I had a patient the other day - CABG x 3 but had to go back to the OR for a bleed. Upon returning to the unit, the pt was still bleeding some. The MD wanted to give some platelets and draw some bleeding studies. The pts platelet count was within normal limits, but he wanted the platelets anyway. OK, no problem.........I get a phone call from the lab - not the blood bank - the lab - asking me "why do you want to give platelets? The platelet count is within normal limits. Does the doctor know what the count is?" I said yes he knows and that I need them. She proceeded to ask me why - over & over - "Why would you give plts if the count is normal" Keep in mind, this conversation is pulling me away from pt care - fresh post op - on levophed - kind-of sick (coworker watching pt while I was on the phone!!). We kept going back & forth :argue: - After I quickly and as nice as I possibly could at the moment - told her this was a very sick pt - I hung up on her. I had a coworker call the blood bank and got my plts up.
One more situation - when we draw aptts - the lab calls and gives us the out of range result, but always asks if they are on heparin? Do they have to document this somewhere? Why do they ask?
Shouldn't they just give us the out of range levels and be done? We as nurses will call the MD with the abnormals if appropriate.
Has anyone else had the lab question them like this?
Specializes in Telemetry, ICU, Resource Pool, Dialysis.
Personally, I think the reason we have so many problems with support departments is that some of the people in those departments have NO idea what the big picture is all about. They see situations from behind their computer screens, or microscopes and have no grasp of reality.
I work with some of the best lab, pharmacy and radiology people on Earth, and a few of the worst. One of my favorites (I can look back now and laugh) was when I had some STAT lab drawn on a pt with a subdural hematoma who was being flown to another hospital. The doctor didn't want her to leave until he got the results back from the lab. We waited... I called.... He called... nobody knows where the blood is. Or the tech. 20 minutes later they find him and the blood in the ER chatting with some pals. His excuse? "What's the problem?? I came over and got it DRAWN STAT!"
I currently work in the lab and I will say that most of the folks I work with are very good about simply reporting the results as they are and not asking questions. The one reason that I can think of in regards to asking if the patient is on heparin (for the PTT) would be that the reference ranges (point at which the result becomes out of range) are different for patients who are on heparin as opposed to patients who are not. But then again, that's not a question that lab is required to ask.
Specializes in Infection Preventionist/ Occ Health.
I had a patient the other day - CABG x 3 but had to go back to the OR for a bleed. Upon returning to the unit, the pt was still bleeding some. The MD wanted to give some platelets and draw some bleeding studies. The pts platelet count was within normal limits, but he wanted the platelets anyway. OK, no problem.........I get a phone call from the lab - not the blood bank - the lab - asking me "why do you want to give platelets? The platelet count is within normal limits. Does the doctor know what the count is?" I said yes he knows and that I need them. She proceeded to ask me why - over & over - "Why would you give plts if the count is normal" Keep in mind, this conversation is pulling me away from pt care - fresh post op - on levophed - kind-of sick (coworker watching pt while I was on the phone!!). We kept going back & forth :argue: - After I quickly and as nice as I possibly could at the moment - told her this was a very sick pt - I hung up on her. I had a coworker call the blood bank and got my plts up.
The reason the tech was questioning you is that we in the lab have a specific protocol for when platelets are to be transfused. These standards were approved by the American Association of Blood Banks, and reflect the fact that platelet transfusions carry with them many risks, among them infection, transfusion reaction, and development of HLA antibodies. We are held accountable by the pathologist if proper procedures are not followed, and this includes ascertaining the reason for the transfusion when it does not appear to be clinically indicated.
There must be solid clinical evidence to back up a decision to issue (in the case of the blood bank) or administer a blood product. "Because the doctor ordered it" is not a solid legal defense, and it is not in the best interest of the patient, either.
One more situation - when we draw aptts - the lab calls and gives us the out of range result, but always asks if they are on heparin? Do they have to document this somewhere? Why do they ask?
Shouldn't they just give us the out of range levels and be done? We as nurses will call the MD with the abnormals if appropriate.
Has anyone else had the lab question them like this?
There are a couple of reasons why a tech may question you about heparin administration. First, they may be exploring the possibility of a contaminated line draw. Last weekend, I had just such a case happen, and the aPTT came back as >240 seconds (line draw contaminated with heparin) when it was really 82 seconds (peripheral stick). If this patient had been treated with protamine sulfate, the lab as well as the nurse who did the line draw would have been held responsible. As it was, I had to write up the nurse and send the report to risk management because it was not caught up front.
Second, there are different reference ranges for patients who are receiving heparin vs. patients who are not. It could be that heparin therapy must be noted in the computer in order for the correct reference range to appear on the report.
The laboratory also has something called "delta checks". Simply stated, this means that if a result on a patient differs significantly from what it was previously, the tech is responsible for investigating the possible causes of this discrepancy before reporting the result.
As hard as it may be to believe, the lab is looking out for the best interest of your patients and we care about them just as much as you do. Please try to be nice, and for goodness sakes, don't hang up on us when we're just trying to do our job!
As a side note, I am sensing a lot of hostility towards the lab and other "support" areas. Remember, without them the hospital would cease to function. It is attitudes such as these that contribute to the poor relationships that exist between the departments at many hospitals.
Specializes in Infection Preventionist/ Occ Health.
I currently work in the lab and I will say that most of the folks I work with are very good about simply reporting the results as they are and not asking questions. The one reason that I can think of in regards to asking if the patient is on heparin (for the PTT) would be that the reference ranges (point at which the result becomes out of range) are different for patients who are on heparin as opposed to patients who are not. But then again, that's not a question that lab is required to ask.
If the techs at your lab are good about just reporting out the results, then then I would not consider them to be "good" techs. Part of our job is making sure that the results we report out are correct and appropriate.
My biggest complaint is with Physical Therapy. The other day they had orders to get the patient (who is very large and is non weight bearing) out of bed t.i.d. p.t. got the patient up and three hours later he wanted to go back to bed. When we called for them to put him back the Physical Therapis said "the order was only to get him out of bed you will have to put him back." After threatening to report them to the physician they finally saw things my way.
Specializes in Telemetry, ICU, Resource Pool, Dialysis.
The reason the tech was questioning you is that we in the lab have a specific protocol for when platelets are to be transfused. These standards were approved by the American Association of Blood Banks, and reflect the fact that platelet transfusions carry with them many risks, among them infection, transfusion reaction, and development of HLA antibodies. We are held accountable by the pathologist if proper procedures are not followed, and this includes ascertaining the reason for the transfusion when it does not appear to be clinically indicated.
There must be solid clinical evidence to back up a decision to issue (in the case of the blood bank) or administer a blood product. "Because the doctor ordered it" is not a solid legal defense, and it is not in the best interest of the patient, either.
I understand your point of view. We all have to follow our departmental rules. However, I think it's an example of "thinking inside the box" that is the root of most of these complaints. In a non-emergent situation, argue away. Please feel free to contact the ordering doc yourself and explain your protocols. But, until you've been on the other side of the phone, standing next to an extremely unstable, bleeding patient dealing with an equally unstable, exhausted and frustrated surgeon - please just do what's ordered.
And, by the way, CP bypass destroys platelets. In my experience, these values may be near normal immediately post-op, but will usually dramatically decline in the next few hours. A patient who has been back on bypass a second time is going to show an even bigger drop. There's your "clinically indicated" reason.
Specializes in Infection Preventionist/ Occ Health.
I understand your point of view. We all have to follow our departmental rules. However, I think it's an example of "thinking inside the box" that is the root of most of these complaints. In a non-emergent situation, argue away. Please feel free to contact the ordering doc yourself and explain your protocols. But, until you've been on the other side of the phone, standing next to an extremely unstable, bleeding patient dealing with an equally unstable, exhausted and frustrated surgeon - please just do what's ordered.
I agree with what you are saying. However, I would add that just because it is an emergent situation, this does not mean that we should just "do what's ordered" if it will do the patient more harm than good. These protocols are in place for a reason. Most lab tech (and nurses) would argue that taking a few minutes to consider whether you are making the best decision is worth the time.
And, by the way, CP bypass destroys platelets. In my experience, these values may be near normal immediately post-op, but will usually dramatically decline in the next few hours. A patient who has been back on bypass a second time is going to show an even bigger drop. There's your "clinically indicated" reason.
If you had given this reason for wanting the platelets, I would have given them to you. However, I am under the impression that the OP did not do this. She just continued to insist that the blood bank issue her the platelets without giving a good reason.
If you had given this reason for wanting the platelets, I would have given them to you. However, I am under the impression that the OP did not do this. She just continued to insist that the blood bank issue her the platelets without giving a good reason.
And if the lab needed to document a reason on their end, they could have also mentioned that. Sorry we don't know all the intricacies of each and every department, nor is it reasonable to expect that we should. We also are only supposed to reveal patient information on a need to know basis. Let us know the need.
Regarding heparin... When ever we draw INR/PTT stat or otherwise we have to check of the type of anticoag (heparin or fragmin) and the dosing (daily, bid or tid) or if the are receing none. The values are different depending on the types and dosages of the anticoag given.
Regarding Physical therapy post... just because its ordered for physio does not mean as a NURSE you cannot put your patient back to bed. Why would you let your patient sit for 3 hours if immediately post op and likely deconditioned and barely able to tolerate 1 hour little own three? The PT has to do an assessment when the move the patient, and if there is any doubt about how to transfer the patient then review their assessment as it should clearly indicate assist of 1 or 2... walker... pivot or total lift ie. ceiling lift etc etc.
In hospital, I worked on a 40 bed surgical unit where we shared a PT and PT assistant between two units of the same number of beds. They simple don't have time to come back to put the patient to bed after they have mobilized them and then settled into a chair if they aren't too tired after taking a short walk (which assists in keeping those lungs clear). Why not just spend the 2 minutes it takes to put them back to bed after 45-60 minutes of sitting?
Specializes in Telemetry, ICU, Resource Pool, Dialysis.
I agree with what you are saying. However, I would add that just because it is an emergent situation, this does not mean that we should just "do what's ordered" if it will do the patient more harm than good. These protocols are in place for a reason. Most lab tech (and nurses) would argue that taking a few minutes to consider whether you are making the best decision is worth the time.
Sometimes a few minutes is time that could have been spent doing something more useful for a critically ill patient. Like I said earlier, when you experience it first hand, you will understand. In emergent situations, there is usually not time to consult the latest literature or discuss the pros and cons. As a nurse, I don't make the decision to order and transfuse platelets. The time for asking questions and argument is AFTER the patient is treated. I can't believe you would seriously expect someone to stand there and explain the mechanics of CP bypass and platelet destruction while a patient is crashing. I seriously don't mean to sound so argumentative, but this is a problem many of us have had to deal with.
I've seen blood bank argue about giving up more than 1 unit of blood at a time for a patient who had been opened up in the room and was pumping blood all over the place. This guy was standing in his nice clean, quiet lab arguing about protocol while a patient was literally suffocating due to rapid blood loss.
pricklypear
1,060 Posts
Personally, I think the reason we have so many problems with support departments is that some of the people in those departments have NO idea what the big picture is all about. They see situations from behind their computer screens, or microscopes and have no grasp of reality.
I work with some of the best lab, pharmacy and radiology people on Earth, and a few of the worst. One of my favorites (I can look back now and laugh) was when I had some STAT lab drawn on a pt with a subdural hematoma who was being flown to another hospital. The doctor didn't want her to leave until he got the results back from the lab. We waited... I called.... He called... nobody knows where the blood is. Or the tech. 20 minutes later they find him and the blood in the ER chatting with some pals. His excuse? "What's the problem?? I came over and got it DRAWN STAT!"