More Issues around Uncrossmatched Products

[Malcolm Needs ☆]

39 minutes ago, AMcCord said:

 We have pushed ourselves into the debrief sessions following the mass transfusion/emergency release events - it had apparently never occurred to nursing that we might have something to contribute or problems that they need to help us fix.

How come nurses are so powerful in the States?  I wouldn't give them the time of day if they thought they could 1) run my laboratory and 2) thought we should be excluded from such things.

[Mabel Adams]

Most EMRs with CPOE have a way for nurses to enter orders (in ours they have to choose verbal or phoned) that then show up later for the provider to sign off on.  The RN isn't really ordering anything any more than they used to before CPOE when the transcribed the orders from the patient chart into the computer.

We give crossmatched as soon as the necessary testing is done.  Our massive protocol is unrelated to crossmatched vs. uncrossmatched.  If the patient had a special need for irradiation we would have to override to issue non-irradiated units but we could do it.

We don't capture irradiation need from anything except our history or the current order.  If the need is in our history, we would do what we could to honor special needs and get pathologist permission to deviate if need be.  If there's no time, we notify the provider and then get the pathologist in on it.  One thing the pathologist can help determine is how high the patient's risk of GVHD is.  I'm no expert but I know that they never seem to worry about the non-irradiated units we transfused to the newly diagnosed leukemic before they gave us the special need of irradiation.  Three months post BM transplant might be a different story.

GVHD is caused by live T-lymphocytes in the donor blood that are capable of multiplying and establishing that clone in the body of someone whose immune system can't destroy the foreign lymphocyte.  That means any active donor lymphocytes left after all the bleeding is done could conceivably multiply and cause GVHD in a patient who is at great risk for it (say, recent post bone marrow transplant, rather than just a transplant candidate).  Leukoreduction will have reduced the number of lymphocytes present in the donor units.  Malcolm's point that old stored blood has fewer live T lymphocytes would also contribute to improving the odds (if you aren't having to use your newest stock). It almost seems to me that the effort might be to "save the best wine for last" and fill them up at the end of the hemorrhage with irradiated units.  Of course, as other posts point out, sometimes the last unit is only the 3rd one given.  

Do the best you can, be able to justify your decisions, document everything and discuss it with your staff periodically because they are't reading the procedure in the middle of a massive transfusion.

 

 

[AMcCord]

On 7/8/2016 at 0:50 PM, goodchild said:

I'm not trying to play armchair quarterback. I was only adding a light shade of gray regarding patients with special transfusion requirements.

I agree - trying to outguess things is definitely a game we can't do well at. We just don't get all the information.

I think gray is probably Blood Bank's trademark color, except of course when we say....No, we can't do that...No, we can't allow that and then the nurse/doctor is going to see red.

[AMcCord]

On 7/8/2016 at 1:02 PM, Malcolm Needs said:

How come nurses are so powerful in the States?  I wouldn't give them the time of day if they thought they could 1) run my laboratory and 2) thought we should be excluded from such things.

It's a pretty interesting phenomenon. It sometimes seems like the entire hospital is run by a nursing council/committee, which can only be overruled by medical staff and even then, physicians don't always get the last word depending on the topic (though sometimes that's probably a good thing!). That is why it is absolutely essential to cultivate some key relationships with nurses in various disciplines. The team approach is preached but I think we - the lab - have to work very hard to be included in the team in a truly meaningful way. Always a work in progress.

The current thinking at my facility is that everything has to be focused on easing the life of the nurse so that they have the time to best care for their patients. I have no problem with doing what we can to improve patient care, but sometimes it puts us in some interesting job responsibilities as we 'ease their workload'. There also seems to be a mindset of 'Mother Knows Best' and of course Mother is a nurse. Often Mother does know best, but sometimes she needs to listen to advice.

Another issue is that many nurses do not truly know what the lab does and how, do not understand that we are tightly regulated and that we are actually well educated people. We often bump into issues where we have to say (very sweetly, of course) - I don't tell you how to do your job because I'm not educated to do your job (unless you are messing with my blood products!), so please do not tell me how to do mine.