Emergency Blood Release Form

[Brenda K Hutson]

I am having problems at my current Hospital, getting the Physician's signature for Emergency Blood Release when we take Uncrossmatched Blood to them in a cooler.  The top of the Form is titled "Request for Emergency Release of Blood" and there are other such references on the Form.  However:

• The Physician signs the Form "when they get around to it...." which sometimes, is even after a patient has been transferred to another Hospital (so hours later).
• If they don't use the blood, they don't sign the Form

I think that by "requesting" the blood, they need to sign promptly so they are taking responsibility for it; in case they use it.  To not do so, seems to me to be putting the onus on us until they sign it?

At 1 place I worked many years ago (a Level 1 Trauma Center), we were not allowed to even leave the cooler in the ER until the Physician signed the Form.

I have also worked at other Hospitals....that while we didn't require signature to leave the cooler, we still received the Form back in a reasonable amount of time....with a signature.

I think part of their argument here is that we are a small Hospital and that the Physician(s) in the room are too busy with the patient to stop and sign a Form.

• Just wanted to see what is occurring other places.
• Is there a regulation that states it HAS to be a Physician that signs (or can your procedure allow for a Designee)?  I just can't recall at the other places I have worked over the years, if it has always been a Physician only...

Thanks for your help!  

 

Brenda Hutson

[tbostock]

We don't use coolers, but we do require a physician to sign it.  We consider uncrossmatched to be high risk, so will not even allow a PA or NP to sign it, has to be a doctor.  We usually have to chase them down during a trauma to get it signed, or we get another ER physician to sign if the trauma surgeon's hands are inside the patient or something.

[Brenda K Hutson]

We don't use coolers, but we do require a physician to sign it.  We consider uncrossmatched to be high risk, so will not even allow a PA or NP to sign it, has to be a doctor.  We usually have to chase them down during a trauma to get it signed, or we get another ER physician to sign if the trauma surgeon's hands are inside the patient or something.

Thanks!  Also, I just looked at the CAP Checklist (should have looked before I asked that part of the question) and found this:

 

Life-Threatening Situations Phase II

Adequate policies and procedures have been established for the investigation and

handling of life-threatening situations (such as the use of uncrossmatched blood or

abbreviation of testing) that include the written authorization of a qualified physician

[kirkaw]

AABB standard 5.27.5 (29th ed) states that 'the records shall contain a signed statement from the requesting physician indicating that the clinical situation was sufficiently urgent to require release of blood before completion of compatibility testing....' And I either read in a JC standard or heard at the AABB conference, that that standard is firm regarding the signature; it cannot be a PA or FNP.

As for the timing, I too, have to chase down a physycian. However, our policy is that the MD can sign after the fact. Much like the scenario already stated, the requesting physician may be too busy attending the patient, to sign the emergency release paper. I generally like to have this accomplished by the end of the shift on which the emergency occured. However, I have had to chase that physician down on Monday morning when the emergency was on Sat. night.  Not ideal, but better late than never.

The other recourse you have, if you truly feel like your physicians are abusing the grace period is take this to your transfusion committee. They would be the ones to enforce the signing in a reasonable timefreame.

[David Saikin]

We usually get the MD signature after the fact. We are very small and when it is an emergent situation they really are too busy to sign. I have not had any MD not sign. If that did occur I would make a serious complaint and formalize the policy so that we got a signed form ahead of time. (they usually know when someone is coming in ahead of time).

[goodchild]

We also worry about signatures when things have calmed down.

[AMcCord]

We're a smaller facility and usually get the MD signature later, as David says. If I have a problem getting a signature - like an occasion that the blood is not actually used, but requested as an emergency release - I sic the pathologist on that physician. That gets the job done. I do sometimes have to mail the form to the surgeons office. I send a letter with it asking them to 'pretty please' sign and return at their earliest convenience so I can complete documentation for that case, including an addressed envelope for that purpose. I almost always get that within the week. If I don't get it, I explain the problem to their office manager OR sic the pathologist on them. We often get those types of orders from the ER doc, not the surgeon. Getting the ER docs to sign is much easier - no refusals (they are hospital employees, so we can apply teeth if we need to ).

 

My biggest problem is getting the completed form back to blood bank after its been signed. Nursing and clerical staff tend to stuff it on the patient chart, then Health Information scans in into the patient consent section. I'm thinking (only slightly facitiously) about a big red header on the form that says "Sign It and Give it Back!"

[goodchild]

We specifically want ours scanned to the patient's medical record.

[Brenda K Hutson]

We specifically want ours scanned to the patient's medical record.

Just curious....do you audit that process?  My experience has been that things we do not see, often are not being completed (we audit charts for various processes and I have had to push for proper completion of various Forms). Or are they scanned and returned to you?

[SMW]

Physician signature is required by FDA so that would trump any local or state laws or rules for other providers to sign. 

See 21CFR 606.160((3)(v): Emergency release of blood, including signature of requesting physician obtained before or after release. 

 

Note that the signature is required for the emergent release of the blood and not necessarily the transfusion.  Also note that the requesting physician may not necessarily be the transfusing physician.

 

[Auntie-D]

We approach it a different way - the compatability sheets accompanying the units have, in big bold writing "These units have been issued uncrossmatched and the physician prescribing the blood takes all responsibility for any possible adverse reactions.". The forms have to be signed when the blood is transfused for traceability. We have considered extending the concessionary release form to cover the flying squad but in all honesty - who are we to delay the provision of blood in an emergency situation? That's a clinical decision... If the clinician deems that the patient is bleeding too much to wait for a full crossmatch (or EI) then my view is 'just give them the blood'. The physician is prescribing the units and taking responsibility.

 

What we do however do is fully audit all Massive Haemorrhage initiations and use of flying squad - any that are deemed 'inappropriate' use result in a one to one training session on the implications. In the past two years we have only had one and that was in 'death week' and due to a panicking medic thinking better safe than sorry.

 

ETA - this is in the UK

Edited November 24, 2015 by Auntie-D

[AMcCord]

Once the emergency release form comes back to Blood Bank (IF it comes back to Blood Bank), I scan it into the patient's ER in the Lab tab so it is with the reports/documentation for the crossmatch other blood products. I keep the original with the paper worksheet we use for the initial unit(s) emergency release. If I don't get it back, I call the floor if they are still here and get the form back. If the patient has been discharged, I check the EMR and print a copy from that for my records.

 

I do audit those events. ER, especially, does a lousy job documenting emergency infusions. It all depends on who is working as to how well, or if, there is documentation. I follow up on any cases with missing or erroneous documentation - my medical director, the department manager and quality get a report. This information will go to transfusion committee.

[mollyredone]

We too have some trouble getting the forms back promptly.  We always have a copy to send if the first one doesn't come back, and we make a copy when we send the second one as well!  I have a contact in the ED and she usually gets it back to me fairly promptly. 

 

If there is an antibody problem I know about ahead of time, and this has happened a few times, I require the form signed in advance, and usually tube it to the ED and get it back quickly.  I don't want them saying they were not aware of the risks ahead of time.

 

I think it is a good idea to scan the form into their chart, and I can do that in the lab, so I will start doing that.

[Brenda K Hutson]

Thanks so much everyone for your input.....that is very helpful.  

 

Brenda Hutson

[BankerGirl]

We do the much the same as Mollyredone, making copies in case the original disappears.  Occasionally the form makes its way back to HIM prior to physician's signature, in which case they will send it back to me (still unsigned!).  I have usually already gotten the copy signed by the time this happens, though.  Our lab secretary then scans the form into the EMR and I also keep the form in my files.

[tricore]

Does anyone document this in the Hospital Information System directly rather than having a piece of paper?

[AMcCord]

We don't currently have that capability, but I would consider it if it was possible.

[Teresa.Cline]

Our form is an actual "order form" approved as one of our hospital forms.  It gets scanned into the patient medical record as an order and if it was not signed by the doctor a the time of the need (we do allow an RN to sign at the time of the incident), it gets "flagged" as requiring a signature and when the doctor signs into the computer these pop up for him to sign.  We do follow up and make sure any forms that were not signed by the doctor up front do get signed later.

[AMcCord]

17 hours ago, Teresa.Cline said:

Our form is an actual "order form" approved as one of our hospital forms.  It gets scanned into the patient medical record as an order and if it was not signed by the doctor a the time of the need (we do allow an RN to sign at the time of the incident), it gets "flagged" as requiring a signature and when the doctor signs into the computer these pop up for him to sign.  We do follow up and make sure any forms that were not signed by the doctor up front do get signed later.

I like this idea! We currently scan our forms into the lab section of the EMR as part of the transfusion record, but using the order file would definitely streamline getting signatures on those cases we don't catch at the time of the event.

[ChrisW]

We are a Level II Trauma Center and dispense uncrossmatched RBCs to the ED multiple times daily. When we deliver the first 2 or 4 units in our Trauma Cooler, the MD or a designee for that MD signs the release form and we return the  to Transfusion Services. The Designee is usually the  RN that is the recorder for that case. Our form has two spaces - one for name of requesting MD and one for a signature. Our policies describe this process and it has worked well for us for 20 years. The form is signed regardless if the units are transfused or returned to us.

[SMILLER]

We recently have added "emergent situation" orders for traumas to our hospital ordering system that include electronic consent for transfusing uncrossmatched products.  Only occasionally do we have to resort to getting any kind of paper form signed (like when the computer system is down).

Scott

[Teristella]

On ‎7‎/‎25‎/‎2016 at 8:47 AM, ChrisW said:

We are a Level II Trauma Center and dispense uncrossmatched RBCs to the ED multiple times daily. When we deliver the first 2 or 4 units in our Trauma Cooler, the MD or a designee for that MD signs the release form and we return the  to Transfusion Services. The Designee is usually the  RN that is the recorder for that case. Our form has two spaces - one for name of requesting MD and one for a signature. Our policies describe this process and it has worked well for us for 20 years. The form is signed regardless if the units are transfused or returned to us.

My previous hospital used to do this but I believe having a designee was actually not allowed per state laws. Might be something to check on. Besides the potential legal ramifications, having a designee sign makes the form a bit less watertight if anything should happen to the patient. If it's the physician signing, they can't wiggle out of it if the patient ends up having an antibody and a subsequent reaction, etc.

That said, if it's worked for 20 years perhaps there's no point trying to change it.

[mollyredone]

I mentioned previously that we have two different forms.  One is for emergency release, usually to the ED and we get those signed afterwards.  The other is a high risk emergency release, when we know there is a problem, such as an antibody, and they want units before we can antigen type them.  In this case, we request that it be signed prior to release of any units.  Don't want the doc to say "Oh I didn't know there was really a problem!"  But we are in the process of changing one aspect, and that is a statement on the form that the doc has informed the patient of the extra risk.  The patient really should be told that there is an extra risk, especially if it is just for a low Hgb and not bleeding out from a gunshot.  We had that happen this past week.  A patient we hadn't seen before came in for a TS half an hour before surgery.  Gel screen, panel and tube screen were positive on all cells. Sent it out and it came back as a warm auto, anti-K, anti-Jka and anti-S!!  Incompatible crossmatches (warm auto)  One unit was transfused.  Hgb dropped again.  Hospitalist discussed it with the patient, who wanted to talk to family about it.  He didn't know anything about a problem with the first unit!  So that's where we are heading.  If I were the patient I would want to know!