(P-TS-5) A Six-Month Follow-Up Audit of Making the Type & Screen Orders One Lavender Efficient for Patient’s and How Was the Policy Change Navigated?

Background/Case Studies: In December 2024, the policy for Type and Screens (TS) was changed at Froedtert Hospital. Blood Bank’s (BB) leadership was able to work with IT and the hospital care teams to decrease our Type and Screen samples to one lavender (LAV) 4mL tube from 2 LAV tubes. This change was the result of an audit performed in 2023 to determine the necessity of drawing two EDTA LAV tops. With the evidence that was collected over the course of 14 days, it was noted that less than 1% of TS orders required the use of two lavenders, 1465 out of 1472 only required one tube. An audit was performed at the 6 months post go-live to assess the effectiveness of the TS order policy change. The purpose of this follow-up audit was to reevaluate the policy change of using one LAV tube and determine if this was the appropriate course of action for patients and facility care teams. The audit allowed the BB to determine how many times there had to be a workaround or redraw due to sample scarcity 6-mo post policy change. This audit helped the BB analyze if the amount of specimen drawn was adequate for testing done in the BB on a long-term basis vs the 14-day audit done in 2023.



Study

Design/Methods: For this audit April-May TS samples tested were evaluated to assess the necessity of a second LAV to complete testing. Other items that were considered during the audit were initial screens that tested positive, antibody identifications, and AHG crossmatches needed for patients with antibodies.

Results/Findings: In January 2025, there was a learning curve for all care teams. BB was not receiving full 4mL LAVs until the leadership team worked with IT to have an EPIC order comment stating “Tube must be fully filled” under lab collection instructions. Also, cardiac ICU was asked to start drawing 4mL LAV tubes instead of 2mL tubes. In the BB a workflow was created to determine if additional specimens needed to be collected or if a CBC could be used to complete testing. During the audit of 30 days, 3501 TS samples were tested in the BB. Of those samples only 3 required the use of a CBC LAV (CBC drawn at the same time as the TS specimen) to complete the antibody screen. Of those TS samples audited, 111 (3.2%) resulted in a positive screen. Only 1 of those positive screens required an additional sample to complete the antibody identification. Also, 275 AHG crossmatches (XM) were performed, only 2 (0.7%) of these XM’s required the use of additional sample.

Conclusions: These findings have confirmed that only one 4mL LAV tube is needed for TS testing. With the evidence that was collected in this 6-mo audit it continues to demonstrate that less than 1% of patients require more than 4mL to complete testing. Hence, proving that the policy change has been successful since the implementation. This new workflow has helped reduce costs, storage space in the fridges, and most importantly decrease the amount of blood patients have been drawn.