I'm trying to find some ideas for my annual process improvement project for this year. Right now I'm auditing transfusions for the nursing staff, auditing blood bank wristbands for phlebotomy staff, and checking transfusion vital signs for possible missed transfusion reactions. I'm in a rut and need something else new to do in addition to these projects.

I am auditing patients charts to see if the "record of transfusion" (our transfusion tag) gets on the charts. Our IS department wrote a program which correlates the transfusion tags in the electronic medical record chart with our charges for blood products. There is about a 5% mismatch. Nursing sends a copy to us, so most of the time I can send a copy to the electronic chart.

Hey ruts are good, they keep us from falling off the cliff.

I've been monitoring the amount in $$$ blood waste is costing the facility. It's broken out by nursing unit. It's pretty interesting the kind of responses you get when administration sees the $$$ being wasted by certain departments (ER). Of course ER's response is always, we don't care about money we're saving lives!!

One of our P.I. projects (on-going of course) of auditing selected charts for appropriate documentation of transfusion data revealed a huge black hole in documentation when patients were transfused in O.R. Often they would scribble "see anesthesia records", often there was no 1 hour post transfusion monitoring when patients were sent to PACU, much of the time there was no assessment for transfusion reaction documented. From that, we worked with O.R. staff to create a new transfusion record specifically for O.R. use. We used the "PDCA" format and got lots of kudos from the organization's Quality dept for "interdepartmental" improvement projects.

Any way you could share that OR specific transfusion form?

I'm willing to bet that everyone has problems with OR compliance.

Sure - I don't maintain the form though, so it may take some doing to get it in a format I can post. I'd be happy to share though, so just give me a little bit to see what I can do.

Projects should contain: Training, reduce waste, increase turn around time, increase safety, reduce risk.

1) We monitor 100% of our transfusions for prolonged infusion. I use a weekly Meditech report (and a host of delegated reviewers) to flag infusions going beyond the 4 hr time limit. Then I forward these cases (via transfusion related incident report) to our QI department. Each incident is followed up on with the Director of the affected nursing unit. I found this top-down approach quite effective! (What we found was that the nursing procedure did not clearly indicate that infusion START time was when the unit left the blood bank, NOT when THEY spiked the unit. We also identified "old-school" physicians that were writing "infuse at a rate of 75 cc/hr" and that doesn't quite cut it for a hefty unit!)

2) During our visits to the floor to audit transfusions, I noticed about 10% non-compliance with patient ID (nurses are not asking coherent patients to state their name and DOB). So, that really gets QI people and management fired up too. :-)

3) I've just started monitoring units of blood issued without documented critical H&H's. I have a monthly transfusion report (Meditech) that pulls in all transfused units and the patient's most recent H&H values. From that, I forward the cases that fall out (greater than 8 g/dL hgb) to my QI department. They are going to start reviewing a sampling of these cases (that already fall out of our blood utilization criteria for one measure) during the blood utilization review committee meetings.

For #3, I don't include units given to patients with obvious bleeds that are barely staying above critical as it is. I also eliminate all O.R. transfused units and outpatient transfusions as most of these transfusions are indicated for other obvious reasons. What I'm finding is that a vast majority of single unit transfusions on the inpatient floors are being given without indication. Hopefully we'll be able to educate the physicians to manage these patients without the need for single unit transfusions.

Heather

One of our P.I. projects (on-going of course) of auditing selected charts for appropriate documentation of transfusion data revealed a huge black hole in documentation when patients were transfused in O.R. Often they would scribble "see anesthesia records", often there was no 1 hour post transfusion monitoring when patients were sent to PACU, much of the time there was no assessment for transfusion reaction documented. From that, we worked with O.R. staff to create a new transfusion record specifically for O.R. use. We used the "PDCA" format and got lots of kudos from the organization's Quality dept for "interdepartmental" improvement projects.

I would also be insterested in a copy of this form. Thank you.

Oops! Sorry, this fell off my radar! Will get a copy for you guys ASAP.

Would love to get a copy of that OR form too...... it sounds like an interesting QI projects.

That was my idea too- product wastage. OR is a great source- platelets in the cooler, etc. FFP thawed, never used, the list goes on...

Good luck with your project!

Could I please get a copy of that as well? Does this forum have an area for forms sharing?

Thanks!

Jeni

Do you transfuse outside the hospital, say in an outpatient setting? At my last hospital (I run a railroad now), we sent blood to several dialysis centers, several outpatient hem/onc clinics, and a few home health agencies transfused blood in the home. The regs/standards require that the patient (or attendee) be made aware of signs and symptoms of a delayed transfusion reaction. I audited this and found almost zero compliance.

BC

We do not provide components for transfusion outside the hospital. I can see it coming, but I am going to fight it unless we get better compliance, buy-in, and ownership than I see now.