested we extend up to 14 days. I would like to accomodate their request but I have a list of logistic/IS issues that will need to be tackled (on top of my already intimidating action item list). My primary question for the community is how do you handle the specimens?

 

Right now we have an 'archive rack' database system. Every day we fill one to three racks (72 tube slots). After testing is complete the tube gets added to a completed specimens rack. At least once per shift, or as needed, tubes in the completed specimens rack are scanned into an archive rack for that day and stored in the fridge. Once the racks reach their 15th day, the tubes get chucked.

 

Our initial thought is to simply extend our racks out another week. But what about antibody patients? How good are 14 day old specimens for AHG XMs? Do you ask for a new specimen closer to or on day of surgery for crossmatching? What does everyone else do? I need to do some more reading.

Edited by goodchild
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We do 1 to 30 days prior to surgery.

We have the 3 questions whose answer must be no...has the patient been transfused? Has the patient been pregnant within the last 3 months? does the patient have a history of an antibody or transfusion related complications? Then the 2 questions...Has the patient been transfused withing the last month? Has the pastient been pregnant withing the last month? also must be asked withing 3 days of surgery and answered no. So the questioner signs the first past and the new questioner signs the recheck part which is returned to the blood bank. When I recieve the first part I put a comment in BAD...preadmit order recd (date) for procedure scheduled on (date) or perhaps with an unknown date. Tubes are saved in their racks for 37 days. If they have not answered a question correctly we respond saying they are not eligible for extended xm and must be redrawn withing 3 days of procedure and post it to chart.  

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 I have seen places that freeze preops and save for up to a month. It all depends on your Medical Director's comfort level and the pressure exerted by the Medical staff.

 Somewhere I used to work did this - aliquoted off the plasma and froze it. I was never comfortable with it personally due to the risk of someone aliquotting more than one sample at a time when rushing (ie prelabelling tubes). I shouldn't happen but it did...

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This is interesting conversation for me! Our system seems to be a bit different that systems statet above.

 

We do not have any extensions. Our T&S is valid five days and when the clock is pointing the time the sample was drawn T&S goes out of order and new sample must be drawn. If pt has surgery coming they usually go to phelb one or two days before surgery or the same morning.

 

However we do have pre-op antibody screens and some wards send their patient to phleb for pre op testing that includes this screening. Then there will not be any big surprises.

 

I would be happy to read some references also if there are any or is this based on experience mostly?

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  • 3 weeks later...

We use Ortho gel and the insert states that, "...there is an FDA requirement that the specimen should not be stored for longer than 3 days before testing.  AABB Standards impose more lenient storage limits."

 

How do you get around this when it comes to Inspections?

 

I want to change our storage times also, but feel like my hands are tied because of what the package insert states.  Does anyone have some advice on what to do?

 

The problem I have is Pre-OP testing is done a week or so before, the patient has an antibody that I have to send out to identify.  Now the patient has a surgery scheduled on the following Monday....I have to get a new sample to the Reference Lab on the Friday before surgery because it is an extra charge for us if they come in on the weekend.  Now when the patient comes in on Monday, that is the only day I can use this cross match because of the 3 day limit.  If she needs blood post surgery we have to draw again and send to the reference lab again.  Its like an endless cycle that seems so wasteful in time, money and resources.

 

Any suggestions here would be great!

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I DON'T THINK ORTHO GAVE ALL THE DETAILS.  THIS IS WHAT THE CFR STATES:

 

 

§ 606.151 Compatibility testing.

Standard operating procedures for

compatibility testing shall include the

following:

(a) A method of collecting and identifying

the blood samples of recipients to

ensure positive identification.

(B) The use of fresh recipient serum

samples less than 3-days old for all

pretransfusion testing if the recipient

has been pregnant or transfused within

the previous 3 months.

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