Transfusion, special needs (Transplant, Sickle Cell populations)

[cthherbal]

What does everyone do relating to providing blood products for special needs patients (ex. Sickle Cell or Transplant)? Is it physician order driven or is there a process in the Blood Bank so that the patient will receive the correct products? I appreciate any feedback... Thanks!

[PAWHITTECAR]

I have worked in two tertiary care centers and they both approach it differently.

One had standard protocols in place..Hem/Onc patients automatically get Irradiated, Cardiac gets Leukodepleted, Sickle patients get Skl neg, antigen matched for thier Rh/K, Babies <4 months get Skl=, Irradiated, Leukodepleted.

The other only fills what the doctor orders... We do add "markers" so that if we know a patient needs something (like Skl neg) we make sure they get it (usually) even if the doctor doesn't order it.

I think the first way is safer for the patient because at the second place I have seen many things get missed..

My current hospital just fills what the docter orders, I am still reviewing records to see if we need to set up some kind of protocols but I have not made a firm decision as of yet...probably when the BB computer system comes on line...

[Malcolm Needs ☆]

When we cross-match for a patient at my Reference Laboratory, we always match Rh and K, but, then, it is easy for us so to do, and, in any case, all of our cellular components (except granulocytes!!!!!) are leukodepleted.

If the patient is a sickler, we always give HbS negative blood, and for patients know to require irradiated blood, we provide irradiated blood.

I do appreciate, however, that I am in a very privileged position.

[Dr. Pepper]

In the ideal world, the physician would have that responsibility, since who should know better what the particular needs of the patient are? That being said, the real world leaves way too many opportunities for special requirements to fall through the cracks: different docs caring for the same patient, things missed while transposing orders. etc. I would agree that Pawhitticar's 1st hospital's approach is safest, although one could argue that not all the patients within a group might need the special (and extra $$) protocol - for example, do all hem/onc patients need irradiated? We do it 2 ways: relying on the doctor's orders, and, once a special need has been identified, placing comments and/or markers in the computer that pop up in several places in the work flow and sometimes will stop you in your tracks if you don't do what you should.

[applejw]

Standard protocols are in place but it's up to the physicians to tell us what category the patient fits into. Transfusion requirements are entered into our LIS by staff - if we know they have SCD, leukoreduced. If child with SCD and untransfused, we will do phenotype (complete) and match RBC for C, E and K.

All cellular inventory is leukoreduced but we will still enter the requirement for specific groups - heart or liver transplant or physician request

BMT and neonates < 4 months get irradiated and leukoreduced. Children less than 6 months get irradiated. BMT patients are entered into LIS by the cellular processing lab staff from information provided by BMT program.

[David Saikin]

Being a transfusion service in a very small institution, it is up to the patient's MD to notify us of any special needs (irradiated, cmv=, etc). Once we have that info, we will always provide products conforming to these needs (except in emergent situations). A verbal MD order will set this up; it takes something in writing for me to remove the special need.

[kate murphy]

I'm in a moderately sized place (500beds) and we do protocols: BB staff enter the protocols right into the computer when we first see a patient. We do not rely on physician orders, many residents have no clue about transfusion medicine. I agree that it's safer for the patients, but much depends on how knowledgeable your clinical staff is.

[Justina]

We provide Sickle negative units and add a sickle negative protocol to patients whose diagnosis is sickle disease without a physician request (honestly I don't recall ever receiving a red blood cell order with a request of sickle neg units from the ordering physician). All other special needs the physician has to request it, once that request is made it is added as a protocol. Protocols are usually never removed-for the life of the patient.

[cthherbal]

Thanks everyone. We are struggling with this. Blood Bank is not computerized (yet) but it's coming. We are a 200 bed community hospital. We are banking on the patient history being correct and up to date on patient's card in the file drawer. When blood orders are placed in the HIS they are required to answer if patient has SCD or is a transplant recipient/candidate (Yes/No responses). These orders print in Blood Bank. Yes/No responses are incorrect (sometimes) possibly leading to patient getting incorrect products if we don't catch it. We are working on better solutions.

[DOGLOVER]

All sickle cell patients (if we know they are sicklers) will get HGS neg rbcs. They will also get rh and Kell matched. If they have an antibody then we full phentoype match as much as possible. The majority of our sicklers come from the pediatric sickle clinic so there is never a question. Once in a while an adult sickler, who has been hospital hopping, may show up in the ED without us knowing they are a sickler. For anything else, it is up to the physician to order. Once we get an order for irradiated we enter it into the LIS and it stays there forever unless we are told that it is no longer necessary. CMV neg except for CMV- transplant cases must be approved by the pathologist and then would go into the ccomputer. Everyone gets leuko-reduced and neonates all get irradiated. Everyone gets irradiated platelets (we were having to much trouble with separate platelet inventories, and pretty much everyone except surgicals needs irradiated plts anyway.

[Eagle Eye]

Before goign live with your computer system, it will be a good idea to enter all the comments/history in your computer system. May be do several audits to make sure all historical information is entered in LIS. What computer system do you have? In cerner once you flag the patient with sickle cell disease, the units need to be sickle negative before issue. Based on your set up the computer doesn't allow you to dispense the unit which is not tested sickle negative.

Thanks everyone. We are struggling with this. Blood Bank is not computerized (yet) but it's coming. We are a 200 bed community hospital. We are banking on the patient history being correct and up to date on patient's card in the file drawer. When blood orders are placed in the HIS they are required to answer if patient has SCD or is a transplant recipient/candidate (Yes/No responses). These orders print in Blood Bank. Yes/No responses are incorrect (sometimes) possibly leading to patient getting incorrect products if we don't catch it. We are working on better solutions.

[Likewine99]

I agree with Dr. Pepper and we add attributes to the patient in the BB computer system. aakupaku also has a great point, prior to going live with your BB computer system you will validate it extensively (believe me!). If your hospital has and EMR you can test and see if "special attributes" make it to your blood bank printer.

And as you move away from your manual cards you will have the opportunity to add patient special attributes into your BB computer system so at least you will have some control.

Lots of opportunities for mistakes here due to the number of people who enter orders and their level of expertise in transfusion medicine. You do the best you can do and make the transfusion as safe as a Blood Banker possibly can. Good luck!

[carolyn swickard]

For us - the Drs are supposed to let us know about special orders, but we keep special needs notes on our pt ID cards too and are always checking on this stuff - especially irradiation. Our oncologists don't agree on the same requirements for irradiation, so we get orders for it from some, but if the pt changes Drs, it stops. They are supposed to answer Y/N in the computer orders each time, but we are still cross checking a lot. They either forget to put it in or they don't know what it is , so just answer Y on every pt.

Sickle testing is very tough down here. It is a send-out for us because we get so few requests, the kits were always expiring, so Heme let it go. We are currently working with our Blood supplier to add it to the pedi-unit testing (along with CMV) because they are the only ones who could do it cost effectively. They could do it for all of us (14 hospitals) instead of each of us trying to do 1 or 2 units a month, maybe.

Is anyone having any luck getting their Neonatologists to accept leukocyte reduced units as CMV neg equivalent or is everyone still having to find CMV neg units? We can get enough CMV neg units to cover our stock unit, but if they need platelets or a lot of RBCs in a hurry, our CMV neg percentage is very low in this region and getting units for them is tough. Our FFP and Cryo are not even tested for the entire inventory (yes, I know the plasma products are not supposed to transmit CMV anyway, but neither are leukocyte reduced cellular units) and I am not even sure they realize that.

sorry, don't mean to hijack the thread, but since we're talking about pedi-units anyway....?

[Malcolm Needs ☆]

UK, we still need CMV- for neonates and pregnant women (amongst others, such as SCT patients) despite all our cellular components (apart fromgranulocytes) being leukodepleted.

[PAWHITTECAR]

The childrens's hospital has convinsed the neonatologista to accept leukodepleted with 65+ neonates it is impossible to get enough CMV- to go around. The other hospitals all still use CMV-

[Eagle Eye]

Still use CMV- RBC to neonates, CMV safe platelets are OK for neonates. All other patient population we give CMV safe.

[cthherbal]

Before goign live with your computer system, it will be a good idea to enter all the comments/history in your computer system. May be do several audits to make sure all historical information is entered in LIS. What computer system do you have? In cerner once you flag the patient with sickle cell disease, the units need to be sickle negative before issue. Based on your set up the computer doesn't allow you to dispense the unit which is not tested sickle negative.

Currently we do not have a computer system. I started sequestering antibody patient records from our files. Perhaps now I need to do the same for special needs patients as well. We have someone doing our record validation prior to go live. We are going with SoftBank.

[Eagle Eye]

It seems like you are on right track. Just make sure you do multiple audits of the manul record enteries. Also once you go live audit your system to make sure you are not missing any vital records. As far as I know your facility size is small enough so you can check all the records for a while!! Believe me once you have validated computer system, your techs will love it. there are lots of checks and balances set up in LIS so you have minimal human intervention. I can not think of going back to manual records....

Currently we do not have a computer system. I started sequestering antibody patient records from our files. Perhaps now I need to do the same for special needs patients as well. We have someone doing our record validation prior to go live. We are going with SoftBank.