woebegone1997

I worked at a blood center for years and used the Raycell Mk2 (the 3.5L model, the larger model that can do up to 6 RBCs at once). It was a pain to install and maintain the water source to cool the system. During the colder months (in the Northeast US), the water source had to be bypassed because it was too cold. We had to keep tweaking the pump and the filter system until we found one that could handle our municipal water--amazing how much sediment is in it! The Mk2 was down a LOT, IMHO. It was not like Best Theratronics Cesium irradiator, which was almost NEVER down, but which nevertheless had to be replaced (a) because it could only do 1 RBC at a time, and (b) because of the onus of all the security and NRC regulations. Because it was down so much, and the blood center had to maintain a supply of irradiated blood/platelet products, we had to ask a local hospital to irradiate for us, sometimes for several days at a time. Having said that, I did hear that a nearby hospital was using the Mk2 2.0L model, the smaller one that can do up to 4 RBCs at once, and it was almost never down... You HAVE to consider that the X-ray tubes have to be replaced every 7 years or so, at a considerable expense. Best Theratronics is a Canadian company. Not that I have anything against our neighbor to the north, but the equipment was more than once held up by customs, and PM or repair was delayed, sometimes by several days. I am now at a hospital transfusion service (the one that I used to send the blood center's irradiation to during down-time!), and back to using the Cs-137 GammaCell 1000 irradiator. Because of all the security/NRC compliance issues, I would love to switch to an X-ray irradiator. In my research, I found the Rad Source RS-3400 quite appealing. The sales person at the company said that all PM & repairs--including the X-ray source replacement, are covered by the maintenance contract (15k/year). And this is an American company, so no customs delays! Carrie M., what has your experience been since you switched a year ago? Are you happy that you changed from the Raycell? Again, I would love to go away from the Cs irradiator, and I'd love to hear the comparison/contrast between the Raycell & the RS-3400 from someone who has experience with both.

Thanks, David. Yes, the woes of salaried managers/supervisors!

David, are you the only one who takes call, or do you share on call with your supervisors?

My hospital network has had the benefit of the same transfusion medicine director's expertise and consistency for decades, but we are now preparing for her retirement. Obviously the qualifications and responsibilities of the TM director are driven by the accrediting and regulatory bodies, but we are surveying the practices of other hospitals/hospital networks for best practices of the transfusion medicine profession as we re-build this position. We would especially like to hear from institutions that are similar to ours: our network currently consists of 4 hospitals, the largest of which has about 800 beds, adult level 1 trauma, a children’s hospital, pediatric level 2 trauma, and level 3 NICU. We do most of our own work-ups in the blood bank, and send out only the most complicated testing to the reference lab. Please share your responses to my questions, if you are willing. Thanks! Brief description of your facility: Do you have pathologist(s) whose primary or sole responsibility is TM/BB? How many? Do they all take on-call? For what kind of issues? (We notify our TM director when we have to issue incompatible blood due to WAAs; severe transfusion reactions; clinical decisions; when emergently released products end up being incompatible; to ask her to speak to attending physicians; etc.) Any other useful or interesting things to consider?

Previously (before I joined this organization), my BB had the policy of issuing E _and_ c (big E, little c) negative RBCs if a patient had _either_ an anti-E or an anti-c and the patient was negative for the other antigen; i.e., patient has anti-E and is c neg., or has anti-c and is E neg. We discontinued this practice over 10 years ago, and as far as I know, this had no significant impact on the patients. At our medical director's initiative, we started this practice again for patients with anti-c. The medical director would like to do this also with anti-E patients. However, this would have significant financial impact. Anti-E is among the most commonly identified antibodies among our patients. Screening for E neg units is not difficult (~70% of population), but finding E and c neg brings the number down to about 14%. To make this number even lower, I know that my blood supplier pre-screens the units and reserves at least a half to 2/3 of R1R1s as stock, so the chances of finding one from our general inventory would be somewhere around 5-7%. To order an R1R1 product from our blood supplier would add about $180 per unit. So, a couple of questions: 1. Is anyone else giving R1R1 RBCs to R1R1 patients with just one of the antibodies? 2. Is anyone aware of any literature that studied the likelihood of an R1R1 patient with an anti-E to develop an anti-c? I hope I clearly presented the situation. If you have questions about the situation or what I'm asking, please let me know. Thanks for your input!

The label has only the patient's demographics, with room for the nurses to write. The collecting nurse has to document date and time of draw and initials. A second nurse has to verify and document her own initials for verifying. We implemented the second nurse verification after a wrong-blood-in-tube incident. We reject samples that are missing any of these criteria.

To update this discussion with our experience since we implemented the second sample... We are not using mechanical barriers, so for us, the important part of this process is that the second sample must be from a different phlebotomy from the initial ABO/Rh sample. To ensure this, we print a different colored label in the BB when we have get a sample from a patient with no history, and we send it ALREADY AFFIXED TO THE TUBE to the floor. (And yes, we have had to tell nurses that they cannot peel off that label and put it on a tube that they had drawn along with the first sample for convenience, because they knew that they would need a second tube!) The only exception we made is for trauma. BB management met with Trauma staff, and even they agreed that this was a valuable process, and they wanted to stick with the second sample. To speed things up, as soon as we get the trauma alert and the patient has been registered as anonymous, we send the pre-labeled second sample tube (instead of waiting to receive the first sample). We have been assured that trauma staff WILL NOT take "shortcuts," having been educated that taking such "shortcuts" is a dismissible offense. The patient will get emergency-released blood (O +/- RBC, AB or A plasma according to policy) until we get the second type. As for the small hospitals for whom we provide blood banking services (R1R2: it varies from a unit a week to no more than several units a week), since most of their patients are scheduled, we have decided to add a comment to their pre-admission testing, when necessary, to prompt them to send a second sample. They provide the courier, so a second sample will be sent to us with the courier on the day of the procedure. The courier will wait while we complete testing on the second sample, and then we will issue type specific products. Cumbersome, and a few minutes delay for the patient, but this is what we came up with to conserve precious universal products. As with most new processes, there were MANY phone calls with the nursing staff, doctors yelling at my blood bankers, etc. It's been almost a month, and things are settling down. Most of the hospital has gotten onboard and understand that this process will add another measure of safety for the patients.

Can you please elaborate? I'm not sure what this means.

To elaborate, AABB 5.16.2.2 has been modified from the 29th ed to the 30th ed. No change: Part 1) "Testing a second current sample." Part 2) "Comparison with previous records." Change: Part 3) "Retesting the same sample if patient identification was verified using an electronic identification system or another process validated to reduce the risk of misidentification." From the recent AABB audioconference on the changes to the 30th ed., the push was definitely for the second current sample. We are doing something similar to what QCDan said: we send a tube and a different colored label. Again, our issue is what to do with the small hospitals for whom we provide testing and blood products.

We are about to implement the second sample requirement for ABO/Rh for patients without historical records. AABB hosted an audioconference on this topic some time last year, and again stressed this during its recent audioconference on changes to the 30th ed of the Standards. We have piloted a small subsection of our hospital for a few months, and are implementing the system hospital-system wide. Previously for a patient without a historical ABO/Rh, we just had a second tech repeat the ABO/Rh with different reagents. Now when we get a T/S sample from a patient without a historical ABO/Rh, we send back to the floor the request (and a tube!) for a second sample. The pilot was relatively pain-free; how well this works with the rest of the hospital, we will have to see. For instance, we had one nurse draw two samples at the same time to "facilitate the process," but unfortunately the process requires two separate phlebotomies. :-( Our issue is this: our transfusion service also supplies blood to a couple of small hospitals that do not have their own blood banks; we receive PAT (preadmission testing) samples via courier and send crossmatched units on the day of surgery by courier. We do not accept "outside" records and our MISs are not integrated, so we will likely need second samples for most of these patients on the day of surgery. Is there anyone dealing with the same issue? What strategies have you implemented, or are you considering?

Sorry, I should have posted this topic in a different forum. Please follow it in the "Transfusion Services" forum, if you are interested. We are about to implement the second sample requirement for ABO/Rh for patients without historical records. AABB hosted an audioconference on this topic some time last year, and again stressed this during its recent audioconference on changes to the 30th ed of the Standards. We have piloted a small subsection of our hospital for a few months, and are implementing the system hospital-system wide. Previously for a patient without a historical ABO/Rh, we just had a second tech repeat the ABO/Rh with different reagents. Now when we get a T/S sample from a patient without a historical ABO/Rh, we send back to the floor the request (and a tube!) for a second sample. The pilot was relatively pain-free; how well this works with the rest of the hospital, we will have to see. For instance, we had one nurse draw two samples at the same time to "facilitate the process," but unfortunately the process requires two separate phlebotomies. :-( Our issue is this: our transfusion service also supplies blood to a couple of small hospitals that do not have their own blood banks; we receive PAT (preadmission testing) samples via courier and send crossmatched units on the day of surgery by courier. We do not accept "outside" records and our MISs are not integrated, so we will likely need second samples for most of these patients on the day of surgery. Is there anyone dealing with the same issue? What strategies have you implemented, or are you considering?

I received the following reply from CAP: Once again, I think that this is an over-reading of the TRM checklist, but we are keeping the procedure to test audible alarms daily. And of course we do have a written procedure to address TRM.42500. My point is that in TRM.42750 states only, "All component storage units are equipped with an alarm system that is monitored 24 hours/day (in laboratory or remote), with documented alarm checks (for both low and high settings) performed at least quarterly." (Emphasis mine.) We have refrigerators/freezers with alarm system boards, which do require daily checking, according to AABB Technical Manual (Appendix 1-3, 18th ed), and audible alarm checks are easy enough for these units. AABB also requires alarm activation checks only quarterly, and I don't know of any instance where CAP has more stringent requirements than AABB. We recently purchased units without the system boards, and these are not as easy to make alarm on demand. Depending on the unit, it can cost $1000-$2000 more to buy with system boards. Our CAP inspection is coming up any day, and I will ask the inspectors again, but unfortunately, I don't see us eliminating the daily audible alarm checks. And any future purchases of refrigerators/freezers will cost more! Please post in this thread if you have any encounters related to the topic.

Thank you, everyone, for your responses. You have all corroborated my interpretation of the CAP requirement. I will be following up with CAP, as Quality Guy suggested. I will post with CAP's answer!

I'm the manager of a blood bank, new to the organization. I was surprised to find out that my department does an audible alarm check DAILY for refrigerators & freezers. I was told that this was a recently revised CAP requirement. Now, I came here from another laboratory organization that was also CAP and AABB certified, and I knew of no such requirement (just the quarterly alarm checks). I'm thinking that this was some individual auditor's over-zealous reading of the daily temperature check requirement (acceptable by either documenting a temperature or using a graph/chart, including a "graphical recording device"). According to my staff who were involved in the previous CAP inspection, the auditor demanded to know how we know if the audible alarm is working between the quarterly checks. My answer would have been that we comply with AABB and the manufacturer's requirement for quarterly checks. Does anybody have any similar experience with this issue, or clarification?