Better blood orders improve inventory control
Project eases physicians toward tougher changes
Confusing physicians' orders - sound familiar? They were a long-standing problem for the Laboratory Medicine Department at Indiana (PA) Hospital.
"A lot of times, the clinical secretaries and nurses placing the orders were unsure about what the physician had written on the patient chart," recalls blood bank and hematology supervisor Lori Romanish, MT (ASCP) BB.
"And they were calling us for clarification." In fact, it was all in a day's work for the secretaries and nurses to verify nearly one out of five orders. Not only were 19% of blood orders ambiguous, many called for more blood work than was necessary.
Three years ago, all of that came under the glaring light of the hospital's quality improvement initiatives. Today, vague orders are down to 1.7%. "Ambiguous orders were just the door opener," explains David Bernabo, quality management specialist.
"Now we're looking at deeper changes that actually come closer to the core of the individual surgery practices." (For comparisons of the first two years of monitoring ambiguous blood orders, see graphs for 1996 and 1997, p.47.)
Two tests caused the most confusion.
1. The type-and-screen checks a patient's blood type and screens for irregular antibodies. It's used when the need for a blood transfusion is uncertain.
2. When a transfusion is imminent, the crossmatch is in order. It determines compatibility between donor and recipient blood. Crossmatching is more extensive and involves reserving units of compatible blood units for three days.
"We were receiving orders for a `type-and-screen for two units of blood' or a `type-and-screen and hold,' but the type-and-screen does not involve reserving any units of blood." Romanish explains. "They may have meant a crossmatch instead."
Besides its dollar-gobbling inefficiency, that sort of ambiguity posed a threat to patient care. "There was a concern that if a physician intended to order a crossmatch and thought blood was immediately available, but the person placing or receiving the order interpreted it as a type-and-screen, it could have caused a delay in getting blood for a patient," Bernabo notes.
Bernabo was able to get a handle on the situation in April 1995, thanks to computerization. But he didn't stop there.
Reducing ambiguous blood orders was one part of Indiana Hospital's overall blood review initiative. Achieving it involved four physicians attending monthly procedure review meetings. Enlisting their cooperation "took nothing other than telling them we need to look at our track record," Bernabo says. When the blood orders went electronic, they were entered into the computer as a mnemonic code: TS for type-and-screen and XM for crossmatch.
Next, the procedure review committee added another checkpoint. Clinical secretaries and nurses placing the order typed exactly what the doctor wrote on the patient chart. "This helped with tracking orders by showing how they were entered and how they were interpreted," Romanish explains. "That way, we could see if ambiguous orders were a physician-related problem or a problem with the clinical secretaries or nurses who were placing the orders."
A study of 85 ambiguous blood orders placed during the first quarter of 1996 revealed that most of the confusion started when the orders were written on the patient's chart. From that finding evolved the standard terminology for ordering blood. (See chart, p. 48.)
Still whittling away at the present 1.7% of ambiguous orders, Bernabo hand-carries questionable chart notes to their authors and explains the difficulty. "They have the facts in front of them. They know the writing is theirs, and it reminds them to be more careful."
Another progress note emerged from the blood ordering process. "In the past, physicians had the tendency to order excessive crossmatches so blood was being held and then not being transfused," Bernabo explains.
"This would tie up blood in the inventory that could have been used for other patients," adds Romanish. "As a result, we'd have to keep more blood on hand."
To provide a standard, in July 1996, Romanish wrote a guide to transfusion services for the nurses and physicians. During her inservice presentation on the standard, she reassured them they would have no longer than a 15- to 20-minute wait if typed-and-screened blood suddenly had to be crossmatched for transfusions.
Since 1995, the crossmatch rates resulting in transfusion went from 63% to 73%. "We were able to reinforce that for some surgeries, it wasn't necessary to tie up blood by ordering a crossmatch," Romanish says. "We reduced the amount of blood kept on hold, which improved blood availability for patients and cut costs by eliminating unnecessary crossmatches."
Victory pries open gates to sacred turf
Bernabo regards the blood ordering improvements as the warm-up for the more ticklish quality improvements he envisions within the private boundaries of individual physicians' care practices. As one might expect, their cooperation is difficult to win.
For instance, he suggests that such time-honored practices as reserving two units of crossmatched blood for radical prostatectomy or radical mastectomy are outdated. "Those surgeries used to have high transfusion rates, but with operating room improvements in cauterization, they're not such bloody procedures anymore," he comments.
Building on his experience with the blood ordering process, Bernabo has become deft at gathering data, showcasing it for the doctors and letting the evidence speak for itself. He produced literature and statistics from other hospitals to make the case for fewer pre-op crossmatches.
"It's still laborious," admits Bernabo, "because we meet monthly. But the receptivity of the doctors has increased. They realize that [quality management staff] put in the effort of providing them with good data. As individuals, they are more willing to change their individual practices."
[Contact information: David Bernabo, Quality Management Department, Indiana Hospital, PO Box 788, Hospital Road, Indiana, PA 15701-0788. Telephone: (412) 357-7176.]
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