Does anyone have a letter that is used when the physician is not transfusion appropriately?  Example the patient's Hgb is to high?

We report Serious Hazard of Transfusions if there is morbidity/mortality due to transfusion but other than this, no. Transfusion is a clinical decision and who are we to question this? There is a lot of talk in Medic circles about the 'wellness factor' - that a patient recovers more quickly with a Hb over 100, in fact some drugs have lowered efficacy in low O2, especially chemotherapy and medics will aim to not let the Hb fall below 100.

 

If however, blood is requested that is totally inappropriate i.e. 4 units on someone with a Hb of 120, or 4 units on a little old lady with a Hb of 62 and IDA, then we would forward the request to the consultant haematologist who would likely tell them to rethink their request. I don't think any staff members I work with would issue the blood without question...

We would call the floor or physician to verify the order if the Hgb is over 10. Something on the line of......we have an order, your patient has a Hgb of 11.4 (or whatever it is), is the transfusion order for that patient correct? Very often that will do the trick. They might have been thinking about a different patient, read the Hgb results wrong that AM, etc. If that doesn't work, we will involve a pathologist to make a phone call to the physician - the pathologist is the qualified person to have the medical discussion about appropriateness of the transfusion for that patient. 

 

We do collect stats for transfusions for a quality report. Do you have a transfusion committee or quality committee that you can report to? If you go that route, the physician chair of the committee can write the letter. You are not the bad guy and the physician to physician route is more likely to get the desired effect long term if the guilty party knows he/she is being monitored.  

Edited November 29, 201311 yr by AMcCord

Here is my letter that I use. I insert the appropriate data in the blanks, plus I send a copy of our criteria as well.

hgb-hct letter.docx

Here is my form; real example with patient demographics removed. I prepare the top of the form and give to my Medical Director. He scans the EMR for supporting data. If he finds it and agrees with the transfusion, he checks "justified". If not, we bring to Transfusion Committee for a group discussion. If everyone agrees it still looks questionable then this form would go to the ordering physician and he/she would complete the bottom part and return it. If the Medical Director is then satisfied with the explanation, it goes in as justified. If not, it is deemed "unjustified" and this goes to physician credentialing.

If the ordering doc never responds, then we send this same letter to the division chair for a response.

Example physician review letter.doc