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A timed blood ordering system; requisition forms with a new vocabulary, linking turnaround time to patient need for transfusion, eliminated blood delivery delays in this area.

A timed blood ordering system

When stating how fast blood is needed for transfusion, a clinician must consider the time limitations imposed by blood sampling, testing, recording, and transport. Even then, a common problem--ambiguous orders--may lead the lab to perform procedures that are not needed and thus delay delivery of the blood.

Our regionalized transfusion center serves 12 hospitals providing care for 700,000 people in the Tampa area. After we switched from type and crossmatch to type and screen six years ago, we ran into a fair amount of ordering confusion.

Our clients thought that if type and cross was one activity, type and screen must be an additional one. Therefore, a typical order during the transition period was to "type and screen two units and cross four."

At times we were asked to "type and hold." To us, that meant typing a specimen, then holding it. But those who made the request believed we would set aside crossmatched donor units. Another puzzler was "hold clot." Did that mean do no typing?

Random questioning of nurses and clinicians elicited divided responses on what they thought they were ordering. This ambiguity was not only bad for patients but also left everyone open to malpractice liability.

An earlier review of our experience had also revealed imprecision in terms describing how soon blood was needed. The biggest problem was with "Stat," which ranged in meaning from "he's bleeding to death" to "have the blood before I go off shift" or "my orders are always important." We even had the absurdity of "Stat Stat" and "Super Stat."

One out of every five crossmatch orders received in our transfusion service had on it some note of urgency, such as "Stat," "right away," "as soon as possible," or simply "now," even though it was unnecessary because our regionalized crossmatching service gave patients immediate access to all of the blood supply in Tampa.

In other cases, orders to elective surgery were simply marked "for tomorrow." That allows anywhere from 1 to 24 hours for blood preparation. It fails to communicate the varying needs of patients.

Vague orders promote inefficiency in the laboratory because workload cannot be prioritized. And certainly, transfusion service personnel lose enthusiasm for the quick response that might be required to save a life if they are told, "Dr. DeMand always orders it that way."

Our blood bank and laboratory management developed a timed blood ordering system--TBOS--that eliminates fuzzy terminology and ties requested turnaround time to patient need. It uses common English words with specific meanings. The idea came to us from the Puget Sound Blood Center in Washington. TBOS has no connection with a somewhat similar set of initials, MSBOS, which stand for the maximal surgical blood ordering system.

The first step was to rename our transfusion service lab. It became the compatibility laboratory instead of the crossmatch laboratory, reflecting the fact that our laboratory performs several procedures in compatibility testing, only one of which is the crossmatch. The Eleventh Edition of the American Association of Blood Bank Standards (Section G) defines the compatibility test as the sum of ABO and Rh testing, antibody screening, and the crossmatch (Figure I).

Blood orders indicate which parts of the total compatibility test will be done. For the exsanguinating patient, for example, the compatibility testing might be only ABO and Rh because there is no time to do an antibody screen or a crossmatch. It is still a compatibility test, albeit an abbreviated one. For the patient who can wait, the extent of crossmatch--if it is done at all--might vary depending on the situation, from just the immediate spin test to the whole antiglobulin procedure.

A purist could object that our job is not to test for compatibility but for incompatibility. Strictly speaking, that's true, but at least we have eliminated our old problem of equating the terms compatibility testing and crossmatching. That had led to many arguments between the laboratory and worried surgeons who wanted compatible blood but did not have time for a crossmatch. The surgeons were right, and we were wrong.

Most blood ordering problems stem from how the urgency of need is conveyed. Vague or misused terms like "ASAP," "when ready," "now," and "Stat" have no place in a world of specialized communication. Medical, nursing, laboratory, and other health professionals require a common language to convey messages precisely. A gap in communication is not only dangerous to the patient but also induces frustration and stress in these health care providers.

TBOS hinges on the time needs of the patient, which are not necessarily the same as the desires of the hospital medical staff. Variables such as incubation time and the time needed to transmit orders did no figure into the bloor ordering system. Only the total time from the statement of the need to the availability of the red cell product was considered.

Three categories are used in TBOS to define requested turnaround time in terms of patient need: desperate, urgent, and non-urgent. Turnaround for desperate orders is within minutes; for urgent orders, within the hour; and for non-urgent orders, as long as it takes to complete the procedure (Figure II). Patient need is determined by the clinician.

Five per cent of patients at a tertiary care hospital can be expected to have some blood typing or antibody problem. The laboratory manual states that such cases are exceptions to the advertised times. They may require more time and sample, special work, and special blood. If a patient has a rare antibody, it could take days to get suitable donor blood. Problems are usually resolved within an hour or two, however.

We designed a requisition form that is a precise menu of what is available and how long it will take to produce it (Figure III). Nursing unit personnel can check off the options of product wanted and time needed.

A wide-ranging educational campaign preceded introduction of the new requisition form. Laboratory procedures were changed and rewritten to incorporate the new terminology. Our technical and clerical personnel received instruction on the new procedures as well as the reason for, and the meaning of the new language so that they were ready to respond.

One point emphasized particularly to the transfusion service staff was not to require the ordering physician's justification or signature at the time of a "desperate" request, but rather to follow up at a later time. That has worked well--the required justification on a desperate blood request is now obtained easily for the record in more than 99 per cent of cases.

Getting the cooperation of ordering physicians was the critical beginning piont in promotin of the timed blood ordering system. The blood bank's medical director sold TBOS at meeting in the various hospitals with such groups as the transfusion committee, the executive committee, and the medical staff.

Although it was essential that clinicians understand the new system, we did not expect them to use the requisition forms personally. We held in-services for hospital nursing staffs, who would translate clinicians' orders into TBOS. Ward clerks and messengers also were indoctrinated.

It was if we were presenting restaurant menus to the nurses to discuss with patrons (clinicians). No substitutions were allowed, except by consultation between the clinician and the medical director of the transfusion service. For exceptional cases, time would not be the overriding factor; special products could be created to special order.

Medical staff members who missed the initial hospital blitz were brought up to date by the nurses, who realized that our terminology provided an opportunity to interpret what the clinician wanted in terms of what the patient needed. Several suggestions by the nursing staff improved our orientation program. One point they made was that physicians don't read their mail too carefully. To get by that obstacle, we published the new procedures in the hospitals' medical newsletters.

New requisition forms replaced the old ones all at once, and then we waited for orders to come in. There were some problems at the start. Urgent orders came in with the word Stat tacked on, for example. We called back on every incorrectly worded order. If an entire nursing unit appeared not to be complying, we informed the director of nursing, held additional training, and handed out more literature. In time, the number of incorrectly worded orders slowed down to a very thin trickle.

It took about a year and a half to convert the 12 hospitals in our region to TBOS. At the end of that period, we reviewed the ordering practices of the first two hospitals to adopt TBOS. More than 1,000 blood requests were examined for accuracy, and 80 per cent were letter-perfect. Less than 1 per cent of the orders had completely ignored the new terminology. The rest of the deficient orders were not totally out of line. They just included some of the old language along with the new.

The errors reflected the difficulty of changing established ways of ordering blood. Considering the large employee turnover and the floating nursing pools in today's hospitals, the ordering accuracy rate was very good. We continue to work with the nursing development services to orient new personnel to TBOS.

Not surprisingly, we no longer receive irate calls from doctors and nurses about delayed blood delivery. The transfusion service delivers on time 99 per cent of the time. We can accept an order knowint it means what it says. Our laboratory staff is enjoying the rewards of a positive image and a less frantic pace, and the satisfaction of knowing that patients are getting our best care.
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Copyright 1986 Gale, Cengage Learning. All rights reserved.

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Author:Samia, Concepcion T.
Publication:Medical Laboratory Observer
Date:Oct 1, 1986
Previous Article:Quality control in the new environment: ligand assay and TDM; part II.
Next Article:Where and how to improve laboratory operations.

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