Emergency Cooler Protocols

[Brenda K Hutson]

So just trying to see how others handle Emergency, Uncrossmatched Blood delivered in a cooler (have worked in a number of places and has been different everywhere; but am struggling with something here).  So if we get a request for what we call Emergent Protocol, we deliver 4 units of uncrossmatched group O RBCs in a validated cooler (with irreversible temperature monitors).  There are 2 ways they can get this:  1 is to call and request it, and the other is if we hear a Code 11 overhead (then we automatically take one).  The issue I am having is with the placement of Orders.  Those being:

1.  Ever having Orders placed (they seem to think if they don't use anything, they don't have to place an order in the computer (NOTE:  We have Verbal Order Pads and will take the initial order verbally.....but the      understanding then was supposed to be that they place an Order ASAP; so if they need additional blood we can print out Forms with patient information on them, and so we can perform the Type and Screen and Crossmatch).

2. Getting orders placed in the computer in a "timely manner" (see reasons #1 above)

3.  To me, by virtue of our Emergent Protocol and Massive Protocol being defined in Hospital and Blood Bank SOPs (i.e. who gets it; when they get it; how they get it; and WHAT they get), the Order they should be placing is for what they received (which is either Emergent Protocol or Massive Protocol; both are defined Order sets in the computer).  Instead, they usually place orders for what they actually wanted and/or used (i.e. Hold Specimen; Type and Screen; 2 Units Uncrossmatched RBCs).  Maybe my thinking is wrong on this.....but I think there should be an order in the computer reflecting what "they ordered" by us by virtue of our   protocol (i.e. so if we take a cooler because there was an overhead Code 11, I think they need to order Emergent Protocol in the computer because in essence, they ordered that because they wanted us to bring a cooler when we hear a Code 11; or when they call and ask for it).  We used to have problems with them not being willing to sign the Form for Uncrossmatched Blood unless they actually used blood....but I finally got past that....now they have to sign when we drop off the cooler.                            

So, am I asking for/ expecting too much?  Does it "matter" if they place an order in the computer for the specific protocol they ordered (whether they called and ordered it.....or by virtue of overhead page....but just by virtue of the fact that we have defined this process so they are getting that protocol based on an SOP)....or is it acceptable for them to just "after the fact," place an order for what they actually wanted/ used?  Since there is tracking in the computer systems as far as what a patient actually has transfused, I don't see an issue with them placing an order for Emergent or Massive Protocol, even if they don't end up transfusing all of the applicable products??

[ltechlin]

First a question for you, am I understanding right that you may bring a cooler down without having patient ID on each unit?  Do you put patient ID on each unit down in the emergency department?  Our trauma surgeons would like us to do this, but we haven't agreed.

In response to your question, at our facility we are transitioning from a paper authorization form for uncrossmatched to electronic documentation.  The electronic documentation for authorization is part of the uncrossmatched blood, Initial Resuscitation Cooler (2 O neg LRC / 2 AB FFP) and MTP order.  We many more requests for the Initial Resuscitation Cooler than just uncrossmatched or MTP.  Probably 9 times out of 10 nothing is used out of the IR cooler. Our ER also thought they didn't have to order it if it wasn't used.  If we brought the cooler down, we want it ordered so we have record of the authorization.  Although the doctors are suppose to put through the order, we have increased our success at having the IR Cooler put through when we got the rank and file staff involved and explained why we needed the order.  They have instant access to the doctors and have helped our cause.  Note, these three orders are simply for the product, they are not orders to transfuse the products.

Our trauma services department is also looking for the MTP order in the hospital computer for their tracking purposes.  That helped get the docs on board to get it ordered.  It isn't always timely, but usually within 20 minutes of the request for the products.  Same thing with the IR Cooler order, we usually see it 10-15 minutes after we get a phone call to bring the cooler down.  I credit the secretaries and nurses for prompt phone calls!

[Brenda K Hutson]

On ‎6‎/‎21‎/‎2016 at 9:12 PM, ltechlin said:

First a question for you, am I understanding right that you may bring a cooler down without having patient ID on each unit?  Do you put patient ID on each unit down in the emergency department?  Our trauma surgeons would like us to do this, but we haven't agreed.

In response to your question, at our facility we are transitioning from a paper authorization form for uncrossmatched to electronic documentation.  The electronic documentation for authorization is part of the uncrossmatched blood, Initial Resuscitation Cooler (2 O neg LRC / 2 AB FFP) and MTP order.  We many more requests for the Initial Resuscitation Cooler than just uncrossmatched or MTP.  Probably 9 times out of 10 nothing is used out of the IR cooler. Our ER also thought they didn't have to order it if it wasn't used.  If we brought the cooler down, we want it ordered so we have record of the authorization.  Although the doctors are suppose to put through the order, we have increased our success at having the IR Cooler put through when we got the rank and file staff involved and explained why we needed the order.  They have instant access to the doctors and have helped our cause.  Note, these three orders are simply for the product, they are not orders to transfuse the products.

Our trauma services department is also looking for the MTP order in the hospital computer for their tracking purposes.  That helped get the docs on board to get it ordered.  It isn't always timely, but usually within 20 minutes of the request for the products.  Same thing with the IR Cooler order, we usually see it 10-15 minutes after we get a phone call to bring the cooler down.  I credit the secretaries and nurses for prompt phone calls!

Lucky you that you have compliance!  I have explained (numerous times) all of the reasons we need the order placed (ASAP), but it hasn't helped.  We do take the uncrossmatched blood down with paperwork that has Unit information on it but not patient.  It is the responsibility of the transfusing department to write the patient information (Name, MR#) on the Form if the blood is transfused.  In order to have blood "ready to go out the door" at all times, that requires the paperwork be completed prior to the request....so we don't have patient information when they ask for the cooler.

[R1R2]

Do you have a hospital policy on emergency release blood with expectations for lab/MD/patient care area outlined?  If yes, and policy is not followed I would follow up with a patient safety report for your Risk/Quality department to see.    

 

When a Code 11 is called, how often is the cooler of blood coming back unused?   I ask, because we did something similar at a hospital I worked at and at least 90% came back unused.   It was a lot of work for nothing.  

[ltechlin]

On 6/23/2016 at 11:51 AM, Brenda Hutson said:

Lucky you that you have compliance!  I have explained (numerous times) all of the reasons we need the order placed (ASAP), but it hasn't helped.  We do take the uncrossmatched blood down with paperwork that has Unit information on it but not patient.  It is the responsibility of the transfusing department to write the patient information (Name, MR#) on the Form if the blood is transfused.  In order to have blood "ready to go out the door" at all times, that requires the paperwork be completed prior to the request....so we don't have patient information when they ask for the cooler.

One of our trauma surgeons would like us to do what your facility is doing.  The idea of the transfusionist putting the name on the transfusion tags haven't been brought up as a possibility.  The surgeon wants us to head to the ER and then get some chart labels from the secretary, label the units and then bring them into the trauma room.  We have resisted, there is no work space readily available and I just see it as a place for a tech to make a mistake under pressure.  Interesting route your facility took.  How reliable are the transfusionists/nurses with getting the patient information on the transfusion tags?  Is it required that they write the patient information on the transfusion tag prior to transfusion or can they do it after? 

We aren't that big of a facility, but we are a level 2 trauma center and occasionally have more than one patient that requires an uncrossmatched cooler in the ER at the same time. Relying on our nurses to label the units would make me a little nervous.

 

R1R2, some months we are at 90% unused as well.  It is a bit better now that they have classified our traumas into two different groups.  One group always gets a cooler, with the other it isn't automatic.  They still need to call the blood bank with patient name (J. Doe) and MR# before we bring a cooler down.  Yes, a lot of wasted work, but it keeps the staff in practice for the real deal.

[mollyredone]

We also have many issues with MTP and emergency release blood.  Our ED docs have been overcalling MTPs, but at least they are getting better about the lab draws necessary.  We had two this week.  The first patient was shipped to another hospital, and 4 ON PRBCs and 2 liquid plasma were returned to blood bank-all out of temperature.  They were written up as an incident report, stating it was a waste of over $1500 worth of blood products.  I heard that our pharmacy billed the ED for a dose of K-Centra that was made up and not used-$3000!  Do any hospitals on this forum charge another department for blood that has to be destroyed?

The second MTP came back with 2 PRBCs.  (Our pack is 4 PRBCs and 2 liquid plasmas to start) Unfortunately they also returned all of the transfusion forms, so I doubt whether we will get any documentation on the transfusion of those units.

We don't deliver blood-they have to come up and get it.  If the patient has arrived, they bring up a patient sticker, because most of the runners didn't even know who the blood was for, and we weren't comfortable with that.

[goodchild]

I'm not sure how I feel about charging other departments for blood waste.

Dollar values are relative. In blood bank $1,500 may be seen as a huge dollar value but in other departments that amount can be fairly trivial.

It also seems to assign blame in a world of just culture.

That and it gives the bean counters one more thing to do.

I had other musings on the topic but they escape me just now.

[Brenda K Hutson]

On ‎6‎/‎23‎/‎2016 at 1:48 PM, R1R2 said:

Do you have a hospital policy on emergency release blood with expectations for lab/MD/patient care area outlined?  If yes, and policy is not followed I would follow up with a patient safety report for your Risk/Quality department to see.    

 

When a Code 11 is called, how often is the cooler of blood coming back unused?   I ask, because we did something similar at a hospital I worked at and at least 90% came back unused.   It was a lot of work for nothing.  

Yes, our Hospital Policy states that those on the Receiving End are responsible for putting the patient information on the form.  They often use a            patient  label.  We actually go audit the charts when uncrossmatched blood has been used to ensure the Chart Copies were labeled.  Most of the time they have been pretty good...but occasionally we have to notify them to go label the Form.  This is also why we keep trying to encourage them to promptly place an order in the computer....while the first batch they get may have unlabeled forms....once there is an order, we can print out Transfusion Forms with patient information already on them (and still labeled as Uncrossmatched).  Looking back through our records, it appears blood is used "more often" in a Code 11 than when they call us and ask for a cooler (as the Code 11 cases tend to be worse).

Hope that helps....

Brenda

[Brenda K Hutson]

On ‎6‎/‎24‎/‎2016 at 10:24 PM, ltechlin said:

One of our trauma surgeons would like us to do what your facility is doing.  The idea of the transfusionist putting the name on the transfusion tags haven't been brought up as a possibility.  The surgeon wants us to head to the ER and then get some chart labels from the secretary, label the units and then bring them into the trauma room.  We have resisted, there is no work space readily available and I just see it as a place for a tech to make a mistake under pressure.  Interesting route your facility took.  How reliable are the transfusionists/nurses with getting the patient information on the transfusion tags?  Is it required that they write the patient information on the transfusion tag prior to transfusion or can they do it after? 

We aren't that big of a facility, but we are a level 2 trauma center and occasionally have more than one patient that requires an uncrossmatched cooler in the ER at the same time. Relying on our nurses to label the units would make me a little nervous.

 

R1R2, some months we are at 90% unused as well.  It is a bit better now that they have classified our traumas into two different groups.  One group always gets a cooler, with the other it isn't automatic.  They still need to call the blood bank with patient name (J. Doe) and MR# before we bring a cooler down.  Yes, a lot of wasted work, but it keeps the staff in practice for the real deal.

It has been a work in progress.  As with everything else, accountability makes all the difference!  We audit the charts of patients who used uncrossmatched blood to ensure the patient information was documented.  At first, it was problematic....but with time, they have gotten much better.  Now it is very        infrequently that they are not labeled (and when that occurs, we notify them that they need to go to the chart and label the Form).  We don't have any requirement about what stage of the process they have to label the Form.    We are not even an official Trauma Center (moving towards a Level 3) but have rarely had >1 "trauma" patient at a time.....and I understand your concern!  Once there was a male and female and they said they only needed a cooler for the male.....so we took O POS; then found out later they really wanted it for the female and moved it to her room!  We have spelled all of this out to them so why these things occur is beyond me! 

 And once they place an order in the computer, we can print them Forms with the patient information on them.  I can tell you what happened at a large (well known) Medical Center (Level 1 Trauma) when they used the same system we do and had a bad FDA inspection (though I can certainly see how this would be a much bigger risk at a large, Level 1 Trauma Institution than our little 180 bed Hospital).  Unfortunately, when the FDA audited those patient charts (which the Blood Bank had not been doing....not that they are required to), they found:  Missing Chart Copies; Chart copies on wrong patient charts; Chart copies w/o patient information on them.  Obviously they were cited.  So the Hospital "fix" is that now, the Transfusion Service will not issue blood to anyone/ anywhere until an Order has been placed in the computer and they can print Transfusion Forms that have all information on them (patient and unit).  Surprised they were able to push that through at a Level 1 Trauma Center.....but FDA citations can certainly help a cause, right?!  I have threatened our ER and OR with that if they don't ensure these Forms are completed (which is part of why the improvement we have seen), and/or if they don't start putting orders in the computer more promptly (a battle I am still waging).

Brenda

[Brenda K Hutson]

On ‎6‎/‎25‎/‎2016 at 2:28 PM, mollyredone said:

We also have many issues with MTP and emergency release blood.  Our ED docs have been overcalling MTPs, but at least they are getting better about the lab draws necessary.  We had two this week.  The first patient was shipped to another hospital, and 4 ON PRBCs and 2 liquid plasma were returned to blood bank-all out of temperature.  They were written up as an incident report, stating it was a waste of over $1500 worth of blood products.  I heard that our pharmacy billed the ED for a dose of K-Centra that was made up and not used-$3000!  Do any hospitals on this forum charge another department for blood that has to be destroyed?

The second MTP came back with 2 PRBCs.  (Our pack is 4 PRBCs and 2 liquid plasmas to start) Unfortunately they also returned all of the transfusion forms, so I doubt whether we will get any documentation on the transfusion of those units.

We don't deliver blood-they have to come up and get it.  If the patient has arrived, they bring up a patient sticker, because most of the runners didn't even know who the blood was for, and we weren't comfortable with that.

Many years ago a place I worked would charge a dept. who made such kinds of errors....but don't seem to get away with that anymore.  Our Trauma Team is very interested in knowing when any Physician orders Massive Protocol but ends up not using some of the products (unless of course it is because the patient died).  I hope you wrote up your Hospital error report (whatever your system) for the case where the Transfusion Forms came back.

[Brenda K Hutson]

On ‎6‎/‎27‎/‎2016 at 9:03 AM, goodchild said:

I'm not sure how I feel about charging other departments for blood waste.

Dollar values are relative. In blood bank $1,500 may be seen as a huge dollar value but in other departments that amount can be fairly trivial.

It also seems to assign blame in a world of just culture.

That and it gives the bean counters one more thing to do.

I had other musings on the topic but they escape me just now.

I agree with charging other depts. when it is clear negligence or bad judgement.....but it has been many years since we have been able to get away with doing that (i.e. other depts. allowing us to charge them).  I have found through many years and multiple Hospitals that there is a LOT to be said for       accountability as far as making/ forcing positive change (whatever form that accountability takes....and money is usually a big motivator).  It is one thing if a patient dies.....no one can predict that and they had to try.  But to order Massive (and have it come to the floor when you don't know for certain you will use it), or to order K-Centra (which you should know ahead of time whether you need to give it and are going to give it....and yes, it is very expensive) and the not use it, can also bankrupt a medical facility.  Measures like $$ can sometimes get through when just straight talk does not. 

Just my opinion....

Brenda Hutson, MT(ASCP)SBB