mwlister

Thanks, MWL

I have been approached and asked to put this question out for peer review and would appreciate your response. Question: CV Surgeons want blood to be delivered to the OR in coolers and Surgical personnel would do patient ID and clerical checks prior to OR. Once the case started they would not check it again, just transfuse. Does anyone do this? They are claiming that this is done at other institutions. AABB Standards clearly states "the transfusionist shall verify that all information matching the blood or component with the intended recipient has been verified in the presence of teh recipient, item by item" pg. 53-54, Standards. Thanks, Mark

Would anyone be willing to share an example of an Emergency Release Record that contains multiple units of blood for a massive hemorrhage and that contains all the required transfusion information? Thanks, MWL

Generally speaking, 24 hours would be the norm to allow the refrigerator to stabilize. This would also give you time to record temperatures on the charts, thus documenting the temperature had stabilized. We have a refrigerator specialist in our hospital and he has always required us to wait 24 hours after a repair to use it again, if it required unplugging it. As mentioned above, if you had any problems (i.e., plugs, etc) your supply would be in a stable environment until the issues were resolved. I am not aware of any standards dictating a time though. MLW

We are scheduled to open our Open Heart program and we met with the surgeons today. One of the primary area of interest was putting a refrigerator in the Open Heart room and stocking it with blood to support two hearts at a time, in addition to having blood on hand for the nearby unit for the post hearts for three hours. This would require stocking the refrigerator with multiple units of blood for several patients. I would appreciate any input anyone (who currently performs Open Heart Surgery) could provide for the following: 1. Do you support having a refrigerator as discussed above? 2. Have you experience any errors in personnel selecting the wrong units? 3. If you had a refrigerator and removed it could you explain why? 4. Can you provide any references for error rates associated with refrigerators in the Open Heart OR? 5. Any other comments. Thanks, MWL

The answer to your question regarding mechanical barrier's. Yes the bracelet does apply. Please contact CAP and have them confirm this for you. I did and I had my CAP inspection with no deficiencies. MWL

Recently I was approached by an RN who insisted that blood and blood products must be transport from the Transfusion Service Department to the Units in a biohazard bag. He cited a OSHA statement or regulation I cannot find. Would you please advise on the following: 1. Has anyone seen or heard of this regualtion? 2. Do you transport components in a separate bag? 3. Would you use a "Biohazard" bag? This would send a warning to the recipient and/or familiy members. Any input would be appreciated. Thanks, MWL

Question: If blood is considered stored in the cooler in O.R. do you have to provide continuous monitoring of the temperaure? I was told yes by one AABB assessor. I have tried the Temp-Tail and could not maintain a constant reading. Just was too sensitive. Now, I place a thermometer in the cooler, in glycerol, and require them to take and document the temperature every hour. In addition, I use the Hemotemp. The temperature is maintained between 1 and 6 degrees when taken with the thermometer. What are your thoughts on this satisfying this standard? Thanks, MWL

We QC each lot number when we recieve them with an expired unit of blood (autologous).

Assuming you are acquiring your cryo from a large Blood Supplier that supplies blood and blood products to multiple institutions I would stock ten units of each type. If not used one to two months prior to expiration I would return them and replace them with longer expiration dates. Hope this helps, MWL

A mechanical barrier can be an additional Blood Bank I.D. armband (with a distinct BB number) that is placed on the patient's arm at the time of phlebotomy. RN's are required to check this armband for patient ID prior to transfusion. If the wrong patient was drawn he/she would be missing this armband. You can call CAP for clarification- I did and our system, as discussed above, was acceptable. I just had my unnounced CAP inspection and had no issues with this standard. Hope this helps, MWL

The following CAP requirement requires some type of barrier. It seems we will be forced to Barscan or RFID patient ID systems in the future however the BB armband will satisfy this NEW CAP requirement. So, I don't think we have a choice about having a second ID. MWLister **NEW** 12/29/2004 TRM.30550 Phase II N/A YES NO Does the facility have a documented program to ensure that the risk of pretransfusion sample misidentification is monitored and subjected to continual process improvement? NOTE: Mistransfusion occurs once every 12,000 units in the US. Although sample misidentification is a less common cause of mistransfusion than misidentification of a recipient, the former is an error in the transfusion process that the transfusion service may be able to detect, thus interdicting a mistransfusion. Studies from multiple developed countries indicate that approximately 1:1000 samples arriving in the transfusion service are labeled with the wrong patient’s identity. Samples with any incorrect or incomplete element are forty times more likely than correctly identified specimens to have the wrong patient’s identity on the label. The use of mechanical barrier systems or electronic sample labeling systems may help to reduce the risks associated with misidentification. Duplicate sampling of patients (or the transfusion of Group O red cells until this re-sampling is completed) may also reduce the risk. Key to improvement of the transfusion process, however, is active monitoring of the frequency of a failure of patient and sample identification and continual efforts dedicated to improving the process.

How is everyone handling temperture monitoring of coolers in the O.R.? I know most people are using devices such as the Hemo-Temp II but I was challenged by an assessor that said blood that remains in the O.R. and returned to the Transfusion Service Department is considered STORED and it must be monitored and be maintained between 1-6 ^c. In an effort meet this challenge we put thermometers in the coolers and required them to record the temperature every hour. Request for coolers dropped by 90%. Even though the need seemed to drop dramatically I have been asked to look for a better solution. The remaining 10% are stubborn. I recently purchased a digital temperature monitoring device that downloads the temperatures. Don't you know they take it out and put back sending tempertures up and down. A Hematemp II monitor is attached to the units so I know they do not exceed 9^c. They insist on doing clerical checks when the units are brought to the room and do a second before transfusing. Don't argue with that except the temperature monitor is extremely sensitive. Comments to this challenge and/or other monitoring methods are appreciated. Thanks, mwlister

My Pathologist (Transfusion Director) would like to know what everyone thinks about using one aliquot from an irradiated unit and then puting the remainder of the unit in the general blood supply? Could we justify transfusing a unit to a patient that had as much as 50 mL removed? Would it be fair to bill for an entire unit? No HCPCS code for a partial unit. Your comments are greatly appreciated. Thanks, MWLISTER

Hi John: I am at work now and have found the reference. It is in the AABB Technical Manual, Fifteent Edition, page 561. THanks, MWLISTER

I agree with Lcsmiz. One way to get started is to use your Quality Assurance Table of Contents. Example 1: Employee Compentency: Gather employee compentency assessments, training, etc. and do an evaluation and write your conclusions. Example 2: Laboratory Safety: Do an annual evaluation and include what improvments you want to make for next year (i.e., biohazard reduction, chemical reduction). Example 3: Incidents, Accidents, Errors: Do the same as above. Make sure you include any Root Cause Analysis if they exist and what the status is. By the time you finish you will have a lengthy report. I title each topic and write the report in landscape. Be sure to have all the appropriate personnel sign the annual report (i.e., Transfusion Medical Director, P.I., etc). Hope this helps, MWLister

Hi John: I have to ask why so many institutions are using different dates to release neonatal RBC's after irradiation? I have polled at least five hospitals. Some use the unit 10 days to expiration of the unit and some to the day of expiration. I have heard some from 48 hours to seven days. I don't have the AABB technical manual with me, however I believe it said you should not exceed 24 hours after irradiation. Cosequences includes infant death secondary to cardiac arrest. I need to make a decision on expiration and find a way not to destroy a unit after single use. I am impressed with the erythorpoeitin approach. Could you provide me with information on expiration and references? Thanks, MWLister

Thanks to all for your comments. MWLister

Is the Clinic part of your healthcare setting? If the clinic is off site and is not a part your hospital I would require the patient to be registered by your hospital and specimens drawn by your staff. I would not take any specimens drawn by an outside facility for Rh eligibility studies or administration of Rho-Gam. I hope I understood your question and this will help. Thanks, MWL

We have a new Neonatology group. Currently, RBC utilization has doubled. Historically we have not provided irradiated blood for premature neonates. I do have a policy for family donors where they have to be irradiated and the unit expires 24 hours post irradiation. My concern here is that they limit the neonate to a single donor. The Blood Supplier irradiates the entire unit. If I were to switch to 100% irradiated products my wastage would be enormous. What are the hassles and expense of purchasing an irradiator for a 400 bed hospital? Thanks, MWL

Hi Donna: I am reading material that suggest that you should not use RBC's after 24 hours of irradition. This is from Transfusion Therapy. It does however allow use if the RBC's are washed to remove potassium. Can you suggest a reference? Thanks, MWL

I would not write a separate procedure for Massive Transfusion. If you feel you need to address this I would include a section in the Massive Transfusion Procedure. I assume you would know what allo-antibodies are present at the time or could complete a work-up before the bleeding episode subsided. If a transfusion was life threatening I would transfuse emergency release units first and reserve antigen negative units when the bleeding episode was subsiding. Most of the incompatible RBC's would bleed out and you could replace the hematologic deficit with compatible units. Rh Immunoglobulin: You should have a general policy for candidates who qualify. You should also have policies and procdures for pre-natal, post delivery, and invassive or traumatic conditions during pregnancy. A seperate policy for Rh negative recipients recieving Rh positive blood products (i.e., platelets). I would review the CAP checklist. Hope this helps. MWL

I would like to inquire what is a suitable time to expire Pedi Quad RBC's afer irradiation. In addition, how many institutions typically irradiate all RBC's and other products for premature infants? Your comments are appreciated. Thanks, MWLister

See Cliff found it for you. Thats great. Thanks Cliff.

Here are some pictures of standardized grading of reactions: Got this from the internet. Under Google type Blood Bank + grading reactions. Click on Google Pictures and you can get this site. We do competencies four times a year. I have not had any issues with consitency. As long as you define how to grade reactions, and perhaps add pictures for reference, you should be able to obtain consistency. Hope this helps. MWL