CAP standards versus AABB

[Karrieb61]

We had a CAP inspection last year and got dinged because Nursing Administration did not have records of nurses participating in annual Transfusion Administration training (CAP TRM 41025). This year AABB is coming and I cannot find a comparable AABB Standard that says that the Blood Bank must ensure that the nurses receive their annual training on blood product administration.. Does anyone know if this exists? Thanks

[Eagle Eye]

YOU CAN APPLY STD 2.1.2 AND ALSO CROSS REFER IT TO 1.1.1

[Karrieb61]

OK, I will check that out, thanks. Its not something I want to be held accountable for as our Nursing Admin does not take this seriously and I hate being held responsible for nagging them. Oh well, welcome to Monday

[tbostock]

Yes, sadly, we are responsible for anything nurses do involving blood transfusions. I asked about what they used for annual nursing competency for transfusion and was horrified at the content and rewrote it for them. There was a lot of outdated info and some that was just plain wrong. You want to make sure it has updated information in it (such as TRALI).

[tricore]

Is your institution inspected by The Joint Commission?

This is from the Laboratory Section. Check the Hospital section about transfusions.

The organization has policies and procedures to monitor and evaluate the patient and report suspected transfusion-related adverse events.

Standard QSA.05.18.01

Elements of Performance for QSA.05.18.01

1. The organization has written policies and procedures that guide the monitoring of the patient and the reporting of suspected transfusionrelated

adverse events during blood and blood component administration.

2. Policies and procedures that guide the monitoring of the patient and the reporting of suspected transfusion-related adverse events during

blood and blood component administration address the following:

- The protocol for monitoring patients during blood and blood component administration

- The criteria for recognizing a suspected transfusion-related adverse event

- The protocol to follow if a suspected transfusion-related adverse event occurs

- The requirement that suspected transfusion-related adverse events are reported immediately to the physician responsible for the patient

- The requirement that suspected transfusion-related adverse events are reported immediately to the laboratory, whether or not the

physician responsible for the patient deems it necessary to report the event

3. Policies and procedures for nursing services related to blood and blood component administration do not conflict with the laboratory’s

policies and procedures.

4. Patient care staff monitor the patient during blood and blood component administration to detect suspected transfusion-related adverse

events. The monitoring is documented.

5. The organization provides training for staff who administer and monitor blood and blood component transfusions. The training is

documented.

6. The organization assesses competency for staff who administer and monitor blood and blood component transfusions. The competency is

documented.

7. The organization follows its policies and procedures that guide the monitoring of the patient and the reporting of suspected transfusionrelated

adverse events during blood and blood component administration.

[Karrieb61]

Yes Tricore, we are inspected by JCAHO but I don't think they ever come to the Lab since we are CAP and AABB accredited also. No signs of anyone doing traceability back to the lab yet. We do have existing policies on blood administration and patient ID for that matter and they are fine but the annual competency/retraining documentation is dismal. I tried to reach out to the head of Nursing myself to see if I could offer up any assistance (like talking at Nursing meetings and running a mini-refresher from the BB end of things like I used to do in my last job and where I was received with open, welcoming arms) and was told that I was not to contact the Nursing Admin dept on my own, have to work through my Lab Director. Yikes. How do you spell DING

[AMcCord]

Even though we are inspected by CAP and don't see JC much, I can still use them as a weapon encouragement for cooperation from nursing in meeting my regulatory requirements. Every couple of years someone from nursing education asks me why they have to do training for recognizing transfusion reactions and transfusion policies (like YIKES...they can't see the value...Really!!!) and I tell them it's for regulatory compliance, starting with JC. It's unfortunate you aren't getting support from your own department leadership. If JC does a tracer on a unit of blood, you may get nailed (hopefully sooner rather than later, for your patients' sake) - not a bad thing because that will drive change.

[ESIZENSKY]

Is your institution inspected by The Joint Commission?

This is from the Laboratory Section. Check the Hospital section about transfusions.

The organization has policies and procedures to monitor and evaluate the patient and report suspected transfusion-related adverse events.

Standard QSA.05.18.01

Elements of Performance for QSA.05.18.01

1. The organization has written policies and procedures that guide the monitoring of the patient and the reporting of suspected transfusionrelated

adverse events during blood and blood component administration.

2. Policies and procedures that guide the monitoring of the patient and the reporting of suspected transfusion-related adverse events during

blood and blood component administration address the following:

- The protocol for monitoring patients during blood and blood component administration

- The criteria for recognizing a suspected transfusion-related adverse event

- The protocol to follow if a suspected transfusion-related adverse event occurs

- The requirement that suspected transfusion-related adverse events are reported immediately to the physician responsible for the patient

- The requirement that suspected transfusion-related adverse events are reported immediately to the laboratory, whether or not the

physician responsible for the patient deems it necessary to report the event

3. Policies and procedures for nursing services related to blood and blood component administration do not conflict with the laboratory’s

policies and procedures.

4. Patient care staff monitor the patient during blood and blood component administration to detect suspected transfusion-related adverse

events. The monitoring is documented.

5. The organization provides training for staff who administer and monitor blood and blood component transfusions. The training is

documented.

6. The organization assesses competency for staff who administer and monitor blood and blood component transfusions. The competency is

documented.

7. The organization follows its policies and procedures that guide the monitoring of the patient and the reporting of suspected transfusionrelated

adverse events during blood and blood component administration.

 

Is your institution inspected by The Joint Commission?

This is from the Laboratory Section. Check the Hospital section about transfusions.

The organization has policies and procedures to monitor and evaluate the patient and report suspected transfusion-related adverse events.

Standard QSA.05.18.01

Elements of Performance for QSA.05.18.01

1. The organization has written policies and procedures that guide the monitoring of the patient and the reporting of suspected transfusionrelated

adverse events during blood and blood component administration.

2. Policies and procedures that guide the monitoring of the patient and the reporting of suspected transfusion-related adverse events during

blood and blood component administration address the following:

- The protocol for monitoring patients during blood and blood component administration

- The criteria for recognizing a suspected transfusion-related adverse event

- The protocol to follow if a suspected transfusion-related adverse event occurs

- The requirement that suspected transfusion-related adverse events are reported immediately to the physician responsible for the patient

- The requirement that suspected transfusion-related adverse events are reported immediately to the laboratory, whether or not the

physician responsible for the patient deems it necessary to report the event

3. Policies and procedures for nursing services related to blood and blood component administration do not conflict with the laboratory’s

policies and procedures.

4. Patient care staff monitor the patient during blood and blood component administration to detect suspected transfusion-related adverse

events. The monitoring is documented.

5. The organization provides training for staff who administer and monitor blood and blood component transfusions. The training is

documented.

6. The organization assesses competency for staff who administer and monitor blood and blood component transfusions. The competency is

documented.

7. The organization follows its policies and procedures that guide the monitoring of the patient and the reporting of suspected transfusionrelated

adverse events during blood and blood component administration.

Do you know what is JCAHO requirement for adverse reaction documentation. Is it required to document yes or no for reaction outcome for transfusions? I had an FDA inspector indicate that all transfusions required documentation for transfusion outcome . We currently updated to TAR and only  adverse reactions are document .Is this compliant?

[goodchild]

That's an interesting question.

 

We also use the TAR.

 

Somewhere (I'd be curious if someone could provide the reference) it's mentioned that documenting vital signs alone isn't sufficient evidence of "continuous monitoring" for the transfusion. We've instructed nurses to also complete a nursing note to discuss the transfusion(s) that have taken place, usually something as simple as "two RBCs administered during shift no signs/symptoms of transfusion reaction." If there was a reaction the interface would be used.

[tricore]

I would look at the whole hospital Joint Commission requirements for transfusion. I don't have a copy of the hospital requirements, just the lab requirements. I don't know what the nurses record in the computer when they transfuse a patient.

[AMcCord]

Our electronic transfusion flow sheet (which mirrors the paper version we used for years) requires a YES or NO statement to the question 'Is there evidence of a transfusion reaction?' The nurses also make very brief comments regarding the transfusion in their progress notes. We've had no problems with JC over many inspections. Ditto for CMS.

[mollyredone]

We had a CAP inspection last year and got dinged because Nursing Administration did not have records of nurses participating in annual Transfusion Administration training (CAP TRM 41025). This year AABB is coming and I cannot find a comparable AABB Standard that says that the Blood Bank must ensure that the nurses receive their annual training on blood product administration.. Does anyone know if this exists? Thanks

Luckily I was proactive on that standard and worked with the nursing educators to develop a powerpoint LEARN module that the nurses have to take annually.  When we had our inspection last fall, I asked the educators to send me a list of all the nurses that had taken the course, and the inspector was satisfied.

[carolyn swickard]

If your Lab changes to Joint Comm accreditation too, you might have much more cooperation from Nursing on these standards, because they understand Joint and they respond to Joint inspectors better than they ever did to CAP inspectors.  We changed to Joint Comm accreditation for the Lab too (for corporate financial reasons) and FINALLY got yearly documentation of nursing training and competency.  Many hospitals have changed Lab accreditation to Joint in the last few years both for the financial reasons and because they don't have to answer to both Joint and Cap/AABB for Lab operations.  Even if you are not accrediated by Joint in your Lab now, the Joint inspectors can and sometimes do, come to the Lab while following their tracers, making the Lab essentially responsible for 2 sets of standards.  Administrators refer to that as double jeopardy.

[kirkaw]

If your Lab changes to Joint Comm accreditation too, you might have much more cooperation from Nursing on these standards, because they understand Joint and they respond to Joint inspectors better than they ever did to CAP inspectors.  We changed to Joint Comm accreditation for the Lab too (for corporate financial reasons) and FINALLY got yearly documentation of nursing training and competency.  Many hospitals have changed Lab accreditation to Joint in the last few years both for the financial reasons and because they don't have to answer to both Joint and Cap/AABB for Lab operations.  Even if you are not accrediated by Joint in your Lab now, the Joint inspectors can and sometimes do, come to the Lab while following their tracers, making the Lab essentially responsible for 2 sets of standards.  Administrators refer to that as double jeopardy.

cswickard,can I ask the size of your hospital? We are considering going from Joint Commission TO CAP and the issue that you describe is exactly our concern. Thanks!

[carolyn swickard]

Hi - just happened to run into this again.  We are now a 190 bed, community hospital and we belong to the Lifepoint Healthcare system, headquartered in Tenn.