If the patient comes through the ER, self identifies as a JW, and has a "no blood" card or advanced directive, then the ER registration staff place an armband on the patient. If a question is raised about the pt's status, then the House Nursing Supervisor may get involved and place an armband (especially if there is no advanced directive). The Supervisor speaks with the patient, obtains a signed "Refusal of Transfusion" form and places the identifiers. A message is left with the Blood Mgt Coordinator for follow through when they are available.

Elective PreOp patients who are identified as being unwilling to accept blood transfusions (this is done on our scheduling form from the MD office) are contacted in advance by the Blood Mgt Coordinator who verifies their information, assists with surgical planning, monitors preop bloodwork, etc. Pt. identification bands, signs, stickers, etc. are provided to the PreOp area (along with BMC notes, etc.) in advance and the preop staff place the armband when the patient arrives at the facility for the procedure. If the pt has not provided a copy of their "no blood AD" in advance, they are asked to sign a "Refusal of Transfusion" form in the preop area.

All other inpatients / observation patients are identified through the nursing assessment (done within a minimum number of hours) upon admission. In our electronic record, this "triggers" a pop-up identifying the need to contact either the Nursing House Supervisor (if the issue is urgent or the pt. is actively bleeding) or to leave a voice mail for the BMC to followup when next available. This "trigger" also goes to a BMC daily "list" that is generated by the computer when either a "no" answer is provided to the question or the pt's religious preference indicates JW.

While we do not expect the registration personnel to label the pts with the "no blood" band, we do expect them to ask questions about "advanced directives" and obtain copies if they are available. Registration also scans these "advanced directives" into the permanent electronic record so they are easily retrievable upon subsequent admissions.

The problem with non-clinical folks "banding" the patient (from my perspective) is that there needs to be more discussion of a clinical nature to determine pt's rationale for their decision, provide education, discuss alternatives acceptable to the patient (such as personal conscience issues), etc. before identifying a "no blood" patient in our facility so insure that a patient truly has an "informed" decision, either pro or con to blood transfusions. Because we will honor the patient's decision and try to avoid "pressuring" tactics from our physicians and other clinical staff, we want to insure that the initial decision was truly "informed" and backed up by paperwork.