Opposites attract, according to an old saying. Janet Cass-Baxter, MT(ASCP)SBB, and Roger Baxter, CRNA, can certainly attest to that. The couple, who have been married for more than 30 years, are both health care providers but are on very different sides of the patient care continuum. Cass-Baxter is a blood banker at Anne Arundel Medical Center in Annapolis, Md., while her better half is a nurse anesthetist with the U.S. Army Medical Command. Baxter understands from first-hand experience the panic clinicians feel when they see a patient suddenly in desperate need for a blood transfusion, but only when he started talking to Cass-Baxter about some patient cases did he begin to see the other side of transfusions.

“Nurse anesthetists have very little training in blood banking services and what they do. It’s not very technical; it really skims the surface,” he said. “After a day at work, I often go to my wife asking her, ‘How does this work? How does that happen?’”

Of course, not all clinicians have a blood banker spouse available to field questions. To help the others, some blood banking experts came up with a “top 10” list of things clinicians should know about transfusion services.

10. Know Which Products Are Refrigerated and Which Are Not

“Sometimes clinicians or hospital staff store cryoprecipitate in the same cooler we had sent them previously with red cells, not realizing it should stay at room temperature,” said Linda Fatolitis, MT(ASCP)SBB, director of the compatibility laboratory at Florida Blood Services. “Clinicians should know that some components — such as cryo and platelets — should not be refrigerated and are optimally stored at room temperature.”

Using components that have been improperly stored, such as refrigerated cryo, can create problems. For one, the products may not work as well as they should. After infusing a component and not observing an optimal reaction, a clinician might believe there is a problem with the patient when, in reality, the improperly stored component is not working appropriately. Fatolitis employs a low-tech strategy to try to avoid this situation.

“We use a red stamp that says ‘DO NOT REFRIGERATE’ on the transfusion record that is enclosed with the product,” she said. “Nonetheless, products that are not supposed to be refrigerated occasionally end up in the cooler. We need to increase awareness on this issue. The blood bank in particular should be involved in clearly letting both clinicians and hospital staff know which products do and do not need refrigeration.”

9. Realize Why Blood Bankers Operate in a Highly Regulated Environment 

Anyone who has experienced an FDA inspection will realize how rigorously the industry is regulated. This type of inspection is a good thing because it creates uniformity in quality and safety, said Gregory Wright, MT(ASCP)SBB, blood bank manager at the NorthShore University HealthSystem in Evanston, Ill.

“If a clinician came down to the lab, they would probably be surprised to learn about all the particular steps, rules and procedures we need to follow,” he said. “The reason we do this is because we want to keep patients safe and provide clinicians with the most effective products to treat their patients.”

“Clinicians need to realize that it’s not that we’re trying to be difficult, but that in some areas we just don’t have the latitude to compromise. Hospitals do have processes in place to provide uncrossmatched blood in cases where time is of the essence. Clinicians need to weigh the patient’s best interests, and, if necessary, order the appropriate products emergently,” Wright said.

8. Order Irradiated Blood Components Appropriately and In Advance

Some confusion remains surrounding irradiated products. Clinicians may unknowingly order irradiated blood for patients who don’t need it or fail to order it for people who do, said Suzanne Butch, MA, MT(ASCP)SBB, CQA, blood bank administrative manager at University of Michigan Hospitals.

“Unfortunately, patients who need it and don’t get it may suffer a life-threatening complication,” she said. “In today’s medical world, you may end up in the ER where the staff are very familiar with trauma, heart attacks and other medical emergencies, but they may not always be aware of all of the patient’s conditions. They may treat an emergency with a standard transfusion without ordering irradiated blood. Unfortunately, in some cases, such as with particular leukemia patients, the use of irradiated blood is important,” she added. “However, once the patient has been identified as needing irradiated components, the transfusion service can assist in making sure the patient always gets [the proper products].”

Another area of confusion involves cytomegalovirus. Some clinicians think that irradiated blood can prevent the transmission of cytomegalovirus, which is not the case. If preventing cytomegalovirus is their goal, clinicians should use leukocyte-reduced blood rather than irradiated blood, Butch said.

“There also is the ‘just in case’ factor,” she added. “Sometimes when clinicians see the option for irradiated blood in the order form they think, ‘That seems like a good idea; let’s just go ahead and order it.’ But this is really a waste of resources because irradiated blood needs to be ordered from the local blood bank — unless the institution irradiates all its products by using the costly equipment on-site to do so. Electronic physician order entries that ask clinicians to enter the indication for the irradiated blood can help with appropriate use of irradiated blood.”

7. Overordering Causes Waste

We live in a world where the philosophy often is “more is better.” In clinical scenarios, sometimes this tenet holds true because not having enough of the appropriate blood components can seriously compromise a patient’s health. However, in other instances, less can be better. When clinicians order more than what is needed, it can be wasteful and place an additional burden on an already strained health care system.

“Every now and then you encounter a clinician who overorders products just to make sure they’ve got everything covered. This is especially true if they’ve had close calls in the past when a patient needed more units and they [the clinicians] didn’t have them on hand,” said Marilyn Ruzicka, MT(ASCP)SBB, blood bank manager at the Memorial Hermann Southwest Hospital in Houston. “However, if everyone takes this approach, it can slow us down.”

There also is the issue of some products’ short shelf life, Ruzicka said.

“Some things, like cryoprecipitate, have to be prepared as close to the time of transfusion as possible because they are only good for four hours after being thawed and pooled — if it’s not used by then, the product is wasted,” she added.

6. Know When to Order “STAT”

“A ‘STAT’ order has priority over routine work, but what clinicians may not know is that when you’re bombarded with STAT requests, sometimes the best you can do is to prepare orders on a first-come, first-served basis,” Wright said. STATs, he said, should be used judiciously. If an order comes in as STAT but it is not needed right away, it might prevent another person in a more dire situation from receiving necessary components quickly.

“Communication is important in such cases, because in some larger hospitals it may be more difficult for clinicians in one part to know what is going on somewhere else, in terms of blood requests,” Fatolitis said. “There are several ways to eliminate these scenarios. At some hospitals, certain codes or trauma alerts are announced over the loudspeakers to let clinicians know that something major is going on in other areas of the hospital.”

According to Ruzicka, another way to foster communication is to try to keep clinicians in the loop. “It is important that we strive to let clinicians know that we might have other orders in the system, but that we are also working on getting their components ready as well. That way they can know what to expect.”

There are several reasons why a clinician may order STAT when he or she does not have to, she explained, one of which is failing to order the component beforehand for a nonemergent need. “For example, a patient might be ready to undergo elective surgery, but they [the clinician] didn’t order the component ahead of time so they need to order it STAT,” she said. “We need periodic informational campaigns to remind clinicians to order in advance and to keep from ordering as STAT if the component is not needed within the next six to 10 hours.”

“Another way to mitigate the effect of large orders is to give us a blood sample ahead of time — hours or even days before the product is needed,” Ruzicka said. “That way, we can start determining if any antibodies are present. If we find an antibody, we can identify it and find compatible blood; this approach will help us prepare the order for the patient so they can have it when they need it.”

She added that the blood bank staff also tries to prioritize. A STAT in the ER for a person with a gunshot wound, for example, would most likely take precedence over a STAT for a patient with a broken hip who is bleeding. “Coming up with the priority should result as a communication between the transfusion service and those who are ordering the blood. So there again, communication plays an important role,” Ruzicka said.

5. Overordering Slows Down Response Time

Formulas and guidelines allow clinicians to calculate how much of a particular product is needed for a patient. To obtain a precise amount one must consider the patient’s body mass, blood count and recovery rates. Other factors — such as other medications’ effect on the transfusion outcome — also need to be taken into account.

“When you have a patient bleeding in front of you, it may not be the best time to pull out a calculator and start working on a formula,” Fatolitis said. “Clinicians sometimes don’t make the exact calculation. They may just eyeball it or order what they’ve ordered in the past in another similar situation. So there are guidelines and then there are real-life scenarios. But in nonemergency situations, overordering not only creates waste but also slows down our response time.”

Clinician education is the answer for this dilemma, she said. Hospitals should have a formulary available to clinicians, which details the recommended transfusion guidelines for that particular hospital.

4. Be Aware of How Long It Takes to Prepare Each Product

Many hospitals and blood banks store some commonly used units to have them accessible in a pinch. For example, a few fresh plasma units usually are on hand and can be delivered quickly, but the speed of the response may be different if the blood bank needs to match someone’s blood type and an antibody is present.

“Antibody screening alone can take 15 to 20 minutes, and there is really no way around it. We are required to do an antibody screen — in addition to determining the blood type and Rh — for crossmatched units. If the patient has a positive antibody screen, it will take a bit longer than usual to identify it and find compatible blood. We also have to antigen type the blood units to make sure they’re antigen-negative for the corresponding antibody,” Fatolitis said.

“Clinicians should also know that it takes 20 to 30 minutes to thaw Fresh Frozen Plasma, as long as optimal conditions prevail. In other words, if we’re using the water bath to thaw a large order, and as a result the temperature on the bath drops 10 degrees lower than what it should be, then it might take more than 40 minutes to thaw the plasma. Unfortunately, there is no way to do this faster. It’s just something that cannot be circumvented. So clinicians should always have in mind how long it takes to prepare certain products,” Fatolitis said.

3. Correct Specimen Identification Is Key

Correct patient identification is linked to safety. Misidentifications can lead to unmatched transfusions, which in turn can result in severe adverse reactions. To address this issue and minimize misidentified specimens, many hospitals have very specific guidelines on drawing blood from the patient and labeling it at the bedside.

“At our hospital, we have an extra red armband exclusively for transfusion services in addition to the patient’s regular ID armband. On the red armband the phlebotomist writes the patient’s name along with the medical record number, the date and time of the collection and the initials of the person who drew the sample. Once filled out, the band has a peel-off label that can be placed on the specimen while a carbon copy with the same information remains on the patient’s red armband. There is a unique letter-number combination on each red armband, which also helps with identification issues and reduces mix-ups,” Ruzicka said.

“We have received samples in the lab that have absolutely no patient identification. If we don’t know who the patient is, we can’t work on the order. We are very strict on patient misidentification because it can be unsafe. Just one letter can make a big difference: take John Smith vs. Joan Smith, for example. Taking the extra minute or two to make sure the label is accurate can really cut down on delays and the back-and-forth between the patient location and the lab,” she said.

2. Blood Components Are a Finite Resource

Many common hospital items, such as gauze, saline solution or common medications, can be easily found on the shelf. If the hospital has run out of a common supply item, a quick toll-free call might solve the problem. This is not always the case with blood. Unlike many products that are “one-size-fits-all,” blood usually must be highly personalized.

“Blood needs to be compatible with a specific patient. If we’re looking for a blood product for a patient who is hard to match, it might require multiple calls to various blood centers around the country — or even the world — to find the needed unit. This might take significant time and effort,” Ruzicka added. “We just can’t have every type of blood stored because of financial and space constraints.”

1. Yelling at the Staff DOES NOT Improve Performance

“Most blood bankers have probably received a call from an agitated clinician who has lost his cool because he’s not getting what he needs immediately,” Wright said. “I can certainly see this happening if a clinician has a patient bleeding profusely right in front of him, and he doesn’t have the blood components to treat the patient.”

“Unfortunately, having someone lose their cool is something that sometimes happens, and we just have to understand that, move forward and do the best we can. Nonetheless, keeping communication professional and low-key is essential,” he said.

“Most of the problems we have to troubleshoot are communication problems such as when a blood banker tells the clinician one thing but the clinician hears something else. The reverse is also true. Because of this, the blood banker should also do the utmost to communicate with physicians if a delay is expected, such as when the patient has an antibody or when the lab is being bombarded with orders,” Wright said.

Besides communication, Ruzicka believes that opening the doors to the lab could help. “We offered tours of our lab as part of the National Medical Laboratory Professionals Week. The goal was for hospital staff to visit the lab and learn more about what we do. We showed them where we store the blood, and our techs went over some of our procedures,” she added.

“I think that what our visitors took home is that ultimately we’re here to serve patients, but also that we have a specific way of doing things and this takes time. Our procedures are in place not out of whim but to ensure the quality and safety of the products. In the final analysis, we follow those procedures because we really care about the patients and clinicians.”

This article was published in the current issue of AABB News.