How do you comply with

BBTS Std. 8.2 Monitoring

11) Monitor critical laboratory results before and after transfusion

One of the few nice things Meditech did for us was a custom report (free of charge!) that lists each transfusion with the pertinent lab values (H+H, plt ct, INR, APTT) for that component within a specified time range of the transfusion. We use it for our initial screening of retrospective appropriateness review.

Dr. Pepper what version of Meditech are you using? Currently we're Magic 5.64 and upgrading to 5.66 next month. Meditech does have a standard Transfusion report where you can pull in Test View groups that you've assigned to a product.  How does this differ from your custom report?

Thanks

One of the few nice things Meditech did for us was a custom report (free of charge!) that lists each transfusion with the pertinent lab values (H+H, plt ct, INR, APTT) for that component within a specified time range of the transfusion. We use it for our initial screening of retrospective appropriateness review.

Dr. Pepper,

 

I am on Meditech 5.66 can you  give me more information on this transfusion report. Is  it  a custom I can ask Meditech  to update for  m y version . 

Dr. Pepper what version of Meditech are you using? Currently we're Magic 5.64 and upgrading to 5.66 next month. Meditech does have a standard Transfusion report where you can pull in Test View groups that you've assigned to a product.  How does this differ from your custom report?

Thanks

 

We are CS 5.66. We do run that standard report. The custom (it's a NPR report) is quite a bit more convenient as it shows all the labs before and after the transfusion. We have one for RBC, one for platelets and one for FFP. It's nice for appropriateness, as you can see if the transfusion met the trigger criteria. You can also see at a glance, for instance, if someone's hemoglobin fell from a 15 to an 8 in the 24 hrs between the CBCs before the transfusion, so obviously there was a bleed. And you can see if the transfusion had the desired effect of raising the H+H or plt ct or lowering the INR with the post-transfusion labs. I run them monthly.

Dr. Pepper,

 

I am on Meditech 5.66 can you  give me more information on this transfusion report. Is  it  a custom I can ask Meditech  to update for  m y version . 

 

I just spoke with my IT guy who is going to try and send me the files as email attachments. I'd be happy to share. He said your on-site IT guys should be able to install them. They may need to tweak a few variables (lab sites, test mnemonics etc). Please send me a private message if you are interested.

 

Phil

How do you comply with

BBTS Std. 8.2 Monitoring

11) Monitor critical laboratory results before and after transfusion

We already review ALL "Critical" Lab results on a daily basis, but mostly because we are checking documentation per JCAHO.  Got to say that this has never come up here with the FDA or JCAHO, which does our lab inspections.

 

Having said that, they may have used a poor choice of words here, and by "critical" I suppose they mean those tests that are critical to monitoring the effects of transfusion or whatnot.  This would make it more of a utilization review item I think.

 

Scott

We look up pre- and post-transfusion lab values for utilization review.

Dr. Pepper, I would like the information on that report - my pathologist has been requesting that and IS has not created it to his satisfaction.  Yours sounds like it might. Please send info to edie.stiner@parrishmed.com.

I do understand the need to monitor blood utilization.  I just don't know if it is worth placing patients at risk to have the sole tech in the Blood Bank checking all the pertinent lab values prior to transfusion, calling the floor to determine the need for the transfusion if the lab values do not meet criteria, and then leaving the lab to go to the Medical Director's office down the hall to get approval to transfuse the blood.  This has been mandated by our Laboratory Director.  The other day, I was working on 4 patients, left to go get the approval and came back to a line of floor personnel waiting on me to issue blood to 3 patients.  I am often the only one in the lab who can issue blood, answer any Blood Bank related questions, or perform any Blood Bank testing.   I often do the daily reviewing/paperwork after second shift arrives and there is no overlap in Blood Bank between the first and second shift schedules in the Blood Bank.  There are 2 techs in Hematology and two in Chemistry during the day, but the Laboratory Director states they are unable to get the Pathologist's approval because these technologists do not have the pertinent information on the patient.   When I told the Lab Director today that it adversely affected patient safety for the day shift Blood Bank tech to be interrupted so much while working on multiple patients, I was told I talk too much about patient safety.   How do other places handle reviewing all values pre-transfusion while performing all of the work in the department?

mcgouc.....

 

My sympathy - your lab director sounds like a prize. I can't think of anything more important than patient safety.

 

I do all the things you are talking about, with similar staffing some days, but someone else in the lab can check out blood if I'm down the hall running down the Medical Director. I understand your frustration. In these days of cost cutting and penny squeezing, I think we are doomed to have it continue.

 

Can you cross train a hemo or chemistry tech to help with blood checkout? That's a small task, but an important one that any tech should be able to do. It doesn't take very long to perform and it could be a bit of help for you. 

What computer system do you have?  We have Meditech and the "pertinent" values pop up when we are ordering product (INR for FFP, Hgb for PRBC, Plt for PPH) and when we bring up the patient to result testing.  Most of our docs are using reasonable transfusion criteria.  Our one outlier is the nephrologist who insists on transfusing patients if their Hgb is <10 OR Hct is <30.  So they can have a Hgb of 9.9 and a Hct of 30.3 and they will still get a unit with dialysis!  We're trying to convince him not to transfuse if either of the parameters is over 10 or 30.  It's an uphill battle.

I can see from where you are coming mollyredone, but this is a situation, surely, where, if the computer says "No", it doesn't get done, unless there is a very good reason (which would have to be discussed). The problem is that, in certain circumstances, the patient's condition has to be taken into account, rather than what the computer says, and, in such circumstances, it is often a life or death situation, and there may just not be time to discuss the situation (I am thinking of such things as HELLP syndrome, cardiac patients, etc). Surely, in such situations, the computer should be ignored, and, if it means that blood or blood components are issued unnecessarily, it is a matter for discussion (and repercussion) after the fact?

We don't involve our pathologist/Medical Director unless it is a really bizarre request.  Otherwise, we check pre-transfusion criteria and call the nurse to notify the physician that the transfusion is outside the established guidelines.  If the physician insists, we write down his/her reason and we give the product and this would go to Transfusion Committee for group discussion.

Dr. Pepper,

Your report sounds exactly like what I am looking for to assess transfusion appropriateness. Could you please email me more information?

juliewinter@lmhcare.org. 

We don't involve our pathologist/Medical Director unless it is a really bizarre request.  Otherwise, we check pre-transfusion criteria and call the nurse to notify the physician that the transfusion is outside the established guidelines.  If the physician insists, we write down his/her reason and we give the product and this would go to Transfusion Committee for group discussion.

 

This is what works for us. If it feels really inappropriate - to the detriment of the patient potentially - we talk to a pathologist, who makes a call to the physician.

Malcolm,  The patients to whom I was referring are ESRD, our repeat inpatients for dialysis.  When they are inhouse, we will transfuse them daily with dialysis if Hgb <10 or Hct <30.  I always check for comorbidities in the chart and the doctor's notes.  This same nephrologist transfused PPH two days in a row, asked for another the third day, with a Plt count of 35.  When our pathologist called him, he stated that he wasn't the primary doctor for this patient, his oncologist was.  We called the oncologist who said he didn't need PPH.  So why was the nephrologist ordering them???

Thanks for that mollyredone.

I am now much clearer from where you are coming, and I think I would have done the same in the circumstances.

What computer system do you have?  We have Meditech and the "pertinent" values pop up when we are ordering product (INR for FFP, Hgb for PRBC, Plt for PPH) and when we bring up the patient to result testing.  Most of our docs are using reasonable transfusion criteria.  Our one outlier is the nephrologist who insists on transfusing patients if their Hgb is <10 OR Hct is <30.  So they can have a Hgb of 9.9 and a Hct of 30.3 and they will still get a unit with dialysis!  We're trying to convince him not to transfuse if either of the parameters is over 10 or 30.  It's an uphill battle.

Yes, our nephrologists also have the 10 and 30 stuck in their heads from the 80s and 90s.  Current guidelines are much more restrictive in this group: less than 7 unless unstable cardiac disease, then it's less than 8.