Emergency Release/Uncrossmatched RBCs

[Brenda K Hutson]

My apologies; am coming on again with a question even though I have not had time in quite awhile to logon and participate. Hopefully, someday my life will allow me more time to visit this site

We are expecting CAP any day now and another local Hospital was just cited on something that seems questionable (have not had the time yet to look at checklist and see the specific CAP Question).

The Inspectors are citing them because the Uncrossmatched (Emergency Release) Units they dispense do not have any patient identifiers. They are saying that they must still have 2 identifiers (apparently they called CAP to clarify and CAP agreed to this requirement). Having worked in several large Trauma Centers, I have seen that some places use a generic Name and MR#; then cross-reference it once they have the specific patient information. But sounds like they are saying it must have "something."

So, just wondering what others out there do with regard to Patient Identification on the Chart Copy paperwork you attach to Units being Issued as Uncrossmatched (and for whom there may not even be a Patient ID at the time they need the blood).

Thanks for you help on this!

Brenda Hutson, CLS(ASCP)SBB

[PAWHITTECAR]

I have worked at two different level 1 trauma centers and they both do it differently.

The first one requires two identifiers before any blood is issued, even emergency release. When a trauma comes in they put a green "typenex" armband on them and that number (MKZ 1234) is one identifier then they give them a "name" MKZ 1234, White male. When they get an actual name they merge the accounts where you can look up the "trauma name" and it will take you to the correct patient.

The second has a 2 "trauma boxes" with 2 units O neg that they keep on ice and a tech or RN can walk in and get the trauma blood at any time and you never know who it is going to. After given you get the forms back with who it was given to. It can get really confusing when both trauma boxes are out at the same time.

I personally like the first best. It is less confusing and easier to track. The second hospital is CAP inspected and have never been cited for this practice.

[Brenda K Hutson]

Thank You. Follow-up:

1. So at the time they request the Uncrossmatched blood for the Trauma patient (in scenario 1), are you given the green armband # and the "name?" And if YES, do you write that on the Chart Copies that go out with the Uncrossmatched blood?

2. Your 2nd scenario kind of scares me. I can think of a number of things that can go wrong with a system like that.

Brenda

I have worked at two different level 1 trauma centers and they both do it differently.

The first one requires two identifiers before any blood is issued, even emergency release. When a trauma comes in they put a green "typenex" armband on them and that number (MKZ 1234) is one identifier then they give them a "name" MKZ 1234, White male. When they get an actual name they merge the accounts where you can look up the "trauma name" and it will take you to the correct patient.

The second has a 2 "trauma boxes" with 2 units O neg that they keep on ice and a tech or RN can walk in and get the trauma blood at any time and you never know who it is going to. After given you get the forms back with who it was given to. It can get really confusing when both trauma boxes are out at the same time.

I personally like the first best. It is less confusing and easier to track. The second hospital is CAP inspected and have never been cited for this practice.

[PAWHITTECAR]

YES the second senario really scares me too. I know of many issues in the 11 years I've been associated with them. The answer I get when I question it is that its O neg blood so if they do give it to the wrong patient "no problem".

In senario 1 we either print an emergency issue form directly from the computer with the "name" and "number" already printed on it. Or we have blank forms that we write in the numbers. I personally find it quicker to print them. In a trauma a few seconds can matter.

[kirkaw]

We too, require 2 patient identifiers. If the patient has not been positively ID'ed, the following is done:

'If the identity of the patient is not know and there is no patient information, the patient will be entered as First name military alphabet (Alpha - Zulu) and the last name Doe. The middle initial will be M or F for male or female. The date of birth on all unknown patients is to be 1/1/1899.'

Once the patient is identified, the 'Doe' record is merged with the correct patient by the Medical Records department.

[Eagle Eye]

We do not have any identifier on the trauma units but as soon as they take the blood out from ref. (in ER/OR), they apply patient identification number and name on the transfusion slip and also write in the log book. Blood bank checks inventory of trauma units daily. Once the unit is transfused blood bank receives emergency paper and transfusion slip that is how we know the blood was used. The units gets xmatched & issued in our system.

If they use all the units from ER/OR and need more unit...we issue emergency release unit from blood bank BUT for those we definately need two identifier and we issue it in our computer system.

Once in a while we see unit missing from ref. and we follow up with nurse manager immediately and the unit gets reconciled with in 48 hrs as we check inventory of those unit daily.

If unit is missing and the manager can not find the patient they have to look through all the admission with in 24 hrs and look at all the charts and it is lots of work and they know that incident will be entered in our system. So most cases we do get paperwork immediately.

[dld]

We are not a designated trauma hospital, but we have the occasional gunshot victim whose "friend" drops them at the emergency room and takes off. Anyway, if we do not have a name they are registered as "John Doe" (or Jane) and given a medical record number. When ER calls for an emergency release, we take a cooler to ER with 2 Oneg and 2 Opos along with the emergency release form the DR signs at some point. At some point the real name is obtained, and we document, with the unifying link being the medical record number.

[SMILLER]

Our method is also simular to scenario one. All patients must have two patient IDs. We use the med rec number and the "John Doe" (eg: Doe 2013-01, John or Jane). These are assigned from a list in ER, often before the patient arrives. The units are tagged accordingly. Once the patient is identified later, everything is cross-referenced for the record.

Problem with scenario 2 is that it would be hard to prove to a regulator that particular units of blood went to a certain patient.

Scott

[DeeMc]

We used to have the policy as stated in #1 until there were two instances where blood was needed without time to even initiate trauma ID banding. For example, teenage gunshot victim "deposited" in the main lobby of the hospital (exsanguinating). Due to these instances, our medical staff will not allow withholding of emergency blood if no ID is available at the time of need. We have never been cited by the FDA nor CAP regarding the practice. That said, most of the time the trauma ID banding is in place and two IDs are available.

We have a "vending machine" remote refrigerator in our intensive care. If necessary, an RN can access emergency blood from the refrigerator without patient identification (can be configured differently per institution). In that case, the RN removing the unit is identified by the system and we receive an audible alert in the Blood Bank that emergency units have been removed. We can then immediately call to find out the identity of the patient.

[AMcCord]

We follow the same protocol as Scott. However, if there is an extreme need and there hasn't been time to register the patient with the J Doe name and MR#, they will use a typenex trauma band. That number, patient sex and sometimes a physical description (like red hair) will become the patient identifiers. We tag the units with the patient identifiers prior to release - usually handwritten - unless it is an extreme, dire, out-of-control situation. Fortunately the no-tag situation is very very rare. We are in the process of revamping our trauma protocols, so that may change, but we will insist on patient identifiers, if it is at all feasible to use them in a given situation.

[PAWHITTECAR]

I seams to me that there would never be a time that they couldn't somehow ID who they were giving the blood to. Even if it was "teenage GSW in Lobby" at least you would have some idea of who they were picking it up for. In the Senerio #2 we never know who its going to, what the problem might be, should we expect them to need a lot more or what? It is very nerve racking when they pick up the box without having any clue where it is going. Sometimes we do not even know where in the hospital it is going, was it ER, OR the transport team or who that came to get it.

[Brenda K Hutson]

Thank you all for your input. Just a couple of follow-ups you might be interersted in:

1. The local Hospital that brought this issue up this week while having a CAP Inspection: When the Medical Director called CAP, they said NO, it is not a requirement that there be even "generic" identifiers on Emergency Release blood. However, when the Inspector was told this, she then called CAP and they told her YES, that ALL blood going out must have 2 identifiers on it. They also said that the interpretation of that Question might differ depending on who you spoke to at CAP (I know, shouldn't be that way).

2. I checked in with 2 large Trauma Centers I worked at previously (have changed Protocol since I was there), just to see what they did. They do both receive, and require at least a Generic Name and MR#; and they do put that on the Blood Products before they leave the Blood Bank. One of them (1,000 beds, Level I Trauma Center) has developed a rather elaborate process (am surprised the Trauma Physicians, or any of the Physicians for that matter agreed to it; but I think it came about from numerous charting errors found during chart audits and numerous citations for problems). It is mandatory that they receive an Order (can be electronic or manual) for ALL requests for Uncrossmatched Products; and it must be signed by the Physician or other Licensed personnel. Their computer systems are set up such that they can then access that information in the Blood Bank computer and actually Print Out their Transfusion Chart copies, with the generic information on it. I think the mandatory Order came from discrepancies (i.e. clerical errors from verbal orders).

Brenda Hutson