jshepherd

@Neil Blumberg Exactly. We've all had the odd cases that survive when it doesn't seem they should, and I agree that it's certainly case by case and dependent on hemostasis and coagulation like @Auntie-D said above. We use TEG for coagulation eval as well. I think my trauma surgeons are looking for a prompt to make them aware of how many products they've used, so they can evaluate the futility of continuing versus stopping. Anesthesia is the group transfusing these products, and they can easily lose track as well, so we're looking for an estimate of when the blood bank staff might give them a nudge to let them know they've hit a threshold, and to evaluate the entire picture of the patient with that knowledge, rather than being tunnel visioned into fixing the damage only. I have heard 30-50 units of red cells is the sweet spot as well. We consider more than 30 units of red cells to be a super massive transfusion, so that would jive.

Hello everyone! Controversial topic coming up here: Is there a point in an MTP where the further transfusion of blood products does more harm than good? I know some facilities have published studies on this issue, and some have assigned their own lethal dose, or LD50, to blood products, to say that once a patient is transfused X number of red cells or X number of total products that resuscitation is futile and MTP should be discontinued. We are exploring doing this research ourselves, but I was asked if anyone out there has an actual policy or SOP on this topic. For ethical reasons it gets really touchy, so here's the disclaimer that I'm not trying to rile anyone up, just wondering what everyone else is doing! And......go!

Excellent points from Neil and Malcolm as always! Most of us are slaves to the standards though, and/or don't have pathologists willing to take this same point. @RRay Lots of food for thought here! I think we will be implementing something similar here, adding an "antibody" to the patient file in the BB LIS only that will require an AHG XM when additional drops of plasma are used to resolve a blood type.

This was an issue here as well, the full address of the hospital was in the header of all of my SOPs. I removed them all one by one as updates/reviews were required. There is nothing in JC/FDA or AABB that says you need the location of the lab in an SOP. You are correct that this needs to be on reports. I left the name of the hospital and Department of Pathology and Laboratory Services in my header, that's it.

I'm working from home today, so the AABB standards are not at my right hand, but I'm pretty sure AABB requires a front and back type to be resulted to count as a full blood type for adults. There are exceptions for peds of course. No full blood type means you should be giving type O red cells and type AB plasma, which no one wants to do unless warranted!

Agree with Neil and Malcolm, might adopt that here! You could have an "antibody", or some other way to require the system to prompt techs, that you add to the patient in your blood bank LIS, which will direct staff to perform an AHG crossmatch. That way, there isn't an antibody actually resulted in the HIS, but the staff will be alerted to the need for an AHG XM rather than relying on them catching that there was a weak backtype.

This is mentioned as "increasing the serum to cell ratio" in tech manuals and guides, but it is SUPER vague! I agree that you should not allow your techs to do this if it's not in the SOP. I have RT and 4C incubations as things to try to resolve blood type discrepancies in my SOP. The only place we mention increased serum to cell ratio is to enhance weak antibody screen reactions by using 3 drops plasma and 3 drops PEG to one drop cells. We don't change serum to cell ratio for blood types or ISXM.

There is a recommendation, or maybe a standard I can't put my finger on right now, that says that access to the blood bank should be controlled. Meaning people can't just walk in and take blood. Nothing that says it must be a separate room. My entire lab is behind badge access doors, and the blood bank is semi-separated by a counter and some swinging half doors (saloon doors) so that people picking up products would certainly be noticed if they just popped into the actual department.

Same. Many of our SOPs refer to the manufacturer's manual for things, easier that way.

Purchasing a liquid in glass thermometer still requires validation, even when it comes with a certificate. We measure it at the single point temp it will be used at, so if it's a platelet rotator thermometer, in the range of 20-24, if a fridge thermometer, in the range of 1-6. We re-validate our thermometers annually at the temp they are used at. If the thermometer can be used at multiple temps (like a min/max thermometer), we validate each range. Electronic thermometers..... that is SO broad. Thanks FDA! Honestly, I would say an infrared is electronic, but I would also say that a system like Rees or Primex (what we use) is also electronic. But calibrating the thermometer MONTHLY is unreasonable. Primex actually verifies their electronic probes for 2 years, and they provided me a statement to this effect, that the probes are very stable, even beyond 5 years. Otherwise, they were wanting probes to be replaced every 2 years, and a new temp probe would mean a new validation for each piece of equipment. If the company can provide you a statement or certificate about their probes, perhaps you can get around the monthly calibration? I'd also query the FDA as to what, exactly, do they consider an electronic thermometer......and then tell us what they say!

We usually have enough expired units for this, but if we don't we use real units. The coolers are checked so often, you should be aware that it might fail, and just like a fridge, you'd bail any real units out before that happens.

We get our blood products from several suppliers. I swear in years past I've seen in the AABB standards that we must keep these paper shipping documents (the attestation that says the units were packed appropriately at XXXX time and date, etc) for a certain amount of time. My previous employer only kept these for 1 year. My current employer has been keeping these for 10 years. I would love to not have all these paper documents taking up valuable storage space any longer! I cannot find in the 33rd standards these specific documents listed in the 6.2A table. I'm wondering if it got removed entirely? I see standard 4.3 stating that all products must be received, inspected and tested as appropriate, and this is all recorded in our computer system of course, and kept the requisite 10 years. Does anyone know, or how long do you keep these for?

You can give them the lit on giving type A plasma for traumas.... Yazer had a good paper. But honestly, they should be following SOP, and if they're not, they need discipline! If you have good SOPs that direct them to use the best possible option of first expiring units, they need to be following it. We attempt ABO compatible as much as possible, but it's not always feasible.

This is so incredibly disheartening to hear. Since my last post 6 months ago, the BB staffing is still going well, and I thank my people ALL the time! Other hospitals nearby continue to offer sign on bonuses, and we still cannot afford to do so, for lab or nursing. The core lab was down 13 positions at one point, mostly nights and evenings, and has a revolving set of 2 travelers every few months. We have our own MLS school for post BS training, and will graduate 8 people in November. Everyone is hanging on for that basically. The only other MLS school in the state graduates about 20 every May, and they always head to the bigger better sign on bonus so far through the pandemic. In Denver, there are TONS of MLS jobs, with a bunch in blood bank, so people can take their pick.

@jayinsat makes a great point about quickness. If we had a current TYSC on a patient, we would prefer to give XM'd products, type specific, if able to be done quickly. If not, we would go for quickness with our pre-made trauma packs of O pos or O neg RBCs and A or AB liquid plasma, depending on the patient. We only do WB as part of the MTP for our trauma patients, which is upon arrival usually, so there isn't a known blood type, and if they were to stabilize and need MTP again later in their admission, we would do component therapy as described above. We've only been live with WB as part of our MTP for a year and half, so other centers doing this longer may have more input!

We went live with Softbank in Jan 2021, switching from SafetraceTx, but prior to that we had Sunquest. When evaluating what system we wanted to switch to in 2019/2020, Sunquest still had Roll N Scroll, and their transfusion reaction, reagent QC and emergency issue functions were no better than they had been 5 years prior when we used the software. I can't speak to updates they've done since then, but it was not encouraging at that time.

There is an AABB standard that your facility has to have a policy on how many out of group PLASMA transfusions are allowed. This very broadly encompasses LTOWB. It's 5.15.4. That said, our level 1 adult center will give 4u of LTOWB once MTP is activated, then switch to component therapy, of which our packs consist of 4 reds and 4 type A liquid plasma. Obviously, we end up transfusing incompatible plasma on occasion to B and AB patients with our normal process. Once we have a patient type we switch to type compatible plasma of course. Our policies state this, but there is no maximum number we have defined of how many units we'll give, as sometimes we don't ever get a sample until much later than we'd like, which means we're giving A plasma for a bit. We capped our LTOWB at 4 units, mostly due to inventory constraint when we started this program, but also to ensure we weren't overloading patients with too much O plasma if they weren't type O! Our supplier has a low titer cut off of 256. I track all of the patients who have gotten our WB, including their native blood type, and we are monitoring for issues, but have had none yet. I have heard of programs that will give up to 8 units of LTOWB per patient.

Typical to transfusion services, we offer RhIg prophylaxis to Rh neg patients who received Rh pos platelets. We also transfuse liquid plasma to our patients, which is typically contaminated with red cells. These are usually used for MTP patients, in which case Rh considerations can go out the window, but sometimes there is an unexpected/urgent need in normal OR cases. During those times, we will give liquid plasma since it's the quickest product available, and its usually only 1-2 units. I'm wondering if anyone out there also transfuses liquid plasma, and what you may do, if anything, for those Rh neg patients who get 1-2 units of Rh pos liquid plasma which contains Rh pos RBCs? I haven't seen any literature to indicate that we should offer RhIg prophylaxis in these cases, but if we're using the same thought process with platelets...... my brain hurts.

We currently have a paper form for writing down the temps and inventory in our department. The Inventory is pulled from our BBLIS and transcribed onto the paper....seems silly to me. I can't find a regulation that says we need to have a snapshot of the inventory daily, it's available ad hoc whenever we need it, and we check it daily to ensure our incoming blood product orders will be sufficient. Otherwise we don't typically refer back to the papers that tell us the certain point in time's inventory. The temps for equipment are all on an electronic monitoring system (Primex). The system creates a report with the last 24 hours of temps, and the dayshift staff sign off a review of this report daily. I also sign off a review of all the temps monthly, but could make it weekly if needed. This should be sufficient for temperature monitoring and reviews right? Our temp/inventory form has a place to mark each piece of equipment as "ok" from the Primex reports. Seems duplicitous. I'm aware that regulations require temperature monitoring and review of those records. Basically, would love to go all electronic with these two things, and wondering what others are doing? Any insight is helpful! We have Epic/Beaker and Softbank for BB.

For several years, Helmer suggested either tap, DI or distilled water. Then they switched their manual to say only tap water. I've seen both at two different places in my career! They have recommended either their proprietary CleanBath or any "waterbed conditioner" to help keep things nice. I haven't seen scale deposits before, but I would think if you're draining it weekly as instructed and cleaning it after a unit breaks in it, that would prevent most issues. Helmer technical service has always been great, and can likely give you a quick answer on the CLR question.

There isn't an extra charge that I'm aware of for an MTP. We charge for all the blood products transfused, and all the work done by techs like crossmatching etc, but there is nothing else.

Precisely! Our current conundrum is a snarky Ortho attending who is insinuating that our blood supplier and my blood bank gave the patient "contaminated blood" and he shouldn't have to be the person to notify the patient. Snarkiest of the snark, and its clear there is little understanding of the risks of transfusion. My medical director wants to involve our Patient Safety and Quality folks or Risk/Legal, since this is an FDA requirement, and I think we'll have to take that route, if for nothing more than educating the physicians.

At our facility, when a lookback notification is received and the transfusion recipient/patient must be notified, the blood bank supervisor (me) will reach out to the attending physician to have them contact the patient for testing of HCV or HIV. These happen so rarely, and sometimes the lookback is from so long ago, that we are getting pushback from the attending physicians. How is this notification of need for testing done at other hospitals? Do the clinical pathologists or transfusion service medical director own this process? Our clin paths feel it is not in their scope to be contacting patients directly, as they don't have any sort of relationship with the patient in place. Does your Risk Management team do this? We are exploring all options to make this smoother for the few times per year we need to contact patients! Thanks!

The FDA regs state that even if the patient is deceased, you must notify. There is no end date to that, as much as I wish there was.....

Getting your SBB is great knowledge to have, and I agree with Cliff that it will open more doors for you to do other things. Having worked in large busy trauma center BB's for 17 years now, I can tell you that my SBB knowledge rarely comes into play in a hospital BB, unless you have ALL the things (complex antibodies, washing/irradiating product, neonatal population, ref lab for system hospitals etc). If you have goals of Ref Lab or a private company, many of them require an SBB. You can also get in with a teaching program with an SBB easier than without. I've heard many hospital labs would like to have their admin directors be blood bankers with an SBB, as it brings a quality eye that other candidates don't have, but it seems rare to find those people because so few of us want to do that job! As far as helping you run your blood bank, it likely won't be that beneficial, as most of the curriculum is a deep dive into antibody qualities and rare things, but there is some info on supervisory duties and such. I graduated from LifeShare's SBB online program in 2019, after having worked in the BB for 10+ years. I personally liked the online program, as I already was the supervisor of the BB at the time, had two small kids and was not able to move across country to attend a program in person. LifeShare and UTMB share their curriculum, and an SBB from LifeShare is eligible to go on to the Masters in Trans. Med from UTMB should you wish to do that. Katrina Billingsley is the director of the program at LifeShare, and she is fabulous; would highly recommend her program.