Making patients safer in the OR
One hospital revamps its blood availability process
A pediatric patient at Shands Healthcare at the University of Florida, Gainesville made it to the operating room (OR) for a surgery likely to require blood, but upon arrival, no blood or active blood type and screen was available.
That's when Stephen Lucas, MD, division chief of the Division of Regional Anesthesiology and Preoperative Pain Medicine at the University of Florida and medical director of the ORs at Shands, decided to investigate the process of getting blood to ORs.
Lucas knew the 850-bed hospital needed a new process to put an end to incidents like this. "Our ultimate goal in the beginning was to ensure no patient ever entered an operating room for elected surgery who might need blood products that we had not arranged, and that we'd have those products available immediately," he says. "We wanted to promptly obtain blood in the OR for all elective cases where it might be needed."
The new blood stop check process has been in place for more than a year now, during which time there has not been a situation in which blood is unavailable for an elective surgery patient.
Determining whether blood is needed
Lucas and his team first assessed the blood distribution process as it already existed, which revealed a few issues that needed to be addressed.
Lucas and his team broke down the entire process, including how the blood was first ordered, how the need for blood was determined, and how the hospital confirmed whether blood was available.
The problem, they found, began with admission. The form on which blood was ordered was misleading.
"It was essentially a bed request form, not a physician order sheet," Lucas says. "The nature of the form misled surgeons to think they were writing orders, so we eliminated the form altogether."
After identifying that issue, Lucas realized that there was no foolproof method to confirm whether a patient had his or her blood typed and screened or whether there was blood available.
"We were relying solely on surgeons if blood was available or not, and while some were on top of their game, others were not," he says.
To determine whether a patient should have blood available during surgery, the team looked to the current procedural terminology (CPT) codes. It scanned the entire CPT book for surgical procedures and pulled out every code that would indicate a patient's blood type and screen should be taken. The team brought these findings to the chairs of the surgical department to whittle down to a more reasonable list of codes. CPT codes are now posted in the ORs to alert staff members if a blood type and screen is recommended.
Getting blood samples processed in a timely manner
The major component of the blood availability stop check process heavily involved the blood bank.
Belinda Manukian, MT(ASCP)SBB, blood bank manager at Shands, was also involved with the development of the blood availability stop check process. She recognized a few areas for improvement in the blood bank.
"We started addressing an issue in which the blood bank was not getting preoperative type and screens 24 hours ahead of time to work on," Manukian says. "We were getting orders the day of surgery and even when the patient was in surgery."
The blood bank didn't have much time to produce the blood, especially if there were any complications, such as problems with blood antibodies.
"It caused a huge impact in patient care and turnaround issues," she says.
Manukian's team discussed the process issues they saw with the surgical department. A patient was getting a preoperative blood type and screen 24 hours prior to the day of surgery only 30% of the time. Manukian and her team aimed to increase that number through the use of CPT codes.
The blood bank also now has a night shift staff member review the next day's schedule of surgeries to look for the blood type and screen recommendations. That person then checks to see whether the patient has an active type and screen for the procedure-meaning the patient's blood was typed and screened recently-and if it hasn't been, he or she takes the appropriate action.
"We increased to 70% of patients getting type and screen 24 hours prior to surgery, which has allowed us to have a more stable workload," Manukian says.
The team also discovered that a blood type and screen only stayed active for 72 hours-creating more work than necessary.
"If the most recent screen was more than 72 hours old, a new sample was required to be drawn and the screen to be repeated before blood was allowed to be dispensed," Manukian says.
For example, if a surgeon sees a patient Thursday and schedules him or her for surgery Tuesday, the type and screen would become stale and inactive Sunday night. The blood bank updated the process to allow outpatients a 30-day time period for a blood type and screen to remain active, with certain restrictions: They could not have had a blood transfusion or become pregnant within the past six months.
Within almost five months, the blood bank and the hospital had successfully implemented the new time period.
New tower leads to new issues
In the midst of the project, Shands opened a second tower across the street. This created another challenge as there was now an OR on both sides of the street, with an underground tunnel connecting the two. The hospital's initial plan was to have only one blood bank, so it was moved to the new tower.
"When we started simulating this, we found it took too long for, say, a cardiac surgery to get its blood," Lucas says. His team had to undertake a process redesign, leading to the use of BloodTrack® HemoSafe®, a proprietary product on the market used as a blood vending machine.
The HemoSafe brought up a few more questions, including who would access it. The OR nurses could be trained to use the HemoSafe, as could the charge nurses, but Lucas and his team determined that when blood was needed quickly, nurses might be too busy.
"We located the HemoSafe in our staff laboratory and trained the staff lab technicians on the use of the HemoSafe so there would always be someone there who could do it," says Lucas. After it was placed in a staff lab directly outside of the OR, concern was expressed about the products that couldn't be kept in the safe but might be needed quickly. (The HemoSafe cannot contain less commonly used blood items such as cryoprecipitate and irradiated blood.) For those types of products, the team created a satellite dispensing station.
"We have this satellite blood bank that doesn't do any testing, but they do have all major components of blood and can dispense to make the process move along much faster," says Lucas.
Implementing one last check
To ensure that staff members were following the new process, Lucas' team implemented a surgical checklist to use as one last hard stop before having a patient brought to the OR. As an added bonus, the hospital uses hard stops to generate error reporting so the team can review and investigate why blood need wasn't determined earlier and at what point in the process blood availability need was overlooked.
"I feel comfortable that the hard stop works," says Lucas. "We know how frequently that hard stop has to be invoked in preop, and it's typically once or twice a month." Progress is measured based on the frequency of the hard stops.
"The new process has been a huge improvement in patient safety at Shands," Lucas says.