Brenda K Hutson

We have an official verbal order form but it is only used for an initial emergency order (uncrossmatched blood). We keep it with the paperwork saved on these patients (i.e. the form signed by the Physician to accept uncrossmatched blood; et. al.). It must be followed up with an electronic order when things calm down (or ASAP). Brenda Hutson

Oh, I did the opposite move almost 5 years ago.....from California (all of my life) to Maine! Your direction is better... What culture shock. Santa Barbara is beautiful.....enjoy! Brenda Hutson

Ok, shorter post. I need to know your protocol, but also probably need some info from your L&D Dept. to really resolve my dilemma (if anyone has a moment to check this out with them....would very much appreciate it; I know that is asking a lot). We currently use a black screw-top clot tube for Cord Blood Specimens (and apparently it is sterilized). I want to switch to EDTA (which I have used in 5 other places....so know it is possible). We would be able to put that on the new automation we are getting (currently performing manual testing). So I have asked L&D to draw both black-capped tube and pink EDTA on all OB patients for awhile so I can do correlation studies and switch us over. Problems: 1. They are saying Physician has to change gloves to put specimen in pink EDTA since tube is not sterile....and they are not liking that...so want me to find a "sterile EDTA tube" they can use. I am "thinking" you could not sterilize a tube with an anticoagulant in it. At first they just said they would not be able to do it for C-Sections (due to sterility), but then added vaginal deliveries as well. 2. Having been able to use EDTA everywhere else I worked, have to wonder what the problem is here......are they changing gloves at all of those other Hospitals....or, is it "not an issue" to use the same gloves and put cord specimen in an EDTA? I don't know the process at the other places I have worked, just that they were able to use those tubes. Wondering what kind of tube you guys use......and if it is not a sterile tube, if you would take a moment to call your L&D Manager and ask how it is collected (i.e. does the Physician change gloves to obtain that)? I know it is do-able....just need to find out what the secret is. Thanks in advance, Brenda Hutson, MT(ASCP)SBB

Right, we can override it from an LIS perspective. I am more concerned about the question of what you can get away with once you have switched to crossmatch protocol. I think at the very least, we will have to have a means of getting a waiver if we simply cannot keep up with irradiation. Guess I need to run it by Trauma, Oncology and Pathology docs. Thanks Brenda

Might have to let the Trauma Team docs and Oncology docs battle that one out......and we wouldn't honor it if still in the uncrossmatched mode....just not sure that once we are on crossmatch protocol, we can justify as easily, not honoring special requirements? Thanks Brenda

Sorry ahead of time that this e-mail is long....I don't seem to know any other type of e-mail than long..... I have worked in large Trauma Centers as well as medium and small sized Hospitals that were not trauma centers but might get the occasional "trauma" patient (currently at 180 bed Hospital moving towards becoming a Level 3). So I know protocols used in various places and situations, but am struggling with a couple of things here (I think it is difficult to be "between" being a trauma center, and not being a trauma center). Here are the current issues I could use your feedback on (and what your practices are): 1. I am told that in the State of Calif. (which I no longer live in), the Law is that only a Physician, P.A. or N.P. can place electronic orders for emergency protocol products. I don't know if there is any such law in my state. But one of the problems we have is that up until yesterday, the Physician taking care of the patient (i.e. in ER or OR) was the one expected to place the electronic order (though a Nurse could call with the verbal order). This means we end up waiting a long time for the order so we cannot enter testing results and/or print subsequent "uncrossmatched" Transfusion Forms with patient information on them. So in an ER meeting yesterday, we discussed having another Physician, a P.A. or a Nurse enter Emergent or Massive Protocol on behalf of the Physician. Do any of you have Nurses placing these orders in the computer? Both names would then be displayed in our particular system. 2. So we have 2 emergency protocols.....Emergent (4 uncrossmatched RBCs) and Massive (4+4+1). With both protocols, we do not honor any special requirements the patient may have (i.e. Irradiated; CMV-; etc. which I believe is the standard-of-practice). Emergent Protocol is always/ only uncrossmatched RBCs. However, we have said Massive Protocol could be Uncrossmatched or Crossmatched (if a patient is bleeding for awhile, we may have completed their testing and as we all know, Physicians prefer crossmatched RBCs.....but they still may need the type/ numbers of products that constitute Massive so they would then be receiving Crossmatched Massive Protocol). Problem is.....for Crossmatched RBCs, our computer system actually performs a patient history search and forces Irradiated Products when appropriate (and a Physician can add a Health issue to request Irradiated if desired), but it does not perform this search for Emergent or Massive Protocol (automatically defaults to Leukoreduced). And while we would give Leukoreduced to any patient needing Uncrossmatched Massive Protocol....if we follow our Crossmatched protocol, we should be honoring any special requirements the patient has (i.e. Irradiated). But 2 problems with that now: a. Would be difficult to keep up with Irradiating Units on a patient on Massive Protocol b. Because our computer system does not do the Irradiation Search for Emergent or Massive Protocol (and cannot differentiate Crossmatched massive from Uncrossmatched massive)...unless a patient already had certain restrictions, we would not know then if this patient should receive Irradiated products (in our Hospital....and these days with the use of Hospitalists.....it is more difficult for them to have the knowledge of what patients should receive Irradiated products; that is why we built our system to search by pre-programmed diagnosis and/or a location of Cancer Center....so cannot depend on a Physician ordering Crossmtached Massive Protocol to necessarily tell us that this patient should have Irradiated products. Just wondering, do you guys only give Uncrossmatched Massive Protocol....or are there others that also offer Crossmatched Massive Protocol? And if you give Crossmatched, do you honor special blood requirements? Thanks in advance for your help..... Brenda Hutson, MT(ASCP)SBB

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

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.

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

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

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.

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??

We have had 2 ProVue's but are now in the process of purchasing the Erytra. Just liked the features and equipment better (Vision was also pretty loud). We will only be purchasing 1 Erytra, but will also get the Manual Workstation and DG Reader which will also be interfaced with our computer system. Barring any "long" downtimes by the Erytra, we can handle our workload with 1. I will be going to training in Sept. and that is when the machine will be brought in "and the fun will begin....." Brenda Hutson, MT(ASCP)SBB

Yes, we will interface with our current Sunquest. Until the Erytra is validated and ready to go, we will keep one of our ProVue's going. As a back-up once we are only using the Erytra, we have also purchased the Manual Station as well as DG Reader (which we will also interface). Brenda

Thank you so much for responding....I was hoping someone could answer this for us. Brenda Hutson, MT(ASCP)SBB

Thank You....that is very kind of you.. ......combination of some health issues and WAY too many projects going on at work (getting ready to purchase, train on and implement the Erytra). Brenda Hutson

Have seen 3 days across the board (as your Physician has requested), up to 30 days. There are pros and cons to different outdates. A Pro for 3 days is consistency....we know that anytime you can keep Policies consistent, there is less room for error due to exceptions. That also leaves you with a fresher specimen (though if you use electronic crossmatch, not so much an issue). If you use separate Blood Bank Armbands and your Policy is that those armbands MUST be placed on the patient at the time the blood is drawn (even if it is a Pre-Op Outpatient), you may have angry Physicians, Nurses and Patients who feel you are not being considerate of the patient (making them walk around for days with an armband on.....plus can have problems if it gets wet in shower). But perhaps those armband issues are N/A for you. By limiting it to 3 days, it makes it difficult for patients who live far away and/or that have transportation problems with limitations. Those patients may end up getting drawn on day of surgery, thus resulting in increased stress for Blood Bank and delay of surgery. Those are just some of the considerations..... Brenda Hutson, MT(ASCP)SBB

So when Sunquest was first built here, %ARC was built for unit re-types. A different code was built for patient re-types (called RABR). Problem is, RABR does not look at history for confirmation of accuracy or matching. If we wanted to go back now and use %ARC for patient re-types, can it still also be used for unit re-types? If not, what code are you using for unit re-types which will still look at the type entered at Receipt to confirm accuracy? Thanks in advance..... Brenda Hutson

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

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?

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

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

We require a Type and Screen "that admission," but does not have to be post-partum. Brenda

Hi All, Just trying to find out the Policy on some other Institutions with regard to testing performed on pregnant women (when they come in to deliver). It appears our Surgeons do not entirely agree with the protocol of our Obstetricians.....so I told them I would try to get a feel for the standard of practice out in the community. Does your Institution routinely perform a Type and Screen on ALL women coming in to deliver? Does it routinely perform a Type and Screen only on c-sections (then other patients, only if Physician feels a need to for some reason)? Is the testing at delivery, totally a case by case protocol (so nothing standard)?I guess that is what the issue comes down to....is it necessary to automatically perform a Type and Screen on all women coming into the Hospital for delivery, or, should more discretion be used? I know some of you may not know if your Hospital has a specific set Policy on this issue.....but if you do know...... Thanks in advance for your feedback. Brenda Hutson

I guess I also just like to see the word "Negative" over "Positive" (i.e.if positive in GEL but negative in TUBE); but that was partly because I have not been sure if some of them were false positives (i.e. technique vs. warm auto or panagglutinin). Brenda