transfusion reaction and requesting more products

[tkakin]

I have a question about how you guys handle requests for more products before a transfusion reaction work up is completed. We are wanting to make a firm written rule that they cannot receive additional products until a transfusion reaction workup is complete with the exception of life saving circumstances. Is this a rule that is unreasonable?

 

Also we allow the attending physician to decide if they want to continue the transfusion. This rule is also being questioned.  Do  you guys allow the continuation of transfusion or do you stop the transfusion no matter what?

 

I appreciate any and all advise on this subject

Thanks in advance

Teresa. 

[efg21]

We do allow our physicians control over the transfusion reation, the nurse alerts the doctor and the doctor will decide wheather it is a transfusion reation or not, they know the patient better then we do and if it is from a medication they gave to them/anything else in that nature. 

 

Once the nurse has alerted the doctor and they decide to call it a transfusion reaction, they then call blood bank, give us all the information we write it down, they fill out a form, bring us all the blood products/bag/saline/lines that were being used.  they draw a new sample and we perform our testing on the before and after sample, also doing a new type and screen on the newly drawn sample.  once we our finished, we need a pathologist approval before we issue anymore products

[Malcolm Needs ☆]

I agree that nothing should be given until the reason for the reaction has been resolved, except in life-threatening circumstances. Whatever the cause of the reaction, the fact remains that there has been a reaction and, until the cause is resolved, there is every chance that a further transfusion may cause a further reaction and exacerbate the situation.

[Joanne P. Scannell]

We have in place the following:

1. If the patient exhibits signs/symptoms related to transfusion reactions (there's a list), there is no choice ... the transfusion is discontinued and a Transfusion Reaction Investigation is ordered.  Period. 

• This is because the transfusion is under the license of the BB Medical Director who is thereby responsible for it. 
• Besides, if MDs have the powers to 'instantly know' whether the symptoms are due to the transfusion or not and that the blood was completely compatible or not causing any allergic, TRALI, Overload, etc. without any testing/rechecking/investigation, then  why do we need the Blood Bank investigations at all?  It is safer to stop and do the investigation than to rely on a variety of MD 'instincts'.  As much as they like to think they are, they (especially the residents) prove over and over again that they are not the experts in these matters.  (e.g. some of them are not aware of the symptoms or how to treat TRALI.)  I always think about 'how would this look in court?' 
• The only exception is 'Hives Only'.  If this happens, the infusionist is instructed by SOP to pause the transfusion, see if the hives subside, confer with MD to see if they want to administer medication, and then continue the transfusion.

 

2. When a Transfusion Reaction Investigation is ordered, a specimen is drawn that becomes a) the 'Post Reaction' specimen for comparison studies (color, DAT, etc.) and the new pretransfusion specimen for subsequent transfusions.

• All units that were crossmatched with the original specimen are released (i.e. not allocated to the patient anymore.) (n.b. we are on a BB Band system so each specimen is a separate entity)
• During the investigation, no units are issued unless the attending MD documents that there is a life/death situation where only the continuance of the transfusions will sustain life.  We haven't had this happen yet, but when it does, we plan to issue the prior compatible units with this documentation ... not sure if we should call this 'Emergency Release' or not ... now that I'm focusing on it, we probably should.

[KAPMT]

Our procedure is similar to that noted by efg21. We will not perform a transfusion reaction workup until the physician has signed the form after being alerted by the nurse. Once we have the signed form with the required information we will procede with our transfusion reaction workup.

 

If further blood products are requested before the workup is complete we are required to obtain the okay from a pathologist,

[Dr. Pepper]

^{I agree that there's a real danger in letting a physician decide in his/her infinite wisdom that the symptoms are coincidental with the transfusion. Years ago I read of a case where a psychiatric patient was getting a unit and reported anxiety symptoms, including a sense of impending doom (they should have listened!). They shot her up with morphine, upon which she fell into a sound sleep, and continued on with the transfusion (maybe gave her a second?). Somewhere along the line they noticed her urine was jet black. The blood was ABO-incompatible. I think she lived  to worry another day.}

 

 

 

^{If a patient is bleeding out and shows reaction symptoms, the MD must pick the lesser of the evils: delaying the transfusion or the small but real possibility of a hemolytic reaction.  But that's a minority of our  transfusions. So...................}

 

 

 

^{Like Joanne, we stop the transfusion if the symptoms are on the hit list. The doc is contacted, not to decide if it's a "real" reaction but to initiate therapy for the symptoms if need be. If they need more blood before the initial workup is completed, they have to sign a release form. If the workup indicates the possibility of a reaction (pos DAT, visible hemolysis), then we do a comprehensive workup. Again, if they need more blood before that is finished, we need the release form.}

Edited September 27, 2013 by Dr. Pepper

[Dansket]

 

We have in place the following:

1. If the patient exhibits signs/symptoms related to transfusion reactions (there's a list), there is no choice ... the transfusion is discontinued and a Transfusion Reaction Investigation is ordered.  Period. 

• This is because the transfusion is under the license of the BB Medical Director who is thereby responsible for it. 
• Besides, if MDs have the powers to 'instantly know' whether the symptoms are due to the transfusion or not and that the blood was completely compatible or not causing any allergic, TRALI, Overload, etc. without any testing/rechecking/investigation, then  why do we need the Blood Bank investigations at all?  It is safer to stop and do the investigation than to rely on a variety of MD 'instincts'.  As much as they like to think they are, they (especially the residents) prove over and over again that they are not the experts in these matters.  (e.g. some of them are not aware of the symptoms or how to treat TRALI.)  I always think about 'how would this look in court?' 
• The only exception is 'Hives Only'.  If this happens, the infusionist is instructed by SOP to pause the transfusion, see if the hives subside, confer with MD to see if they want to administer medication, and then continue the transfusion.

 

2. When a Transfusion Reaction Investigation is ordered, a specimen is drawn that becomes a) the 'Post Reaction' specimen for comparison studies (color, DAT, etc.) and the new pretransfusion specimen for subsequent transfusions.

• All units that were crossmatched with the original specimen are released (i.e. not allocated to the patient anymore.) (n.b. we are on a BB Band system so each specimen is a separate entity)
• During the investigation, no units are issued unless the attending MD documents that there is a life/death situation where only the continuance of the transfusions will sustain life.  We haven't had this happen yet, but when it does, we plan to issue the prior compatible units with this documentation ... not sure if we should call this 'Emergency Release' or not ... now that I'm focusing on it, we probably should.

 

We do the same.  There is no way a physician can diagnose over the phone whether or not a patient is receiving a serologically incompatible blood transfusion!

[carolyn swickard]

We just finished getting ready for our first Joint Commission inspection and they have a standard the takes away the Dr's choice.  Essentially - if the Blood Bank finds out about a transfusion problem - the transfusion reaction workup has to be done, period.

 

QSA.05.18.01  section 2 - bullet 5

 

The requirement that suspected transfusion-related adverse events are reported immendiately to the laboratory, whether or not the physician responsible for the patient deems it necessary to report the event.

 

This follows the requirement that the physician be notified too.  I guess the Joint Commission decided to take the physician's decision out of the process too. 

[Eagle Eye]

We have two immediate notifications 1) RN notifies physician immediately  2) Notifies blood bank immediately

We do not issue any additional products until the workup is completed EXCEPT life threatening situations where we need pathologist approval before issuing any products before the completion of workup.

Our Nursing policy says that if physician wants to continue the transfusion they can do so after the documentation that they are taking a responsibility and the continuation of transfusion is more beneficial to patient AND they must send the specimen for the workup while the transfusion is still in progress. So our RN can tell the doctors that they will continue the transfusion but the workup must be initiated other wise RN will get a report.

[tbostock]

 

We have in place the following:

1. If the patient exhibits signs/symptoms related to transfusion reactions (there's a list), there is no choice ... the transfusion is discontinued and a Transfusion Reaction Investigation is ordered.  Period.

• This is because the transfusion is under the license of the BB Medical Director who is thereby responsible for it. 
• Besides, if MDs have the powers to 'instantly know' whether the symptoms are due to the transfusion or not and that the blood was completely compatible or not causing any allergic, TRALI, Overload, etc. without any testing/rechecking/investigation, then  why do we need the Blood Bank investigations at all?  It is safer to stop and do the investigation than to rely on a variety of MD 'instincts'.  As much as they like to think they are, they (especially the residents) prove over and over again that they are not the experts in these matters.  (e.g. some of them are not aware of the symptoms or how to treat TRALI.)  I always think about 'how would this look in court?' 
• The only exception is 'Hives Only'.  If this happens, the infusionist is instructed by SOP to pause the transfusion, see if the hives subside, confer with MD to see if they want to administer medication, and then continue the transfusion.

2. When a Transfusion Reaction Investigation is ordered, a specimen is drawn that becomes a) the 'Post Reaction' specimen for comparison studies (color, DAT, etc.) and the new pretransfusion specimen for subsequent transfusions.

• All units that were crossmatched with the original specimen are released (i.e. not allocated to the patient anymore.) (n.b. we are on a BB Band system so each specimen is a separate entity)
• During the investigation, no units are issued unless the attending MD documents that there is a life/death situation where only the continuance of the transfusions will sustain life.  We haven't had this happen yet, but when it does, we plan to issue the prior compatible units with this documentation ... not sure if we should call this 'Emergency Release' or not ... now that I'm focusing on it, we probably should.

 We do the same...no more blood goes out the door and we have it in our policy that no physician is allowed to continue a transfusion when the patient is showing symptoms of a reaction. Not only do most physicians not know what TRALI and TACO are, they can't even spell them. LOL Edited October 2, 2013 by tbostock

[aafrin]

Terri, 2 points -

 

<We do the same...no more blood goes out the door and we have it in our policy that no physician is allowed to stop a transfusion when the patient is showing symptoms of a reaction. >

 

Then who will stop the transfusion?

 

 

<Not only do most physicians not know what TRALI and TACO are, they can't even spell them. LOL>

 

Couldn't agree more.

[tbostock]

 

Terri, 2 points -

 

<We do the same...no more blood goes out the door and we have it in our policy that no physician is allowed to stop a transfusion when the patient is showing symptoms of a reaction. >

 

Then who will stop the transfusion?

 

 

<Not only do most physicians not know what TRALI and TACO are, they can't even spell them. LOL>

 

Couldn't agree more.

 

Yikes! Typo! I just fixed it: "no physician can CONTINUE a transfusion"....good catch aafrin! Thanks.

[MAGNUM]

If the patient exhibits signs and symptoms of a transfusion reaction, it does not matter what the type, the transfusion must be stopped.  We use BCTA and should the patient exhibit symptoms, the nurse charts in BCTA the symptoms and the computer prompts her/him to stop the transfusion, and if they do not stop it, they must give a legitimate reason why not, and because the physician said to continue is not a legitimate reason.

 

As to receiveing more products, until the reaction investigation is completed, the patient will not receive anything unless it is life and death.

[Mabel Adams]

The reason for policies that allow a transfusion to be "paused" and continued if the workup shows no problem is from the days  before the firm wording of the JC std quoted above.  The oncologists would not want the reaction reported on platelets when the patient spiked a temp. The option to pause, do the workup and continue if there was no evidence of serious reaction was a way to get them to allow the reactions to be reported.  Also, it avoided tossing what might be your last platelet available.

I think adhering to the JC standard and stopping all but mild allergic reactions is best if you can get the MDs educated to follow the std.  There should be a mechanism to allow for a pathologist to consult in situations where there would be no more platelets available for the patient and it is highly likely that the patient was spiking temps already and in other similar situations where balancing the risks and benefits to the patient are required.

[goodchild]

After a suspected transfusion reaction is reported: we allow them to continue a transfusion or continue transfusing additional units provided the physician documents an emergency transfusion order based on the patient's condition.

[Auntie-D]

We are not allowed to deny a physician blood - it is a clinical decision. All we can do is provide them with all the information they need and let them determine the risk. End of discussion

[kirkaw]

Many have stated that more blood products cannot be issued before the transfusion reaction investigation is complete. How do you define that endpoint? Is it when the workup is done serologically (including clerical check) and there is no evidence of hemolysis? Or do you define the endpoint as when the blood bank medical director signs off?

[Malcolm Needs ☆]

In my case, it is when we finish the serological work-up.

I agree with you Auntie-D, but you have to make ABSOLUTELY certain the physician knows the risks, particularly in the case of a sickle cell patient. Further transfusion in the case of hyperhaemolysis, without IVIG and, possibly, steroid cover is more often fatal than a transfusion reaction due to a red cell antibody.

[tbostock]

 

Many have stated that more blood products cannot be issued before the transfusion reaction investigation is complete. How do you define that endpoint? Is it when the workup is done serologically (including clerical check) and there is no evidence of hemolysis? Or do you define the endpoint as when the blood bank medical director signs off?

We don't release more blood until the medical director (or pathologist on call) approves it verbally. It's usually officially signed and sent to the EMR the next working day.

[tbostock]

 

We are not allowed to deny a physician blood - it is a clinical decision. All we can do is provide them with all the information they need and let them determine the risk. End of discussion

 

Agree with the concept, but we also have to keep in compliance with our regulatory agencies, which do require Medical Director approval before releasing more units.

[kirkaw]

Terri, can you tell me what the regulatory requirement is that prohibits the release of blood products until after the med director has signed off on a transfusion reaction? My medical director insists that if there is no serologic evidence of hemolytic transfusion reaction, that he not be called in the middle of the night to sign off on a transfusion reaction.

 

Also, is it in your nursing policy that they draw a blood specimen when a transfusion reaction is reported? Our nursing staff looks for direction from the transfusion service on that; I thought it was 'standard practice' for a blood specimen to be drawn when a transfusion reaction is called.

 

Thanks!

[Michaele]

The nurses notify the physician and the Blood Bank.  The doc can choose not to do a workup if he feels like it is due to the patient preexhisting condition.  We do have authority to over-ride them though. 

[AMcCord]

The nurses notify the physician and the Blood Bank.  The doc can choose not to do a workup if he feels like it is due to the patient preexhisting condition.  We do have authority to over-ride them though. 

 

This is how we handle it as well.

[Brenda K Hutson]

We make the Physician call the reaction.  I say "make" because over the years, and different Institutions, I have always had those situations when a Nurse is trying to get us to tell them if it is a reaction (which is already spelled out in a Nursing Policy that was created interdepartmentally).  We are not there with the patient and do not know their clinical situation; so I constantly remind my staff that this is a respoonsibility they absolutely cannot take on (unless they want to be liable)!

If they call a reaction, they are instructed to stop the transfusion (unless MD feels just allergic and opts to give Meds and continue; and that is their call), and send blood products, Transfusion Reaction Form and specimens to Blood Bank.

I created little Tags that staff are instructed to place on any Assigned Products for the patient...that basically say...Transfusion Reaction Work-Up In-Progress.  This is their alert that they cannot Issue more products until the immediate work-up is complete (obviously not talking about a 5 day culture result pending) and it is safe to transfuse; then they remove the tag.

Brenda

[Brenda K Hutson]

We make the Physician call the reaction.  I say "make" because over the years, and different Institutions, I have always had those situations when a Nurse is trying to get us to tell them if it is a reaction (which is already spelled out in a Nursing Policy that was created interdepartmentally).  We are not there with the patient and do not know their clinical situation; so I constantly remind my staff that this is a respoonsibility they absolutely cannot take on (unless they want to be liable)!

If they call a reaction, they are instructed to stop the transfusion (unless MD feels just allergic and opts to give Meds and continue; and that is their call), and send blood products, Transfusion Reaction Form and specimens to Blood Bank.

I created little Tags that staff are instructed to place on any Assigned Products for the patient...that basically say...Transfusion Reaction Work-Up In-Progress.  This is their alert that they cannot Issue more products until the immediate work-up is complete (obviously not talking about a 5 day culture result pending) and it is safe to transfuse; then they remove the tag.

Brenda

NOTE:  Added File of Tag in the Library if anyone interested....

Brenda