We are a new Level II trauma center. We have a form for the Emergency Release of blood that the physician is required to sign for uncrossmatched blood. This form, however, does not have space to include an area for the taking of vitals at 0, 15, 60 and completion of the transfusion. I'm trying to find out how other hospitals handle the taking of vitals during an emergency situation with uncrossmatched blood. I would appreciate any ideas you might have. Thanks!

In a trauma situation they are monitoring vitals constantly and documenting them everywhere. The last thing you need to worry about is having them documenting vitals specifically for the transfusion.

We require pre, 15 min and post transfusion vitals on our form(STATE requirement). For Rapid transfusion lasteing <15 min, we do not require all the vitals. As long as we have two signature, reaction and document showing it was rapid transfusion. We allow them to attach OR records instead of actual vitals documentation on trnasfusion form for multiple rapid unit transfusion in OR.

Personally, I think there is no better monitoring of a person having a transfusion than a physician and at least one nurse standing over the patient surrounded by whatever technology is needed, whether it is in the OR Suite or the Trauma Room. Generally, the documentation of these events is very, very good.

Now, try to explain that to an inspector looking for a completed transfusion form ...

We have a form that we hand out with every transfusion that has spaces to document vitals, along with information about flow rates, signs of transfusion reaction, etc. The unit tag attaches to this form to be charted. It works very well, but with trauma (we are also a level II), when the blood is rapidly infused, they do not use the vital sheet. The trauma team is with the patient constantly, and the patient is on a monitor so vitals are contantly monitored. Yes, I agree that an inspector could make a case against this, but we could show that the transfusion was completed within 15 minutes in most cases, so all we would have is pre and post-transfusion documentation.

I have never seen any inspecting agency that told me HOW things needed to be documented, only that they did.

I recognize that my experience, while long, is not terribly wide spread so there may be some state agencies that will tell you how but I am not aware of them.

As long as you can show where things are documented and everything is covered, I would cnallenge any inspector who didn't like it because that's not how they did it and I have challenged a few on occasion and won.

:explosion

We are a level II trauma center, use an Emerg Rel form that the doc signs and in the vital sign area of the the slip we send with the blood they usually write, "see flow sheet".

We could mine that data from the ED electronic medical record if we needed to but luckily I've never been asked by an inspector to do it!