POLICY #: TR210.0 DATE OF ISSUE: 4/10/17 DATE(s) OF REVISION: N/A

Transcription

1 ARNOT HEALTH POLICY AND PROCEDURE MANUAL POLICY #: TR210.0 DATE OF ISSUE: 4/10/17 DATE(s) OF REVISION: N/A APPROVAL: Dr. Yafei Wang M.D. Medical Director of SJH Laboratory Dr. Terence Lenhardt, M.D., PhD Medical Director of AOMC & IDMH Laboratories Medical Director of Transfusion Services FACILITIES COVERED: AOMC AMS SJH IDMH TITLE: Collection of Blood Bank Samples ORIGINATOR: Laboratory Blood Bank PURPOSE Positive patient identification is critical in the collection of blood bank samples. This procedure defines the appropriate steps for collection of these samples. The main steps of the process are outlined in this policy. There are unit specific workflows as appendices SAMPLE REQUIREMENTS Full Pink top EDTA tube, or a lavender microtainer for NICU samples Lab Order label must be on the sample Two collector codes must be on the sample Home draw Patients must have Verification form completed Time of draw must be on the sample If any of the requirements are not met, the sample will be rejected and must be redrawn PROCEDURE 1. Order for Type and Screen or Type and Crossmatch is placed in Quadramed 2. Obtain the lab order labels a. If they are unusable, get lost, or can t be used for any reason, contact the Blood Bank for a replacement label b. In the Event of computer downtime: Place a chart label on the sample with both Quadramed Codes and time of draw written on it. THIS IS THE ONLY TIME IT IS ACCEPTABLE FOR A BLOOD BANK SPECIMEN TO BE SENT WITH ONLY A CHART LABEL. 3. Positive Patient Identification at Sample Collection

2 TITLE: Collection of Blood Bank Samples POLICY # TR210.0 Page 2 of 14 a. Two people must be involved in the patient identification at the time of sample collection a. One of the two must be licensed (RN, LPN, MD, DO, PA, Nurse Practitioner or Med. Tech from the Lab) b. Ask the patient their name and date of birth c. For non-verbal patients, the patient s family or Nurse must confirm ID d. One person verifies the name and date of birth against the registration bracelet, outpatient requisition or Chart Photo/MARS for SNF patients e. The second person verifies the name and date of birth against the lab label f. If there is ANY discrepancy between the patients verbal response, the label or the Requisition/wristband STOP. Blood sample cannot be drawn until the discrepancy is resolved. g. After positive patient identification, collect blood sample, write both QuadraMed codes on the label and the time of collection h. Place lab order label on the sample before leaving the patient 4. Send Sample to the Laboratory 5. Patients with no previous Blood Bank History a. Patients blood type must be verified with a second sample drawn at a different time than the first sample b. For all nursing units/patient care areas EXCEPT the AOMC and SJH ER, every attempt will be made to use a previously drawn lavender tube c. A laboratory Phlebotomist will obtain the second sample for Emergency Room patients at both AOMC and SJH a. For outpatient testing that will not result in the administration of a blood product: a second sample is not required. (Prenatal Blood Bank, Outpatient ABORh, DAT, Antenatal Rhogam) b. NICU: All cord bloods that do not have a full cord blood workup ordered will have a Blood Type Confirmation performed. If the neonate needs blood in the future, the type and screen or type and crossmatch must be drawn with the Double Verification process. If a cord blood was not sent, every attempt will be made to use a previously collected sample, but if one is not available a sample must be drawn. It will just be a regular blood draw with a lavender microtainer and only one QuadraMed Code. Chart Labels are acceptable. 6. If a sample must be collected: a. The confirmation cannot be ordered in QuadraMed and will be ordered by the Blood Bank b. The lab order label may be sent to the patient s location or the sample may be sent with chart labels in emergent situations c. Confirmation Sample does not require 2 person verification, will be in a lavender or pink tube and chart labels are acceptable d. For patients that are difficult to draw, only a very small sample is necessary and can be a fingerstick sample collected in a lavender microtainer e. The patient will only be able to receive O Negative red blood cells until this confirmation is complete due to the precious nature of O negatives red blood cells, this sample should be collected ASAP 7. Some areas of the hospital have work flows that are unique. Please refer to the appendixes for department/nursing unit specifics

3 TITLE: Collection of Blood Bank Samples POLICY # TR210.0 Page 3 of 14 Appendix I: Regular Workflow (AOMC L&D, MAT, ICU, Med Surge Units) Appendix II: NICU Appendix III: Operating Room/Recovery Appendix IV: Pre-Admission Testing Appendix V: Outpatient Phlebotomy Appendix VI: AOMC Emergency Room Appendix VII: SNF/TCU Appendix VIII: SJH Emergency Room Appendix IX: SJH Infusion Center and Falck Cancer Center Appendix X: SJH Mixed Medical and C4 Unit

4 TITLE: Collection of Blood Bank Samples POLICY # TR210.0 Page 4 of 14 APPENDIX I: General Workflow: ICU, Med/Surg, MAT, L&D

5 TITLE: Collection of Blood Bank Samples POLICY # TR210.0 Page 5 of 14 APPENDIX II: NICU Workflow

6 TITLE: Collection of Blood Bank Samples POLICY # TR210.0 Page 6 of 14 APPENDIX III: Operating Room/PAR Workflow

7 TITLE: Collection of Blood Bank Samples POLICY # TR210.0 Page 7 of 14 APPENDIX IV: Pre-Admission Testing (PAT) Workflow

8 TITLE: Collection of Blood Bank Samples POLICY # TR210.0 Page 8 of 14 APPENDIX V: Outpatient Phlebotomy Workflow

9 TITLE: Collection of Blood Bank Samples POLICY # TR210.0 Page 9 of 14 Appendix VI: AOMC Emergency Room

10 TITLE: Collection of Blood Bank Samples POLICY # TR210.0 Page 10 of 14 Appendix VII: Skilled Nursing Floor and Transitional Care Unit (TCU)

11 TITLE: Collection of Blood Bank Samples POLICY # TR210.0 Page 11 of 14 Appendix VIII: SJH Emergency Room

12 TITLE: Collection of Blood Bank Samples POLICY # TR210.0 Page 12 of 14 Appendix IX: SJH Infusion Center and Falck Cancer Center

13 TITLE: Collection of Blood Bank Samples POLICY # TR210.0 Page 13 of 14 Appendix X: SJH Mixed Medical and C4 Units

14 TITLE: Collection of Blood Bank Samples POLICY # TR210.0 Page 14 of 14 Appendix XI: Home Phlebotomy and Satellite Phlebotomy Draw Stations (Only 1 phlebotomist)