We had an inspector recently inquire about our process of reviewing returned crossmatch cards for completeness. Along with two signatures for transfusionist/identifier, we have start date/time, end date/time, volume given, adverse reaction? (Y or N) and "Pre," 15 Min" and "Post" documentation of Temperature, Pulse, B/P and Respirations. The inspector was recommending a procedure which would include how we would identify a change in the vital signs if it was not noticed by nursing and was not marked as an adverse reaction. Our blood administration procedure states a rise in temperature of 2F (1C) and/or a temperature greater than 101.0 F as indicating a possible adverse reaction, but we have nothing that specifies what would constitute a difference in the other vital signs. I think it may be very difficult for the transfusion service to define what to consider as a "significant change" and feel that should be a review (if necessary) by nursing personnel. Has this been addressed by anyone else with any helpful recommendations? Also, does anyone have any spreadsheets or programs set up to address tracking reviews of returned crossmatch cards that they would be willing to share? Thanks for your help!

Sandy

sandra.rothenberger@hcahealthcare.com

fax: 813-634-0127 (Attn: Transfusion Service)

Almost all places I've worked does a "completeness" check of the returned document: signatures, vitals, "no Rxn" box, etc. (Quite a hassle getting them to correct them in retrospect, and it's part of our CQI program.)

But other than some parameters on temperature or calling a code, an audit of the values themselves without the chart or knowledge of the patient would be guesswork. A "significant" change in vital signs is subject to the professional judgement of the transfusionist and a complete knowledge of the patient. We require consultation with a physician before a transfusion reaction workup is inititiated, which implies that the nurse had a concern in placing the call, too. Maybe your transfusion committee can discuss the issue and render an opinion regarding the appropriateness of the current policy.

Once, I performed a reaction workup on a patient anxious about getting blood, and had an immediate and significant change in vitals as she watched the blood flow down the tubing toward her arm !! I get as irritated today with the waste of time as I did years ago when it happened ...

Given the HUGE variety of patient types and acuities you deal with, your current policy seems quite reasonable. Did you happen to ask the inspector how he defines "significant" change in his insitution and what he does about it when he finds it a day later? Makes me wonder if he charges for a reaction workup ...

Larry

We don't get anything back. Also you could remove the vital signs from your crossmatch tag and have them charted in the nursing part of the chart. It is a nursing responsibility let them monitor it. I review charts for one month every six months for proper documentation of patient identification and then file a report with administration. This seems to get more attention than when we were reviewing every bag tag and trying to adress each rpoblem as it came up.

We've made it part of our transfusion audit/utilizataion review. Twice a week, we look at all the transfusions from the previous day. We check the pre-trans H/H against our cutoff (8.5/27). Any that fail that first pass, go to nursing utilization review. They check the charts for documented reasons for transfusion (surg bleeding, cardiac, etc.). While they have the chart, they also check for signed consents, pre/post vitals, and completed unit tags. Any that fail the second pass, go to the BB med director. She may accept the utilization after review of chart, or bring the case to the trans committee, who may accept or request a letter of documentation from the ordering MD. If no reply, then the letter gets sent to the chief of service. Stats on all these reviews are presented to the trans comm. End result is that 5-10% of trans are randomly reviewed. Unit tag completeness results are also sent to VP of nursing. We've seen a marked improvement in this area in the past 2 yrs since we've gone this way. JCAHO also remarked favorably on this system.