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Brenda Hutson

Workflow for 2nd Blood Draws

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I know there must have been discussions on this topic, but in my search, only found it as it relates to young children (which is not our patient population).

We are moving towards a 2nd blood draw/ blood type on patients with no historical blood type.  I would be interested in hearing how others are managing that as far as workflow and hospital staff buy-in.

1. For Pre-Ops, when do you get that 2nd specimen?

2.  For Outpatients, when/ how do you obtain that 2nd specimen?

3.  For Inpatients they want to transfuse, what is the protocol?

4.  Do you require it just be a different time of draw, or does it also have to be a different phlebotomist?

5. etc. etc.

ANY/ALL Feedback would be much appreciated.

Brenda Hutson, MT(ASCP)SBB

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   We have been doing the 2nd draw for a while.

    1. Pre-ops we do the day they come in for surgery.

    2. Outpatients that are being transfused, we usually give them type O and an immediate spin crossmatch until they come in a second time. If they aren't getting blood, like a pre-natal, we get them when they deliver or wait until they are admitted as a patient.

   3. When we get the first specimen and see there is no history, we order another type on them. We always wait though until we have that first tube.

   4. yes we require a second draw at a different time. We use both BBID bands and positive patient ID. We let the same phlebotomist draw the second tube since we make them put another sticker from the blood bank band on the tube and use positive patient ID. The phlebotomist don't know when we are going to ask them to draw another tube.

   5. If it is a patient that has already gone to the OR, again we will use O blood and do an immediate spin crossmatch.

  6. We give platelets on one type since we don't always give type specific.

We have educated the doctors to let them know that we need this second type. Some of the ED docs don't like to wait but usually we try to get the second type before the type and screen is completed on the first specimen.

       Kathy Angel

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17 minutes ago, Brenda Hutson said:

1. For Pre-Ops, when do you get that 2nd specimen?

2.  For Outpatients, when/ how do you obtain that 2nd specimen?

3.  For Inpatients they want to transfuse, what is the protocol?

4.  Do you require it just be a different time of draw, or does it also have to be a different phlebotomist?

Our computer system is set to search for a historic type.  If there is none, it will automatically order a confirmation type once the first specimen is received.

1.  A type and screen is collected at the preop visit, mainly to prevent any surprise antibodies day of surgery.  Another type and screen is collected day of surgery that we transfuse from.  This also will count as their 2nd specimen.  If, for some reason, no blood bank was collected at preop visit and they have no history, a second specimen will need to be collected day of surgery.  We send them the label after it prints in the BB.

2.  Outpatients are always coming back to be transfused so, if necessary, we collect the second specimen the day they return.

3/4.  The second specimen has to be collected by a different person than drew the type and screen.  This can be phleb or RN.  They shouldn't even know they need a confirmation until the first specimen arrives to prevent them collecting them both at the same time.

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1. For Pre-Ops, when do you get that 2nd specimen?

We get the second specimen on the morning of surgery.  They collect a pink top on every surgery case in the morning if we need it or not.

2.  For Outpatients, when/ how do you obtain that 2nd specimen?

The second specimen is collected on the day they come in for transfusion.  The outpatient cancer center collects it first thing when the patient comes in.

3.  For Inpatients they want to transfuse, what is the protocol?

We call and request a second specimen if we need one.  We first look for a CBC that was drawn at a separate time to save the patient from being stuck again.

4.  Do you require it just be a different time of draw, or does it also have to be a different phlebotomist?

We require it to be drawn at a different time.  We prefer a second phlebotomist, but do not require it.

Another thought - We are looking into getting a special sized pink top tube to send to the floor when we need a second specimen collected.  We have recently noticed that the floors are drawing two specimens at once and labeling them with a different draw time.  This was recently noticed in our LDR and ER locations.  Nurses denied it, but we had people physically witness this.

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Do you always do a second sample draw on pre-op patients?  I had one yesterday for a hysterectomy, hgb 13.3, no prior history.  I didn't get a second sample for retype because the chances of her needing blood were slim.  I figured that if she needed blood in the OR, a nurse could draw me a second sample.  Most of our surgical patients do not need blood the day of surgery, it's usually a few days after if at all.  I hated to have her stuck again for no reason since there was no blood ordered to be crossmatched or transfused.

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We always get the second sample for surgeries because we have had instances where blood was needed quickly and a second sample was not able to drawn because the patient was not in a position where the arm was available.  We find they stick the patient while setting up the IV and draw them then.

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21 hours ago, mld123 said:

We always get the second sample for surgeries because we have had instances where blood was needed quickly and a second sample was not able to drawn because the patient was not in a position where the arm was available.  We find they stick the patient while setting up the IV and draw them then.

We've had the same problem and have had to resolve it the same way...draw in Preop.

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Thank you all very much for your responses....they are very helpful (and enlightening).  Not surprised at people trying to short-cut the process at times (we see that for other things, right)?  I know there will be pushback but we will get there eventually.  I really like the idea of the computer being able to initiate that 2nd blood draw (but don't think we have that capable of a system); that would be ideal.  I also appreciate seeing some things we should "watch out for."

Thanks again for your assistance....let the fun begin! :wacko:

Brenda Hutson, MT(ASCP)SBB

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23 hours ago, Brenda Hutson said:

  I really like the idea of the computer being able to initiate that 2nd blood draw (but don't think we have that capable of a system); that would be ideal. 

Brenda Hutson, MT(ASCP)SBB

We have a "History" (Y or N) question on our result screen.  If there is no history, a patient retype (forward type only) reflex orders on a new requisition, so the specimen can be collected.  You just need to set it up like any other reflex order.

Our L&D nurses draw most of the specimens from their patients.  They also draw the extra tube for our retypes, but we often wonder when the labels are printed just 1-2 minutes apart.  Everyone we ask verifies that the specimens were collected at separate times. I see that we're not the only ones with that concern.

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12 hours ago, TreeMoss said:

We have a "History" (Y or N) question on our result screen.  If there is no history, a patient retype (forward type only) reflex orders on a new requisition, so the specimen can be collected.  You just need to set it up like any other reflex order.

Our L&D nurses draw most of the specimens from their patients.  They also draw the extra tube for our retypes, but we often wonder when the labels are printed just 1-2 minutes apart.  Everyone we ask verifies that the specimens were collected at separate times. I see that we're not the only ones with that concern.

I really like this idea. Do you use the History field for documentation of the history check too?

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1. For Pre-Ops, when do you get that 2nd specimen? Pre-ops get their retype the morning of surgery when they start the IV.

2.  For Outpatients, when/ how do you obtain that 2nd specimen? Same process as pre-ops. When they come in for transfusion, a retype is collected if needed.

3.  For Inpatients they want to transfuse, what is the protocol? We document the history was checked and a retype is needed on the original type and screen order.  If the floor needs to transfuse, they have to collect the retype. We will crossmatch a unit of O neg if needed while they collect the retype.

4.  Do you require it just be a different time of draw, or does it also have to be a different phlebotomist? We are a nurse draw only facility. We do not require a different collector-just a different time of draw. Retypes can only be collected in the pink 4 ml tubes and only blood bank has the tubes. We will not accept the 6 ml tubes for a retype since it was most likely drawn at the same time as the original type and screen. Blood bank places all the retype orders in EPIC and sends the needed tube to the floor, infusion center or OR.

We will use a purple top and sometimes green or blue from another draw already in the lab for the retype too. This specimen will not have our unique BB number, but must match the MRN, DOB, and name and be stored appropriately and not adulterated in anyway.

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On 3/5/2018 at 2:12 PM, Brenda Hutson said:

1. For Pre-Ops, when do you get that 2nd specimen?

2.  For Outpatients, when/ how do you obtain that 2nd specimen?

3.  For Inpatients they want to transfuse, what is the protocol?

4.  Do you require it just be a different time of draw, or does it also have to be a different phlebotomist?

5. etc. etc.

1. Day of surgery.

2. When they arrive.  Since most of these patients are oncology patients, we usually have a historical type.  If the second type will cause a delay/upset we will just use type O for this visit.  Our system will reflex an immediate spin XM.

3. The verification type is generated by blood bank if we do not have a historical type and packed cells are ordered.  The patient is not charged for the testing.  If we have a hematology specimen from a different phlebotomy event, we will use it for the confirmatory ABO/Rh (but not for compatibility specimen).  If not, it goes for a collection.  If it’s someone unlikely to be transfused, but physician wants blood on hold, the tech may select O until the next scheduled phlebotomy.

4. We prefer different phlebotomist so that two different people have identified the patient with consistent results.

5. Type O is a hard stop without two types in our system.

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Does anyone charge for these type verifications.  I was told you could not but have heard of some people charging.  Just wondering.

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On ‎3‎/‎20‎/‎2018 at 9:23 PM, MOBB said:

I really like this idea. Do you use the History field for documentation of the history check too?

We actually have two history questions on the result screen.  The original Type History question is the one that a "No" reflexes the re-type specimen.  There is also a "Previous History Check" that was added when we went up on BCTA (Bar-code Transfusion Administration). The We have four possible answers for the previous history check question -- No history, Yes hemolytic reaction, Yes non-hemolytic reaction, and Yes no reaction.  There is no reflex order from this question.

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On 3/22/2018 at 4:39 PM, TreeMoss said:

We actually have two history questions on the result screen.  The original Type History question is the one that a "No" reflexes the re-type specimen.  There is also a "Previous History Check" that was added when we went up on BCTA (Bar-code Transfusion Administration). The We have four possible answers for the previous history check question -- No history, Yes hemolytic reaction, Yes non-hemolytic reaction, and Yes no reaction.  There is no reflex order from this question.

That is a great idea. Do you have access to the rule or order group that allows the reflex?

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1. For pre-ops usually when they come in. But if the patient doesn't want to be stuck a second time at this point, the aborh 2 is drawn the day they come into surgery. The night before the BB sends down to pre-surgery a copy of the surgery schedule and note the patients that  need aborh 2's

2. Our outpatient transfusions get O positive until we know their blood type. The population is children so  really can't get the kid stuck twice in one sitting.

3. If no history  the ABORH 2 is ordered the time the type and screen/cross is being processed. We don't hold up blood for the ABORH 2 especially if it is emergent.

4. Second phlebotomist is preferred. But same phlebotomist different time is acceptable                      

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We have a history prompt that we answer with the patient's type/antibody status (AP/NAB/BN/PAB).  For a history of NONE, there is a reflex to the retype.  It is canceled if the patient is group "O".  IF the patient has a previous antibody(PAB) the user is prompted to enter the specific antibody, strength at last testing and the date of that testing.

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On ‎4‎/‎8‎/‎2018 at 2:05 PM, dmed03 said:

That is a great idea. Do you have access to the rule or order group that allows the reflex?

I have attached the screen shots of the set up of the Order Group and Test in Meditech.

Type Reflex.docx

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Another question related to the requirement for a 2nd ABORH--We are part of a large health system using Epic, with blood types posting from all testing sites into the shared EMR of Epic.  For those with a similar scenario, are you accepting these historical ABORH results performed at other sites within your system, as your 2nd ABORH?

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16 hours ago, lisakg said:

Another question related to the requirement for a 2nd ABORH--We are part of a large health system using Epic, with blood types posting from all testing sites into the shared EMR of Epic.  For those with a similar scenario, are you accepting these historical ABORH results performed at other sites within your system, as your 2nd ABORH?

We do.  As long as the current sample matches (and the historical blood group is in the LIS) we are good to go!

s

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