Ellie Ross

[ATTACH]320[/ATTACH] I hope I did this right. I have included an attachment of a copy of my transfusion audit form, I have had many requests for. If it does not open: I can be reached at ellie.ross@providence.org Transfusion Audit Form .doc

AABB Technical Manual under Quality Systems - Blood Utilization Assessment it states: To "investigate" (taken to infer audit) 5% of the number of "cases" (transfuison) occurring within a defined time frame(detremined my each facility) or 30 cases min, whichever is "larger" But you will find we all have difficulty with the volume. If i followed this I would have to do 40 a month and most of us do not have the staffing to do this. So we set a numer greater than 30 which is required to do per year

Before we send out any workups to a reference lab we first run a gel panel. If the auto control is negative and all allo-antibodies are ruled out, with one or more positive cells, we will call it a non specific antibody, so full crossmatching is done, a patient safety issue. I know gel has been an issue with, a lot of non specific reactions, but keep in mind gel is much more sensitive than tube method so you cannot just dismiss a positive gel result by getting a negative tube result. Then there are patients in which everything is positive in gel so we tag them to use tube method only, this may be due to an antibody to the gel itself. We do alot of workups. Cold antibodies do get detected in gel. If we do get Mixed field reactions we convert to tube method to rule out colds and rouleaux. If we get a positive auto control in gel, we repeat it by tube method and if still positive in tube we then send it out to a reference lab for warm auto antibody workup. These are just a few things we do. I have a whole SOP just dedicated to working ABI in gel. Even though it may be some cost we do keep 3% screen cells and 1 3% panel on hand. This has saved us the more costly sendouts to a ref lab.

At my facility I created an SOP called Anitbody Indentification Guide ever since we went to gel and had all these problems. What we do if we see Mixed Field in gel is repeat the antibody screen using 3.0% cells and continue on using tube method. i.e Saline replacement is used for determining Rouleaux, it is not a method for crossmatching. Or Cold agglutinins. BE CAREFUL about using WARM Saline for saline replacement, you could be washing away an antibody. ROULEAUX is due to the high proteins in the myeloma patient and is a nuisance but must be careful of your methods as not to miss antibodies. Patients who react in gel due to your discribed problem we tag them to be done by tube method. This has cut down on repeat problems each time they come back for transfusions.

Anyone wanting a copy of my transfusion audit checklist please contact me at ellie.ross@providence.org. I seldom have time to check requests via BloodBank Talk due to workload and am more easily reachable through email.

Will send you copy of audit checklist. a Procedure can be easliy written from it

will send you copy of audit checklist.

Unfortunately this is a routine event at our facility also and our bands cannot be reapplied either, I have fought this issue a long time and heard all the excuses. What we do is supply surgery with a secondary band in which the number of the BB Armband can be inserted inside the second band and this band is put on the patient after the surgery and before they leave the surgery suite. Even using a barcoding system will not circumvent this problem, what's to stop them cutting off the bacoded armband. If a patient is returned to their room without the armband we require a new Type/Screen and armband assigned. Ellie

I have had requests for a copy of my Transfusion Audit Checklist but have received bad email addresses or had problems sending them. If any one wants a copy please send me an email to ellie.ross@providence.org and I would be happy to send you a copy.

We have an audit system in place. The audit should be checking from issue through transfusion to posting in patient's chart. This should also include checking for written physician's order and signed consent for transfusion in place before the transfusion began. I have all of the blood bank staff involved in doing audits as part of the annual competency. My checklist encompasses each step from issue in blood bank to beside identification, initial vitals taken before beginning. hanging unit (checking that nothing else is running in the line. Then I return approx 4 hrs later to verify completion, transfusion form completion and signed and posted in chart. number of audits per year is based on 1% of the total transfusions in a year.

At our facility the responsibility to order ABORh on babies of type "O" moms falls to the nurses and this is in the nursing policy. Once ordered if the baby is not type O (as mom) we perform the DAT and record on a backup system until the floor orders it. We will also notify the patients RN to order ABORh/DAT on babies whose mother have an antibody.

We normally use specimens for 3 days. We have an exception to this rule. Exception: Our "Disclaimer" policy PreAdmit patients are interviewed for transfusion history. If they are not pregnant and or have not been transfused or pregnant in the last 90 days we will extend the clot to 7 day expiration, a disclaimer is filed out and signed and sent to the Blood Bank. Upon admission the expiration date is then adjusted to 3 days upon transfusion of first NON Autologous unit within that 7 day period. This has worked out great for our preadmit patients who come in 6 days prior to their procedure for the preop blood work.

We currently add our own Facility ID and Registration Number label to the unit. it is placed next to but not covering Indicator window of the Irradiation Sticker on the front of the unit above the face label. We leave the original Facility ID/Reg# intacted. We have not made any decision to change this with ISBT128 yet.