Urgent Requirement for RBCs

[jojo808]

thank you, I stand corrected. Great information!

[goodchild]

But delay in the provision of blood in massive haemorhhage situations is far more likely to result in death than a transfusion reaction - the reaction is most likely to be occurring on the floor...

 

That's the second time you've mentioned that in the same thread!

[Auntie-D]

That's the second time you've mentioned that in the same thread!

 

And your reason for mentioning this?

 

I think people get far too hung up on ensuring that every possible test is complete, sometimes to the point of leavng a patient bleeding to death rather than risk a delayed HTR. At the end of the day it is not our place to say 'no' to the clinicians, but to give them advice as to the possible outcomes - and then it is their decision whether to transfuse or not. We have a concessionary release form for this very reason.

[mollyredone]

We do a moderate amount of emergency release, without tests being completed.  That being said, it is the blood bank's responsibility to complete testing after the fact.  I think goodchild was just looking for info on what type of forms different hospitals have to deal with different scenarios, to ensure the physician is aware of the particular risk involved. (goodchild-correct me if I'm wrong!)

[goodchild]

Resurrecting this thread. 

I would love to see Emergency Release process/procedure documents from anyone who is willing to share.

Definitely still curious how everyone else handles the unique situations; such as when the antibody identification is incomplete or if the patient has multiple antibodies (or an antibody to a high prevalence antigen) and uncrossmatched/incompatible-crossmatched blood is requested.

Also curious in general how people handle trauma situations.

What level of detail your institution's process/procedure goes into.

Is your policy more rigorous to ensure traceability or more liberal for providing large volumes of blood for the patient.

Do you issue an emergency release form for the physician to sign for each unit? Do you have a single form that lists all the blood products? Do you have a single form that simply approves emergency release blood for a particular time period? Do you use electronic orders instead of/in addition to forms and what kind of information is inside the electronic order?

Stuff like that.

 

Molly you were basically right. I'm just kind of curious how other institutions handle some of these equivocal scenarios. There's such a wide range of variability between blood banks so it's an interesting topic to examine. I was recently talking with someone from another institution out of state where the blood bank delivers the blood during a massive hemorrhage scenario (despite the fact that the blood bank has only one technologist on duty during most shifts) and that blew my mind. I'd also love to see some forms.

Edited June 30, 2015 by goodchild

[tbostock]

Resurrecting this thread. 

I would love to see Emergency Release process/procedure documents from anyone who is willing to share.

Definitely still curious how everyone else handles the unique situations; such as when the antibody identification is incomplete or if the patient has multiple antibodies (or an antibody to a high prevalence antigen) and uncrossmatched/incompatible-crossmatched blood is requested.

Also curious in general how people handle trauma situations.

What level of detail your institution's process/procedure goes into.

Is your policy more rigorous to ensure traceability or more liberal for providing large volumes of blood for the patient.

Do you issue an emergency release form for the physician to sign for each unit? Do you have a single form that lists all the blood products? Do you have a single form that simply approves emergency release blood for a particular time period? Do you use electronic orders instead of/in addition to forms and what kind of information is inside the electronic order?

Stuff like that.

 

Molly you were basically right. I'm just kind of curious how other institutions handle some of these equivocal scenarios. There's such a wide range of variability between blood banks so it's an interesting topic to examine. I was recently talking with someone from another institution out of state where the blood bank delivers the blood during a massive hemorrhage scenario (despite the fact that the blood bank has only one technologist on duty during most shifts) and that blew my mind. I'd also love to see some forms.

Here's my form. The physician signs once, for all units that may be associated with that specimen (3 day limit). We still use the paper form because nurses frequently order for physicians in our EMR in emergency situations and I still want that signature from the MD to prove that he authorized it.

And yes, we also deliver ALL emergency release units and all MTP units. We don't have the staff either, but we need to make sure the blood gets to the right bedside and that patient care is not delayed. They will not hesitate to throw BB under the bus if something goes wrong so I want to be able to prove that we did everything in our power to provide the blood.

Emergency Release Form.doc

[MERRYPATH]

I speak as a Blood Banker on evening shift. When we have a STAT type and screen and we have a positive screen, either previously pos or a new pos, we have a worksheet Antibody Screen Positive-Evaluation Form. The form asks a number of questions to determine if a new workup is required. We notify the nurse of the Critical Result and document. We also answer if there is a STAT RBC order present...Were emergency units offered to the PCU...Was the Blood Bank Physician notified...These questions are intended to involve the BB Doc at the time the patients team is deciding if they need to transfuse in an emergency. As often as they are afraid to transfuse with the presence of an antibody they are also without fear to transfuse if the are thinking emergency in their minds. It can be foolish either way. We get the BB physician involved to be the go between...with two blood bankers on evening shift we have to stay on task and get as much information as possible advanced as quickly as possible in the work up so the BB Doc needs to step in to evaluate what is happening.  In the past we did not necessarily involve the BB Doc and our bigger problem was that the patients team would not communicate an emergency need once we said "antibody" They might wait when they needed to  transfuse. We don't often have a true exsanguinating emergency with no prior history. Our emergencies will happen more commonly with ORs gone bad or sudden changes of status on the floors or a patient coming back in via the ER. When we do have a Code Red called in ER we send 2 O negs with our Emergency Release. The beginning of a Massive Transfusion Protocol with an antibody patient may begin with 2 uncrossmatched units if we do not know the name of the patient. Once we know the name we we can alert the team to an antibody history. Alert the BB Doc. Start looking for a tube to begin a workup with. I have gathered antigen negative units...we often have a variety of antigen negative units in inventory..to meet the emergency needs of a previous anti E with an Anti Jka for example. I can pull units that are set up on other patients as well. Then I have the option of untested RH negative units to make a best chance at E negative. We copy the faces of the units and pull a couple segments for later typing and crossmatching. I have had the local ARC and our own Blood Bank inventory entirely typed over a long night. You do the best with what we have both in personnel and blood supply. One night a man with 5 antibodys and compatible with less than 1% of the populations got close, closer, closest units available with the thought of saving the 7 units negative for his antibodies til the end of the procedure...when they were least likely to be bled out. He survived and made 2 more antibodies. 

[goodchild]

Thank you for the form Terri and the narrative MERRY.  No one else is willing or able to share? C'mon!

[AMcCord]

Here's a process map I have used recently for training purposes. It is going to become a job aid in my new SOP for emergency release.

Process Map - Emergency Release.docx

[KatarinaN]

 

 

I think people get far too hung up on ensuring that every possible test is complete, sometimes to the point of leavng a patient bleeding to death rather than risk a delayed HTR. At the end of the day it is not our place to say 'no' to the clinicians, but to give them advice as to the possible outcomes - and then it is their decision whether to transfuse or not. We have a concessionary release form for this very reason.

 

Resurrecting this thread. 

I would love to see Emergency Release process/procedure documents from anyone who is willing to share.

Definitely still curious how everyone else handles the unique situations; such as when the antibody identification is incomplete or if the patient has multiple antibodies (or an antibody to a high prevalence antigen) and uncrossmatched/incompatible-crossmatched blood is requested.

Also curious in general how people handle trauma situations.

What level of detail your institution's process/procedure goes into.

Is your policy more rigorous to ensure traceability or more liberal for providing large volumes of blood for the patient.

Do you issue an emergency release form for the physician to sign for each unit? Do you have a single form that lists all the blood products? Do you have a single form that simply approves emergency release blood for a particular time period? Do you use electronic orders instead of/in addition to forms and what kind of information is inside the electronic order?

Stuff like that.

 

Molly you were basically right. I'm just kind of curious how other institutions handle some of these equivocal scenarios. There's such a wide range of variability between blood banks so it's an interesting topic to examine. I was recently talking with someone from another institution out of state where the blood bank delivers the blood during a massive hemorrhage scenario (despite the fact that the blood bank has only one technologist on duty during most shifts) and that blew my mind. I'd also love to see some forms.

 

I can not share any form with you because we don't have one.

 

I agree with Auntie-D. In situations where trauma patient has a history with antibodies we use phenotyped (neg for the antibody) RBC's if we have one and we don't have time to crossmatch. If we don't have any we inform the physician in charge and tell that there is a risk in transfusion. It is their decision and we can only give an opinion about the matter (I am BLS).

 

If there is a trauma that needs urgent transfusion before any screenings will be ready (and patient don't have history with antibodies) we give O neg. We do take a samples from the bags to lab and crossmatch them afterwards if the screening is positive. We also inform the ward (by phone) if the screening is positive after the lab results are finished. All trauma blood bags are tagged with patient identifier and there is a note "urgent blood" (don't know how to translate it correctly from Finnish).

 

If the trauma patient is newborn we always have a bag of O neg E-C-K- radiated RBCs that are donated less than 7 days before.

 

In trauma situations we don't have any procedure matresses to follow. We just keep calm, inform the phycisian and the ward and release blood as much as thay want to transfuse. As BLS I can't decide whether it is safe for the patient or not. That is phycisians call.

[Malcolm Needs ☆]

I hope, in circumstances where there is trauma with an alloantibody, and no antigen negative blood is available, the doctors are "encouraged" to give IVIgG and methylprednisolone!

[Dr. Pepper]

Here's my form. The physician signs once, for all units that may be associated with that specimen (3 day limit). We still use the paper form because nurses frequently order for physicians in our EMR in emergency situations and I still want that signature from the MD to prove that he authorized it.

And yes, we also deliver ALL emergency release units and all MTP units. We don't have the staff either, but we need to make sure the blood gets to the right bedside and that patient care is not delayed. They will not hesitate to throw BB under the bus if something goes wrong so I want to be able to prove that we did everything in our power to provide the blood.

Terri, this is a great, succinct form. I love it. I wonder, though, if any physician other than a blood bank one would have the faintest idea what it was talking about.

[tbostock]

Terri, this is a great, succinct form. I love it. I wonder, though, if any physician other than a blood bank one would have the faintest idea what it was talking about.

LOL...not usually. They just want me to point to where they sign. Then the couple times a patient has had a hemolytic reaction due to an undetected alloantibody, they say "wait...didn't I ask you for O Neg? That has nothing on it!". {{{heavy sigh}}}