What is the absolute minimum to issue emergency blood?

[Kathy]

If you have an exsanguinating patient, what is the absolute minimum you need to do to get the type O blood out the door? It seems like the tagging process takes up precious time with our current computer system.  Can we just slap "uncrossmatched blood" stickers on the units, pull the segments, pull a unit numbers from the units, and send the units untagged? Do we have to sign the tags that we did a clerical/visual check when we issue?  Perhaps we can have the ER bring patient labels with them so that we can put those plus "uncrossmatched blood" stickers on the units?

Edited February 20, 2014 by Kathy

[David Saikin]

We do essentially what you have described.  We complete the "paperwork" when the emergency is over.  We document the release time/date on the emergency release form.  If we get a specimen, we will begin wokring on it starting with a stick type for ABORh.  Once we have this we will attempt to issue type specific.  Fortunately we rarely have to go this route . . . it would become a problem if there was more than one pt receiving unxm rbcs (in either ED or OR).  We would have to delay and place a pt name label on the units beside the unxm sticker. 

 

It was like pulling teeth to get my staff to release the blood without having labels and completing all the release documentation.  When someone is in danger of exsanguination the few minutes delay becomes a critical issue.  You know the staff dealing with the emergency is only interested in getting the blood into the pt - their documentation will be sparse too.  We passed our Trauma Designation inspection with flying colors and I quote one of the inspectors "I wish I could get my emergency department to provide service like this - they don't understand." 

 

If you haven't worked in a trauma center it may seem unconscionable to release unlabeled blood.  In the past I have grabbed 20u and run to the emergent areas because that was the fastest way.  In these situations the pt needs the blood more than you need the completed paperwork.

[R1R2]

we have prepackaged/pretagged O negatives ready to go.  I think it is a good idea to record visual inspection of these units before issue.   This inspection can be recorded on a log somewhere or on the emergency release paper work.  We obtain physician signature after emergency is over. 

[Sophie1210]

Our computer system has an Emergency Dispense selection. We can type in the patient name and medical record number or trauma name and trauma medical record number, then we scan in the units, hit save, and tags print. We then tag the units and send them in a cooler. We usually have them in the cooler before the runner hits the blood bank for them. After everything is over, we do all the paperwork.

[carolyn swickard]

You can use a two levele system, if your computer system has an Emergency Release module (Meditech does too).

 

Level 1 - pt is not identified and is not in the computer - use a single Emergency Release form that you place unit number stickers on - save 2 more stickers (if possible) and 3 segments.  Save 2 segments and 1 sticker as usual (for the 14 day unit segment storage),  place 1 sticker on the form and place 1 sticker on a tube with the last segment.  The form has places for date/time, tech initials and then the Dr's signature, etc.  Very fast and can be used for anyone - identified or not - though one always hopes for full pt identification at a slightly later time.  (We have recently discovered that now that we are essentially a "stabilize and ship" hospital, it is much harder to follow up and get the full ID on the pt!)

 

Level 2 - pt now identified and has been entered in computer - save 3 segments and 2 stickers, use Emer Release blood bank computer module as designed, save 2 segemnts and 1 sticker as above and save 1 segemt and 1 sticker for crossmatching post antibody screen.   

[carolyn swickard]

sorry - here is the rest of it

If I can ever figure out how to attach something in this new layout, I would be happy to share our form and SOP, otherwise, just email me at carolyn.swickard@lpnt.net and I will try and get it to you.

Our only problem lately is that, now that we are essentially a "stabilize and ship"

hospital, we are having a little more difficulty following through with full pt ID if the pt is shipped before they are fully identified here. This is something Admissions needs to follow up on, as the pt's full EMR should have a correct name on it eventually.

[tbostock]

^{We came up with O Neg and O Pos "Happy Meals".  Sorry McDonald's, probably a copyright infringement.   But it's been a great improvement.}

 

^{We have 2 O Negs, an Emergency Release form, and preprinted transfusion tags with UNCROSSED labels attached.  Then there is a ziplock bag for each unit with a segment in a capped pilot tube, as well as a photocopy of the front of the unit.  This is all in a plastic basket (picked up at the dollar store).}

 

^{So the ER calls for emergency release, we grab the basket and throw the ziplock bag on the counter and make note of the time.  We are out the door in seconds and headed to the ED.  In the ED we get demographic stickers to put on the transfusion tags and Emer Release form.  We hand them the units and get our physician signature, and wait for the Type and Screen specimen.  Back in the Lab, a tech gets the Type and Screen specimen and has the photocopy to scan in the units to select for the crossmatching of the segments.  We then issue the unit in the computer, with the actual time we brought it over.}

 

^{We have an O Pos Happy Meal made up the same way.  We don't use this very often, just when we are really short of O Negs, then we would bring this for males or older women.}

 

^{As soon as we use them, we make up a new Happy Meal so it's ready to go.  On Sundays, one of the techs takes fresher units to swap out so we don't get near expiration.}

[SMILLER]

Our system is simular to Sophie's, above.  Without some minimal level of ID on the units, we would worry here about them going to the wrong patient when our ER is busy.

 

It only takes a minute or so to issue on the system.  While that is being done, coolers are readied by a second tech, ice packs are gotten out, etc.  For a Massive Transfusion Protocol, we are also ordering more platelets from our supplier, thawing the next batch of plasma, getting the next set of coolers ready.

 

We do not worry about ordering/transfusion documentation until after the crisis is over.  We are a level 2 trauma center in Michigan.

 

Scott

[Brenda K Hutson]

Couldn't tell from the original post; if you are doing these things "at the time you get an exsanguinating patient;" or, if they are done ahead of time?  Labeling the Unit Tag with Unit Information; placing Uncrossmatched Stickers on blood and Tags; Pulling Segments; having an Uncrossmatched Release Form (for MD signature) all ready to go....would obviously save a lot of time.  These can all be done ahead of time. 

As far as patient identification....unfortunately, not every Hospital has a system for even obtaining a "John Doe" type of identification for these patients in time to label the paperwork.  One Trauma Center I worked at requires this (some type of patient identifier; in the computer) for release of Trauma Units.  This is because in auditing patient charts, there were too many examples of Chart Copies either not making it to the Charts; or going on the wrong patient's chart.  The FDA noted this.  The busier your ED/Trauma facility, the more room for error like this to occur (i.e. maybe you have multiple trauma patients come in at once).

 

Brenda Hutson

[Kathy]

We do have a "happy meal" type of system for the first 4 units, which works fine in some situations.  The problem comes  when the patient is bleeding faster than we can tag units.  Our computer system is a real pain when it comes to emergency issue because there has to be some kind of blood bank order in the system in order for us to be able to issue blood to a patient.  It takes time to figure out if that order exists and then to place the order so that we can issue blood. Fortunately, we are going live in 3 months with a new system that is much more "emergency issue" friendly. Until then, we may have to consider not tagging units for exsanguinating patients. 

[bxcall1]

I pull a couple of pigtails, slap a sticker from each unit on the 'uncrossed blood request', throw a florescent orange 'UNCROSSMATCHED BLOOD'  sticker on each unit and they are out the door.

Sometimes I'll have them ready before they ask if I know it's a bad trauma.

[Winter]

What is the policy at your facility if a patient has a known antibody, (like anti-c), and they need uncrossmatched blood? What is the maximum number of antigen negative units you will supply in a crisis? If the antibody reacts at 3+ in the initial identification and still 3+ at  24 hours after administration of 15 or so antigen negative units, at what point in a bleeding crisis is an antigen positive unit okay?

[Malcolm Needs ☆]

That must ALWAYS be a clinical decision.

[kate murphy]

I agree with Malcolm.  Exsanguinating patients with known antibodies is a clinical decision - we explain that there is a risk of hemolysis at the most.  It's their decision.  Sometimes the risk of bleeding to death outweighs the risk of hemolysis.  Our medical director is always available to answer questions if needed. In these cases, we make sure to get the doc's name if not his/her signature before issuing.

 

We also do the "happy meals" scenario - 2 O Negs and 2 O Pos always tagged ready to go on a fictitious patient only in the lab computer system.  We're a very busy trauma service - we need a billing or account number at the minimum which we scribble on the unit tag.  Takes 2 seconds.  Frequently we send units to the ED while the patient is en route.  Often we have multiple patients at the same time.  We complete paperwork after the fact and merge our fictitious patient with the real patient.  Occasionally, we need chart reviews to verify who got what when.  But by and large, our ED staff is pretty good - the trauma rooms are separate from the ED main rooms, so keeping all the paperwork in one place is easier

 

If your ED is not routinely dealing with traumas, it's hard to maintain units tagged and ready to go. 

[David Saikin]

You know sometimes you don't have a choice. Had a pt with Fyb,E,and K abs going for heart surgery. They knew they could go with 3. When I went to work the next night, she was in the OR for the third time and we weren't screening for anything (every unit was screened and/or transfused already). Pt survived and only developed a +DAT with the Duffy a few days post-op. We had discussed this with our Medical Director just prior to surgery and prioritized what we would screen for if the situation deteriorated (esp as we had very little faith (jsutified) in our cardiac surgery team at that time.

[Eoin]

Not in a trauma centre anymore - but back in Oz - we thought like David - gave them as much blood, platelets plasma etc as they needed as quickly as we could (pre-pepared tags & paperwork [minimal].

Do the work-up where and when  -

 

and for anything that could have a "tricky" side to it, we brainstormed what we called "What happens when the fit hits the shan?" - so if we did strike any reactions, during Tx or delayed, documentation issues, Patient ID issues et. al., we had Plans A, B, C etc. 

It was very helpful & with experienced techs didn't take long to map out. Was used a couple of times as I recall. 

Cheers

Eoin

[Jody]

For those of you using fictitious names.... When do you merge with the true patient? Do you have a specific criteria?

[profbaud]

The purpose of Emergency Release is to get the blood out the door immediately.  We have a shelf dedicated to ER release and it contains 4 O Neg and 2 O Pos units.  These units are rotated out weekly.  We have a 10x75 mm tube that  contains 2 segments that has the ISBT sticker on them and a orange Uncrossmatched sticker on it.

We have generic Paper forms printed out in a folder near the issue desk.  The minute we get the phone call from ER, OR or ICU, we open the cooler, put the gel packs inside, pull the labeled segmented tube, place 2-4 units of ER release blood and blank paperwork in the cooler and out the door it goes.  The receiving dept has a ER consent form already filled out to hand to us and a specimen if possible. Then we do the testing and computer work afterwards or rubberband the tubes together and wait for the specimen.

[carolyn swickard]

For those of you using fictitious names.... When do you merge with the true patient? Do you have a specific criteria?

Yes - we had to write a whole "unidentified patient protocol" that defined WHEN and WHERE Admissions could mess with the pt name during a Trauma.  It is very specific, but we have trouble getting Admissions to follow it because they don't get to use it very much here any more and training suffers.  But it did keep them from changing the name in the middle of an event - even worse, they would change the Medical Record # too if they found an older record.  The protocol says they can't do those changes until the patient is stable.  If we have used a trauma name (defined by the Blood Bank wristband number) they must keep the number with the name until the pt is stable, dead or transferred, even though they can ADD the pt name into the pt name field if they learn it.  That was important to other people in the hospital who needed to know who we had here when pt families started calling, etc.

[kate murphy]

I'm sad that we're not the only ones with trying to convince Admissions to follow a protocol when changing Med Rec #s!  Seems like a universal problem!  I think we've finally gotten them to stop changing numbers while the patient is still on the table in the OR.  Shudder...

We usually merge when a "real" identity is known - a real name and a real birthdate.  If the patient is in our system with older data, we use the older #.  If not, then a new MRN is assigned.  Either way - we merge when the wristband changes.  Then we need a new spec, as the old spec doesn't match any longer.