How much responsibility should the blood bank take on to avoid transfusing non-irradiated blood to new patients who require irradiated blood?  Should the blood bank check the diagnosis of every new patient when a type and screen is ordered and place an irradiated blood requirement in the computer system if the diagnosis is one that would require irradiated blood, even if the physician doesn't order it? If the blood bank takes on this responsibility, what happens if something gets through the cracks?  Is the blood bank liable or is the physician?

 

I have read other threads similar to this topic, but not specifically dealing with new patients with no history or alerts.

In general I would say that any dept in a hospital cannot create an order without a specific physician's request, and that includes BB products.  Not sure but I think there are regs covering this.

 

Here, if suspicious, we would question an order and ask the ordering location to check the order and then order something else if needed.  I would say that it is not appropriate for a tech to decide what diagnostically does or does not require a particular product, beyond making sure that there is proper documentation (like an H/H result for issuing RBCs say).

 

If we have a history of say, irradiated products being used, and a regular unit is ordered, we would alert the floor to the discrepancy and ask them to check with the physician.  People do stop taking chemo or whatever and can go back to regular products. 

Scott

We have a policy for what our indications for giving irradiated products are.  It is a joint policy with the Medical Staff and is approved at the Medical Executive Committee, so the physicians are agreeing that this is our policy.  That way we are not placing an order, we are following policy as a standard of care.  This works the same as our reflex policy, which is also approved at Med Exec so that we can automatically order an ABID for every positive antibody screen without having to get a doctor's order each time.

 

So if a physician orders irradiated for a new patient or if we see a new patient that qualifies, we look at their diagnosis and if indicated, we add irradiated as a requirement.  If the physician's specific order for it seems unwarranted (non-cancer patient, sickle cell, etc) we will call and question.

Sure, but usually it's for the opposite reason...irradiated and/or CMV- products are ordered for patients for whom thay aren't indicated. Usually a phone call to the doc and maybe an email to him outlining the indications resolves the issue.

Just doing my job as devil's advocate.  Suppose the patient comes in for a diagnosis unrelated to the reason they may need irradiated blood products.  You would never know.  I've mentioned in the past that I can  play the "what if" game with the best of them.  I think Terri's approach is the best you can hope for but realize that you can never cover every possiblity.  With out a policy such as she describes I have never felt that laboratory staff should be modifying orders on their own. 

Very good points, John.  It is not uncommon to get crossmatches on "irradiated-warranted" patients with ER or admitting diagnoses such as "weakness" or "anemia" or "bleeding."

 

I'm all for calling the doc if something raises your suspicion, but I don't think it is appropriate to make it the laboratorian's responsibility to check diagnoses.

 

 

Donna

Ultimately, it's the responsibility of the ordering physician to request the appropriate component. It is fine for us to be a backup, with problem patient files and computer warnings that a patient may have special needs, and hospital transfusion policies listing "standard order" indications for certain components, and to question odd requests. I don't think we should be the first line of defense, however. If your lab has the resources and backing (like a stable of 24/7 knowledgeable pathologists) to dig deeply into every blood request prospectively and ensure that the component is totally appropriate for the patient, you are blessed. I don't think that describes a lot of us, though.

We are dealing with this issue right now. My approach on things has always been that we do not take on responsibility that is not ours. That being said.....we are going from giving 100% Irradiated Products; to just giving Irradiated to those who fit the criteria (which are spelled out). This information was sent out to all Physicians over a year ago; and I audited the process. Unfortunately, there have been a number of issues resulting in improper orders. Chief among those are:

1. Hospitalists! In this day where they are using Hospitalists instead of a patient's Primary Care Physician (when Inpatients), they just are not going to know all of that patient's history.

2. As mentioned above...the diagnosis given to a patient upon admission, may just be symptomatic (i.e. anemia; nausea; etc.) and not their primary diagnosis.

Because of that...and because of the risk of graft vs. host, I do have my staff looking at diagnosis and location. If the diagnosis is one that is on the list for patient's requiring Irradiated, then we add it to their requirements. I am continuing the audits (> 1 year later) because what I am also working towards, is continuing to educate the Physicians about our Policy change (that we are not giving 100% Irradiated)and to make them take responsibility for ordering appropriately. if we can look back at a patient's diagnosis history, then it seems the Physicians should do that also. Not sure "where this will land" in the end; but feel the need to put the patient first in this issue.

Brenda Hutson

What could possibly be wrong with the blood bank staff checking the patient diagnosis? Our LIS is set up that we have access to this information albeit most times symptoms are listed and not an actual diagnosis. As mentioned, I think Terry B. has the best resolve with the best rational. 

As long as your Lab has a policy to allow it.

 

Scott

If I have the techs check the diagnosis and call the doc and ask if they want to change it, should I also have some means of the techs documenting that they checked the diagnosis and that it did or did not meet our irradiation requirements? The admitting diagnosis is printed out on blood product orders.  Maybe I should have them initial next to the diagnosis that they checked it?

How do you catch that the patient has taken fludarabine in the past few months?  That is an indicator for getting irradiated products.  I guess if everyone works to catch all of the cases that could need irradiation we do the best for the patient, but I don't think they lab should be responsible if they miss one.  Ultimately, it is up to the MD, but we can all try to help prevent mistakes.  Because TA-GVHD is something like 95% fatal it is worth everyone's effort to make sure the patients that need irradiated blood get it.

I agree with Mabel that this is such a critical issue, that it is good for everyone to be involved. For us though, we do not get a printed requisition with a diagnosis; so it takes some sleuthing on the part of the Blood Bank Staff. There is an "admitting diagnosis" in the testing field of the current order....but as mentioned above, that can just be symptomatic (i.e. nausea). So it really involves my staff going into the Hospital computer system and looking at their diagnosis history. This is time-consuming; and they don't feel that responsibility should fall on them (if they can look up the history, why can't the Physician).

So, I feel I have only 2 choices at this point:

1. Go back to 100% Irradiated (which I cannot rationalize given that the majority of our patient's do not require it and it is not the standard-of-practice to do so)

2. Continue to work with the Physicians on ordering appropriately. Fortunately, the CMO is very supportive of me so hopefully the process will improve over time (note: we just received our Irradiator so have not yet switched our Policy; but I have been auditing it for over a year to see what the problems would be).

Brenda Hutson

I agree with Mabel that this is such a critical issue, that it is good for everyone to be involved. For us though, we do not get a printed requisition with a diagnosis; so it takes some sleuthing on the part of the Blood Bank Staff. There is an "admitting diagnosis" in the testing field of the current order....but as mentioned above, that can just be symptomatic (i.e. nausea). So it really involves my staff going into the Hospital computer system and looking at their diagnosis history. This is time-consuming; and they don't feel that responsibility should fall on them (if they can look up the history, why can't the Physician).

So, I feel I have only 2 choices at this point:

1. Go back to 100% Irradiated (which I cannot rationalize given that the majority of our patient's do not require it and it is not the standard-of-practice to do so)

2. Continue to work with the Physicians on ordering appropriately. Fortunately, the CMO is very supportive of me so hopefully the process will improve over time (note: we just received our Irradiator so have not yet switched our Policy; but I have been auditing it for over a year to see what the problems would be).

Brenda Hutson

Brenda, you mention 100% Irradiated packed cells, and given the information that Mable posted I have to wonder why not 100% Irr packed cells? Would the associated cost be that much? Given all of the other processing and testing performed before shipment would Irr really be that much more expensive?

I don't know about Brenda's situation but if we went to 100% irradiation it would be a decent six figure cost increase over what we pay now.

 

We have a policy similar to tbostock.

 

Part of my daily review is following up on the indications for ordering special transfusion requirements and identifying patients who should have been ordered as such.

 

I guess the answer to that would depend on what % of your patient population actually "required" Irradiated Products. For us, it is just not high enough to justify the extra cost (I think about $30/unit if we order them pre-Irradiated....but less for us to do it ourselves). The other problem is that you cannot bill a patient for Irradiated Products if their diagnosis does not warrant it. So what this means for me currently (while we have been giving 100% Irradiated) is that I have to manually reverse charges; either have the units all charge at Issue as non-Irradiated and reverse those patients who I can bill for Irradiation; or vice versa). This is very time-consuming. It was put into practice by my predecessor to make it easier...avoid any risk of giving a non-Irradiated unit to a patient who needed Irradiated. That safety net may be a nice thing to do and require less thinking on the part of the Physician and the Blood Bank staff, but I don't think that is a good enough reason to justify all of the issues; nor do I think it is the standard-of-practice to do so. Just my opinion though....

Brenda Hutson

Brenda, you mention 100% Irradiated packed cells, and given the information that Mable posted I have to wonder why not 100% Irr packed cells? Would the associated cost be that much? Given all of the other processing and testing performed before shipment would Irr really be that much more expensive?

 

 

100% irradiated stock means no more than 28 day shelf life also.

So if you are audited and whoever finds that you have ordered and  CHARGED for IRR products and the doctor didn't order it, how does that fly?  I am concerned about both situations-giving IRR products when they are not ordered by the physician, and getting an order for regular PRBCs when we have a previous marker in our computer stating the patient needs IRR products.  This latter has happened with our oncology docs and I call and ask them to submit a new order, requesting the products the patient needs, or stating that we can delete the marker.  For the former situation, would you give IRR and not charge the patient, and contact the doctor and inform him that you feel IRR products are warranted, and request that future orders specify IRR?

So if you are audited and whoever finds that you have ordered and  CHARGED for IRR products and the doctor didn't order it, how does that fly?  I am concerned about both situations-giving IRR products when they are not ordered by the physician, and getting an order for regular PRBCs when we have a previous marker in our computer stating the patient needs IRR products.  This latter has happened with our oncology docs and I call and ask them to submit a new order, requesting the products the patient needs, or stating that we can delete the marker.  For the former situation, would you give IRR and not charge the patient, and contact the doctor and inform him that you feel IRR products are warranted, and request that future orders specify IRR?

It is hospital policy, approved by the Medical Staff in their Medical Exec meeting.  Same way we are allowed to do an anbody ID without a direct MD order; they agree to it at Med Exec that we are allowed as per policy to do this test without a direct order each time.

Terri,

 

So you are charging for the IRR units, right?  I'll have to check with our medical director and get her feelings about it.  We do have a "relflex" antibody ID that nobody questions.  My feeling about the oncologists is that they should be cognizant of their patient's requirements and order accordingly.  That's just sloppy ordering if they don't, but we wouldn't want to jepardize the patient.

One place I worked also had the policy of 100% Irr. Yes we did charge for it as it was agreed on by Med Exec, like Terri.

For those facilities who don't own an irradiator, like my current one, we'd be paying about $50 more per unit for irradiation. Hard to justify when less than 1% of our patients require it.

One place I worked also had the policy of 100% Irr. Yes we did charge for it as it was agreed on by Med Exec, like Terri.

For those facilities who don't own an irradiator, like my current one, we'd be paying about $50 more per unit for irradiation. Hard to justify when less than 1% of our patients require it.

cthhebal, I am curios, do you know the cost per unit when you have your own irradiator?

And do not forget...if you have your irradiator, you need to be FDA registered and then comes FDA inspections!

We are currently having staff check diagnosis' on patients for irradiation needs. However, our current pathologist is requiring us to report it to FDA if my techs miss seeing a diagnosis that requires irradiation. Has anyone out there encountered this problem?

 

We are currently having staff check diagnosis' on patients for irradiation needs. However, our current pathologist is requiring us to report it to FDA if my techs miss seeing a diagnosis that requires irradiation. Has anyone out there encountered this problem?

 

I believe it is only FDA reportable if the physician orders it and it's missed...anyone else's thoughts on this?