Sonya Martinez

We have one that is pretty easy and used by all departments I will try to attach to this answer.BBWS - 112a competency day.docx
BBWS - 112b competency evenings night.docx

Here's ours.  Hope it helps.  You can disregard the last part with the computer entry unless you use WellSky Transfusion.
BBI0023 Exchange Transfusion 040221.docx

Oh, I forgot we discard are returned products in syringes regardless of how long they've been out since we can't take the temp.

Hi Justine,
We switched from the Safe-T-Vues a few years ago for the same reasons.  We use the Blood Temp 10s in our coolers (we validated for transport not storage) now.  They are great and easy to validate with the coolers.  The only thing is you have to make sure to place the indicator in the middle of the bag (on the back) and not the top or bottom because it can activate if there's no enough blood under the indicator.  We've had problems with our washed RBC units and small volumes in transfer bags if they're not folded properly before going into the cooler.  But I can't imagine having the same problem with whole blood.
You can also get a temperature monitored cooler from MaxQ (they come pre-validated) https://www.packmaxq.com/  The Max Plus Alpha 2.0 has continuous temperature monitoring but I think it's only good for 24 hours.  There may be other continuously monitored coolers out there we just use the MaxQ coolers so I have experience.
 

I was also thinking about 'why not drop the unit retesting' after all of the donor centers went to computerized donor labeling/retesting and I hadn't seen a labeling error in years (you did use to see a very few go by) and then realized that with so many places going to computerized "compatible unit release" - the retesting done by the receiving facility is the only chance they get to check that the RBCs in the unit do indeed match the label on the bag.  Without, at least, an Immediate Spin crossmatch check of the unit vs. the pt - there would be NO other physical check done if unit retesting was dropped.  So there we go, the inspection agencies will want the unit recheck for forever!  If the UK's figures were studied and accepted by the FDA/CMS/AABB, etc. - we might eventually see a change, but it probably won't be soon.  (my 2 cents )

The requirement to perform a donor retype also plays into whether or not the LIS is used for electronic compatibility testing.
AABB 5.16.2.4  The system contains logic to alert the user to discrepancies between the donor ABO group and Rh type on the unit label and those determined by blood group confirmatory tests and to ABO incompatibility between the recipient and the donor unit. *
*FDA Guidance for Industry: Computer Crossmatch"

Since I personally retyped a unit that was labeled wrong I would be very uncomfortable with not retyping. 

I know that some of the early work on ABO-mismatched solid organ transplantation, viz-a-viz ABO antibodies was carried out by Professor Patrick Mollison and his co-workers, and he showed that, whereas inhibition of IgM ABO antibodies is reasonably easy by, in the early days, transfusion of FFP to adsorb the antibodies in vivo, the same is not true of IgG ABO antibodies.  He and his co-workers found the inhibition of these antibodies was much more difficult, and this was almost certainly because only 40% of IgG antibodies are intravascular, as so they "rebound" when inhibited or removed from the intravascular area, whereas almost all of the IgM antibodies are intravascular, and so "rebound" is less likely.

When blood bank is called to release uncrossmatched blood, we specifically ask who the ordering physician is. The blood banker then places an order in EPIC called "Release of Uncrossmatched Blood" which is the statement (taken from AABB Standards) about the situation being critical enough to warrant the release of blood before compatibility testing is completed.  This order must be electronically co-signed in EPIC by the physician that we name as the ordering physician.   We have EPIC and WellSky (Mediware HCLL), but it shouldn't matter what blood bank computer system you have since this is all done (ordered/cosigned) in EPIC.  I'm attaching our uncrossmatched worksheet that includes the instructions that we follow to place this order in EPIC and assign it to the ordering physician for co-sign.  I check each day to make sure it gets co-signed. Once signed, I print the order with the co-sign tracking information, attach it to our worksheet, and file the paperwork for easy retrieval during future inspections/assessments.   
TO-381F01 Release of Uncrossmatched Blood.docx

Working in a children's hospital we only give ABO compatible platelets or type AB but our first choice is identical.  In most cases we use ABO identical and we have a very detailed Selection of Appropriate Component policy.  For patients who received or will be receiving BM/HPC transplants we give compatible based on matching donor and recipient types, or type AB only (example patient type A receiving type O transplant gets either A or AB platelets).  Also our listed ABO incompatible heart transplant candidates we will only give type O RBC and type AB plasma containing products until transplant and then ABO compatibility is determined by donor to recipient type.  I attached our transfusion guidelines for non-transplant patients and BM/HPC transplants.  


 
It has been over 15 years since I've worked in an adult hospital so I'm not sure how hard it would be to implement our policies but I know we have a white board where we keep track of the platelets so we can easily look and make sure we have what we need at a glance.

Cannot post the entire article due to copyright restrictions, but most institutions have access to NEJM through their library. If not, shoot me an email at neil_blumberg@urmc.rochester.edu and I'll send along the .pdf.
If you are transfusing 40-60 platelets a day, giving ABO identical to group O and A individuals should be relatively easy.  When patients are changing  ABO blood group it becomes more difficult. We avoid transfusion ABO antigen and/or antibody that is incompatible with either original recipient type or donor type.  Usually means washed group O red cells and platelets.  That's the bad news. It does require time and effort, and as you say, med techs are in short supply.  Here's the good news. If you transfuse ABO identical or washed compatible platelets you will use between 30-50% fewer platelets per patient, increasing your supply and decreasing your cost/problems. You will also use next to no HLA matched platelets (we used 3 out of 6,000 one recent year), you will have fewer febrile and allergic transfusion reactions, you will have fewer red cell as well as HLA antibodies made in recipients, and you may reduce TRALI and TACO.  Obviously you have to have universal leukoreduction to start with.  Selective leukoreduction misses about 50% of the  patients who will become refractory, probably due to missed or delayed diagnosis of hematologic malignancy, aplastic anemia, etc.  But the big attraction is you will have less bleeding, although that mainly affects the patients and the docs and nurses at the bedside.  

When you transfuse ABO major incompatible, which seems to be the default due to fear of hemolysis from minor incompatible, you don't get any increments, you use lots of platelets and the patients bleed more. (see references below)  Bleeding causes lots of harm, but also impacts the blood transfusion service for obvious reasons.  So figure out a way to start giving patients with aplastic anemia and acute myeloid leukemia who are newly diagnosed only ABO identical platelets and that will be a great start for the patients and the transfusion service.  Those patients will bleed less, need fewer platelet transfusions, have fewer transfusion reactions, will not have positive DATs, and will likely survive their hospitalization and disease at higher rates if our experience is typical.
And if you cannot give ABO identical or washed platelets free of incompatible cellular and soluble antigen and free of incompatible ABO antibody, start out with minor incompatible platelets (e.g., O to A) rather than ABO major incompatible (e.g., A to 0).  The risks of hemolysis are not negligible (about 1 in 800) but are less serious and severe than having life threatening bleeding or refractoriness which occur more rapidly with ABO major incompatible in all likelihood.  There's a ton of antibody that is incompatible with antigen transfused when we give A platelets to O recipients which means each antigen winds up with a ton of antibody making huge immune complexes.  When we  transfuse antibody incompatible we are transfusing a small amount of antibody into a recipient with huge amounts of antigen, so the size and number of immune complexes is probably smaller. These are my best guesses that we've been making exactly the wrong decision when we give ABO mismatched platelets. Best to avoid any, but major mismatched provides no hemostasis, minimal to no increment and is associated with increased bleeding mortality in the study from Columbia (David Roh and colleagues https://pubmed.ncbi.nlm.nih.gov/33649761/).  But ABO identical is not that hard for larger centers for the 85% of patients who are group O or A.  You just have to start small, get the hang of it, and then extend to other blood groups and other diseases than leukemia, MDS and aplastic anemia (including transplants, particularly allo--transplants). All those tables of how to select ABO mismatched platelets for transplant recipients are well intentioned but scientifically without evidence.  Avoid infusing incompatible antigen and antibody as much as possible, and delay transfusion when ABO identical will be available within hours.  Give priority to patient well being over inventory management. Give reduced doses, which work just as well.  Get a Terumo or Haemonetics washing device and wash with PAS. It's a big set of changes, but neither terribly expensive nor rocket science. The dogmas and expert opinion about universal leukoreduction and ABO matching of transfusions are now proven to be tragically mistaken.
 
https://www.ashclinicalnews.org/news/from-the-blood-journals/written-in-blood/outcomes-abo-incompatible-platelet-transfusions-patients-intracerebral-hemorrhage/
https://pubmed.ncbi.nlm.nih.gov/11399821/
https://pubmed.ncbi.nlm.nih.gov/21414009/

Research letter in NEJM describes our findings.  https://www.nejm.org/doi/full/10.1056/NEJMc2034764?fbclid=IwAR1BQRvpaHBAMDaHxCPY07xBjPQHlIHoJCOmpjoT_pBNvQsV7pzzDVdLYaY
Table 1. HLA-Matched Platelets as a Percentage of All Platelet Transfusions, According to the Initiation of Other Protocols.*
Protocol and Timing of Initiation No. of Years HLA-Matched Platelets Difference from Previous Period (95% CI)     median % (IQR) percentage points No leukoreduction and no ABO matching (1985–1990) 6 12.5 (4.2–13.7) NA Leukoreduction and ABO matching for patients with leukemia and MDS (1991–1999)† 5 2.9 (2.0–3.6) 9.6 (9.4–9.8) Universal leukoreduction (2001–2004) 4 1.4 (1.1–2.0) 1.5 (1.4–1.6) Universal ABO matching (2005–2015) 11 0.4 (0.2–0.8) 1.0 (1.0–1.1) Pathogen reduction of platelets (2016–2019)‡ 4 1.7 (0.8–1.8) ND  
The practical fact is that this can only be implemented by medical technologists, not physicians, and this is a daunting prospect.  But the reality is that ABO mismatched platelet transfusions probably exacerbate rather than prevent bleeding, so waiting for ABO identical is likely better than just transfusing whatever is available.  This is going to require a major change of approach because the (incorrect) dogma, based upon no data, is that ABO doesn't matter for platelets.
I understand why many people's instant reaction is this is not feasible. But it is once technical experts in your transfusion service figure out how to implement it gradually. In our randomized trial back in 1993 (see ref below), the ABO identical group only required <50% the number of platelet transfusions (every other day instead of every day on average) compared with the usual first in, first out regardless of ABO type group. ABO mismatched transfusions create a hostile environment with gigantic immune complexes that compromise subsequent transfusion that may be ABO identical. Avoiding this is key.
Our suggestion is to start gradually. Pick new previously untransfused patients with aplastic anemia and good prognosis AML (young, favorable or normal cytogenetics), groups O or A, and start with them. Eminently doable since your platelet supply is 45% O and 40% A, just like your patients, on average. Get the hang of doing this and prioritizing ABO for at least some patients. Once you get this in place, extending it to other patients and eventually all patients can happen. We use washed O or A platelets and red cells for group B and AB recipients when we don't have group B or AB platelets. No increase in bleeding and fewer transfusion reactions, lung injury and congestive heart failure (what we call TRALI and TACO).
In the end, you have more surviving patients and fewer headaches and transfuse many fewer platelets per patient and essentially no HLA if you can get your referring hospitals to stop our current standard harmful practices. Godspeed. Heal JM, Rowe JM, McMican A, Masel D, Finke C, Blumberg N. The role of ABO matching in platelet transfusion. Eur J Haematol. 1993 Feb;50(2):110-7. doi: 10.1111/j.1600-0609.1993.tb00150.x. PMID: 8440356.
 
Happy to have discussions or visitors so our technical experts can show you how it is feasible.

We pull two segments upon delivery.  One for retype, one in the event of a delayed reaction.  We keep them for two months.  The only units that we get back are actual suspected transfusion reactions.

We don't have bags returned to us.  We take off 2 segments when we retype the units and save for a month, 1 week in each bag.  It's easy to find by when it was retyped in the computer and there are only four small bags to check for the correct date.

We tell our clinicians to do exactly that, yes. Likely it won't turn into an anaphylactic event, but it could, so STOP and initiate a transfusion workup. Give benadryl and watch the patient.
For future transfusions, pre-treat with benadryl - even though it's likely a response to that one specific donor's plasma proteins, and a bag from a different donor may not provoke a reaction.

so so helpful!!  thank you sonya!!!

I've attached our policies for preparing aliquots in general and our platelet policy.  Hope this helps.  Oh, we decided all aliquots in syringes expire 4 hours after being made to make it easier for both blood bank and nursing staff to remember.  We used to let the RBC and FFP syringes expire in 24 hours but nursing in particular would think all syringes expire 24 hours and we wasted a lot of syringe aliquots until I changed it.
BBI0015 Preparation of Aliquots.04.03.2020.doc BBI0017 Platelets 04.03.2020.doc

For open heart surgery our perfusion team washes the red cells in the OR (faster than we can) and uses those with a small amount of FFP (for babies usually < 1 year especially those < 4kg).  Our policy is to provide 1 fresh, <6 day old, irradiated (<24 hours) AS3, CPD, CPDA-1 or CP2D packed red cell for post CPB but we give then two <= 10 day old unit (irradiated, AS3, CPD, CPDA-1 or CP2D) and mark them "To Be Washed" for priming the CPB.  For non-pump cardiac surgeries we wash if the patient is <4kg.  I would love to get away from washing RBCs for surgeries (we also wash for major open belly procedures on <4kg infants) but over 20 years ago a patient died because of a K+ overload from a RBC that was irradiated 3 days prior to surgery even thought the unit was still <6 days old.  Now I can't even get our Transfusion Committee to even discuss the topic.  Guess I just wait until more surgeons retire.

For open heart surgery our perfusion team washes the red cells in the OR (faster than we can) and uses those with a small amount of FFP (for babies usually < 1 year especially those < 4kg).  Our policy is to provide 1 fresh, <6 day old, irradiated (<24 hours) AS3, CPD, CPDA-1 or CP2D packed red cell for post CPB but we give then two <= 10 day old unit (irradiated, AS3, CPD, CPDA-1 or CP2D) and mark them "To Be Washed" for priming the CPB.  For non-pump cardiac surgeries we wash if the patient is <4kg.  I would love to get away from washing RBCs for surgeries (we also wash for major open belly procedures on <4kg infants) but over 20 years ago a patient died because of a K+ overload from a RBC that was irradiated 3 days prior to surgery even thought the unit was still <6 days old.  Now I can't even get our Transfusion Committee to even discuss the topic.  Guess I just wait until more surgeons retire.

Does Meditech have a back up system?  We use HCLL and it writes to a downtime tool that we can use in the event of a complete network crash.  We have a local log in to that PC, not network access needed.

Thank you Baby Banker.
If cardiac surgery is for extracorporeal, should red cells be washed if they present more than 24 hours of irradiation time?

We use fresh (less than seven days old) irradiated RBCs.  We wash the units only if they are not fresh.

years ago my boss got all of us blood bank techs assigned to the same salary scale as the pharmacists (since blood is considered a drug by the FDA).  Once again the lab folks  were peeved but no one wanted to work in BB.  Tertiary care,  Very busy.

Sonya,
Thanks!

In the USA, there is an extreme shortage of techs that are blood bank competent. The ones who are are working regular overtime to fill in the shifts to provide 24/7 coverage. They are normally working at least two jobs. The field is facing a crisis as these techs who are qualified are now retiring. We just lost two of our best this year and are struggling to keep the younger, promising techs in the field. I'm afraid you won't really have a choice soon. You will have to take what you can get tech-wise and train them as best you can.