We do quite a few outpatient transfusions and many times the hemoglobins are performed elsewhere.  We would like to have some way to document the hemoglobin in our system before giving blood.  We have Sunquest and it shows the most recent H&H on file. This has caused some confusion as it isn't always the most recent available.  we don't want to imply that we don't trust results from outside---. Does anyone have a policy that would cover this?   I had though about building a separate test that would not be reported or charged but that doesn't seem like a great idea.  Of course we wouldn't charge the patient for it either way.   Thanks in advance for any help you can offer,  Karen

I never had one for rbcs but did have one for platelet transfusions.  It was an approved policy:  we did not transfuse plts until we had a plt ct done by our lab.  You can make it a policy and get paid for it, which you should.  You Directors and Administration would have to sign off on it . . .

Surely the medics are transfusing to symptoms and not to numbers? 

Some of our clinicians are starting to catch on with transfusing to symptoms, but most are still looking at numbers.  And the results from their offices can be wrong; our policy is to always require an onsite lab test (H/H for red cells, plt count for platelets, PT(INR) and APTT for plasma, fibrinogen for cryo) within 3 days of the transfusion.  It's in our policy and is approved by the Medical Staff.

Example: patient was sent in because he was a 6 Hgb at the doctor's office.  We were getting an 11 Hgb.  We called the doctor's office and they said "a lot of our patients are coming out low".  I asked how their QC was and they had no idea what I was talking about; I explained what it was and they said they never do that.  "The vendor takes care of that when they come in periodically".  Oh boy.  Had we given the 2 units based on their result we could have had a bad outcome.  We had a call from that doctor's office later asking if they could send us all of their CBCs for the next few days until their machine was repaired.  Eek!

On 12/31/2015 at 7:52 AM, tbostock said:

Some of our clinicians are starting to catch on with transfusing to symptoms, but most are still looking at numbers.  And the results from their offices can be wrong; our policy is to always require an onsite lab test (H/H for red cells, plt count for platelets, PT(INR) and APTT for plasma, fibrinogen for cryo) within 3 days of the transfusion.  It's in our policy and is approved by the Medical Staff.

Example: patient was sent in because he was a 6 Hgb at the doctor's office.  We were getting an 11 Hgb.  We called the doctor's office and they said "a lot of our patients are coming out low".  I asked how their QC was and they had no idea what I was talking about; I explained what it was and they said they never do that.  "The vendor takes care of that when they come in periodically".  Oh boy.  Had we given the 2 units based on their result we could have had a bad outcome.  We had a call from that doctor's office later asking if they could send us all of their CBCs for the next few days until their machine was repaired.  Eek!

Exactly why we also check H&H, platelet counts and coag prior to transfusion.

I've been wondering where to incorporate this into our policies.

It's been an understood policy for years but not written.  But I can't document employees not following an understood policy. Another procedure to update! yay

On 1/9/2016 at 7:47 AM, amym1586 said:

I've been wondering where to incorporate this into our policies.

It's been an understood policy for years but not written.  But I can't document employees not following an understood policy. Another procedure to update! yay

I have checking appearance and performance of saline as a part of daily QC documentation for tube reagents.

2 hours ago, AMcCord said:

I have checking appearance and performance of saline as a part of daily QC documentation for tube reagents.

Not sure how this reply ended up here..................ignore.

We require an in-house CBC or PT/PTT within 48 hours of issuing out PRBCs, PLTs, or FFP. This policy is incorporated into our nursing blood administration policy. We also have it on our out-patient lab requisition form. Beside the request for PRBC it has (CBC w/in 48hrs), FFP (PT/PTT w/in 48 hrs.), and PLTs (CBC w/in 48 hrs.). When we set up or issue out a product the most current lab value displays. If labs have not been done within 48 hrs. nothing displays and we know to call to get labs ordered.

We had a situation like this recently.  A patient was sent to our hospital from a near by free standing minor Emergency Room for direct admission and transfusion of RBC'S due to low H&H.  The minor Emergency Room reported a hgb below 6.0.  I don't recall the exact number.  Normally, these orders aren't questioned and the blood is prepared as requested.  In this case, the night shift supervisor, uncharacteristically, questioned the order and insisted the floor send down a new CBC for confirmation.  The patient's Hgb was above 11.0! 

That makes you question your policies for sure.

 

We had a problem with the clinics not sending their results then sometimes when they did send them they may be old results, so when we as the transfusion committee rewrote the transfusion criteria I included in the procedure that we require "X" testing for "X" products and that to insure that we had that testing performed, that testing would be ordered for each outpatient transfusion, such as if the patient was to receive packed cells we automatically order a H&H, for platelets we order a Platelet count, FFP a PT/PTT, cryo a fibrinogen.  We then took the policy to the Medical Executive Council and the hospital Policy and Procedure committee.  At both places I pointed out the requirement and they approved the policy and changes without question.  So we now have an unwritten written order for the pretransfusion testing that we need.

Another hint about the patient's true H&H is visually looking at the spun down specimen for blood bank. If the MD's office is telling you the Hgb is 6 or below and VISUALLY the hematocrit looks normal, then I would question the sample. Either the current or previous sample. 

We receive "DRAW and HOLD" specimens from our ER and Oncology Departments. We will start an antibody screen right away when we visually see that the "Crit" is very low. After years of doing this, your eyes get "calibrated" to what a low hematocrit looks like. I know you know what I'm talking about. 

8 hours ago, jojo808 said:

After years of doing this, your eyes get "calibrated" to what a low hematocrit looks like. I know you know what I'm talking about. 

Ah yes! The eyeball Hct. I called the OB unit urgently once and told them that a patient of theirs with orders for a chem test only had a really low Hct, probably in the 5 range, and maybe they should check into it. The doc wanted to know how I could possibly know (and he absolutely didn't believe me). I explained the whole eyeball Hct thing to him, he thought I was ridiculous, but apparently it worried him just a teeny bit because about an hour later we got an order for an H&H. Hgb was 5.0. He didn't believe the instrument either - made us redraw it. Hgb 5.0. Well calibrated eyeballs! 

WHY OH WHY do they never believe an experienced tech with, probably, vastly more knowledge and experience in their own field than they have themselves?????!!!!!!!!!

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I can tell a Hb of less than 8 when it is unspun too...

We request that all OP transfusions are accompanied by a current Hgb (less than one week).  We get pretty good compliance with that.  If not, we require one to be run.  Same with PPH.  We rarely transfuse FFP on an outpatient basis.  "Current" in-house results  for whichever product is ordered (Hgb for PRBC, INR for FFP and Plt for PPH) pop up when we 1) order blood products 2) report results on type and screen with products and 3) when issuing products.  That way we have three chances to catch an inappropriate transfusion before it happens.