LEARNING OUTCOMES

Upon completion of this exercise, participants should be able to do the following:

 
1. Discuss standards and best practices related to monitoring patients before, during, and after transfusion.
2. Discuss best practices for investigating a suspected transfusion reaction.
3. Explain the responsibilities of health professionals for patient safety as it relates to their scope of practice and other health providers.
4. Discuss perceived loss of professional autonomy as an obstacle to collaboration and open questioning within health teams.
5. Describe mechanisms that can allow members of different professions to question inappropriate orders and decisions of other health providers in a collaborative environment.
6. Discuss education to assure that health providers have the necessary skills to provide expected interdisciplinary checks for patient safety, such as questioning physician orders.

Original CASE

This case derives from an unpublished  study case created by Amélie Rivard, Nurse Clinician in charge of Transfusion Safety, McGill University Health Center.  Amélie and her colleague Anna Urbanek work as Nurse Clinicians in charge of Transfusion Safety at MUHC. Amélie Rivard retains copyright for the original case. TraQ has copyright for this web-based case, which has been fictionalized to enhance its educational value. The described events and practices did not happen at MUHC.

TOP

ACKNOWLEDGEMENTS

Special thanks to the following who kindly provided advice, information, and ideas for the case. The discussion benefits from their valuable input (errors or misstatements are entirely those of the author):

• Gwen Clarke, MD FRCPC (Capital Health, University of Alberta, & Canadian Blood Services, Edmonton, AB)
• Denise Evanovitch, MLT, Dipl. Adult Ed (Technical Specialist, Education and Training, Hamilton Regional Laboratory Medicine Program, Hamilton, ON)
• Kate Gagliardi, BA, ART (Regional Blood Coordinator, Ontario Regional Blood Coordinating Network, Hamilton, ON)
• Ana Lima, RN, HP (ASCP) (Transfusion Safety Nurse, Sunnybrook Health Sciences Centre, Toronto, ON)
• Veronika Pulley, RN (Blood Conservation Program Coordinator [ONTraC], Windsor Regional Hospital, Windsor, ON)
• Amélie Rivard, RN (Transfusion Safety Nurse, McGill University Health Centre, Montreal, PQ)

case scenario

The essentials of the case: (Hover mouse over words  to expand to a definition) PRESENTATION A 26 year old single female living with her parents was admitted for a CSF leak from the nose, fever, lethargy, neck stiffness and pain. She had multiple surgeries in the past and her health status was poorly controlled. She was admitted to the ER on Jan. 9 for brain surgery. A diagnosis of meningitis followed within a few days. On Jan. 12 a CT scan of the head showed a large amount of intracranial air in the subarachnoid space and ventricular system. There was a moderate hydrocephalus and the size of the ventricular system had progressed. Between the Jan.12–13 a drain was inserted via a frontal burr hole, the tip of the drain located in the third ventricule. On the following CT scan the volume of intracranial air had slowly decreased and the size of ventricular system was reduced. The morning of Jan. 19 the physician decided to close the drain and the patient stabilized. In the afternoon of Jan. 19 patient hemoglobin was dropping quickly and the physician decided to transfuse 2 units of packed red blood cells (PRBC). Blood Test Results (Reference Range) Hemoglobin               79 g/L (120–160) Hematocrit                 0.270 L/L (0.370–0.470) Platelets                     503 x 109/L (140–440 x 109/L) Past Medical History Retinoblastoma (bilateral resection and radiotherapy) Rhabodomyosarcoma (chemotherapy in 2005) Nasal and sinus surgery Port-o-cath insertion (Port-o-cath) Transfusion Service Laboratory The patient had been tested once before in another hospital as O Rh positive.  A type and screen was done, 2 units of packed red blood cells (PRBC) were crossmatched, and one was sent to the patient's ward. Transfusion - PRBC #1 The first unit was started at 10:55 am. Vital signs were recorded: Blood pressure: 130/72 Oxygen saturation: 96% Temperature: 36.9oC Pulse: 109/min. As the nurse was unable to get an infusion rate faster than 1 drop/10sec., she flushed the port-o-cath with 350 U of heparin. The rate did not increase and she replaced the needle with no success. Finding a new IV access was unlikely because patient had poor vein access and would have required a new port-o-cath insertion or a central venous access, not considered possible as the patient was already unstable. The nurse called the attending physician to explain the situation and charted the conversation as follows: Dr. Brown was made aware; he ordered to continue transfusion even if it takes all day The nurse followed the order and ran the transfusion over a little more than 8 hours. No further vital signs were taken. Transfusion - PRBC #2 The second unit was started by the same nurse (who was working a 12-hour shift) at 19:15 h. Vital signs were taken with no untoward results. No further vital signs were taken until 20:30 h. when the patient started shaking and stiffness was noted. The transfusion was stopped, the physician was contacted, and the nurse followed standard procedures detailed in the facility's nursing manual. Vital signs were Temperature: 40.9 oC  (axillary ) Pulse: 220/min. Blood pressure: 150/99 Oxygen saturation: 98% on rebreather The patient presented decerebration but no clonus opisthotonos , no bronchospasm,  but loss of consciousness. The patient was given Benadryl IV, bolus 250cc and solumedrol IV push. The patient was then transferred to an intensive care unit. In the ICU, patient was covered with cooling blanket and received Lopressor x 4 doses, Fentanyl push, Propofol, Dilantin, IVIg boluses, Tylenol. The patient was finally intubated and put into artificial coma. Blood culture was done and blood bag returned to blood bank for investigation. FOLLOW-UP Laboratory Services Upon detecting the suspected transfusion reaction, the transfusion service (TS) was contacted and the TS performed a transfusion reaction investigation according to its policy and procedure manual, eliminating a hemolytic transfusion reaction as the cause. Because a bacteriogenic reaction was suspected due to fever subsequent to a prolonged transfusion time (8 hrs.+),  the hospital microbiology laboratory performed gram stains and cultures of both PRBC contents, as well as recipient blood cultures. All were negative. Educational Subsequent analysis revealed that the nurse in question required remedial training related to resolving slow running transfusions and critical thinking in general, and also required re-training for how to monitor and document transfusions. A more systemic problem was identified regarding the responsibilities and related skills of health professionals to provide checks for patient safety as part of the healthcare team. In-service interdisciplinary educational sessions were held to discuss and resolve the issues.

DISCUSSION

Proceed to Discussion (includes interactive questions with feedback):

• Part 1: Administering blood products  (inc. time limits)

• Part 2:  Investigating adverse events  (inc. differential diagnosis of transfusion-associated fever)

• Part 3: Scope of practice issues

• Part 4.  Education for interdisciplinary healthcare teams