Ward_X

As far as my interpretation of this standard and how my facility operates, the training is not the same thing as the competency testing. Each area of the lab has an initial competency testing, then the 6 month, then the corresponding annual along with everyone else. I don't think mere completion of training without an initial competency assessment is sufficient. Training is often just acknowledging the trainee has been taught a task and can perform said test; the competency is a pre-set blind sample that already has a determined result, so you can tell if your trainee is passing/failing the competency.
I would say: sign off training, sign off competency, then you can perform solo testing.
There is a previous thread here, and another here about GEN.55500 that may be helpful?

Anyone I know?

Are you asking about which labels can be placed on the bag and which have to be on the base label??  Some irradiation indicator tags - both Rad-Sure and Rad-Control - have a type of adhesive that can touch the actual bag.  Both can go above or below the base label (or at least that is what I have always been told).  Most little labels/stickers, like the original Irradiation label in this thread, do not have this type of approved adhesive and are not allowed to be placed directly on the bag.  You have to find somewhere to stick it on the base label without covering anything else up.  

If at all possible, define a pre-admission process so that a T&S can be drawn prior to the day of surgery.  No one is happy when they find-out that the patient on the table has an antibody that will significantly delay packed cell availability.  I would also "make friends" with your Perfusion team.  Ours are the TEG experts in the OR, and help to guide the component utilization.  We still reserve two platelets for a CAGB, but rarely transfuse these patients.

We apply the 4x4 horizontally and wrap the bottom part of the sticker around to the other side of the aliquot.

True! I was once doing a workup that had both an ABO discrepancy and a positive screen, and they had to be treated as separate issues unless later proved related. Prewarming failed, so another tech following up after my shift had to use cord cells to clean up that mess. The antibody ended up being a non-specific CAA.

Devil's Advocate Asks:  If we establish that the reason for the reactions in the backtype are due to cold agglutinin(s), why are we pre-warming ABO tests?   Pre-warm = 37C reacting antibodies.  If this is a valid alternative to RT/I.S. Crossmatch, then shouldn't we be performing an Extended Crossmatch (37C to AHG) to look for the IGG versions of the ABO Antibodies?
Simple Answer: Immediate Spin Crossmatch:  If due to cold agglutinin (other than ABO) = Compatible by Blood Type.

Well, for the simple reason that 1) you have to prove that the reverse grouping anomaly is really just due to the "cold" auto-antibody, and not to something else, and 2) that there is no clinically significant atypical alloantibody being masked by a "cold" auto-antibody of wide thermal amplitude.

We also only tubed to certain floors. We sent a form with patient and unit  stickers with the unit that the person who removed the unit was supposed to time, initial, and return.  We called when tubing and they had 10 minutes for us to receive the form before we followed up.  If we tubed  to a floor, we had to have the form back before tubing for another patient.  To validate and to do QA checks, we sent a tech to each location  and tubed  an expired unit to each location with a temperature monitor. When we tubed, we called that tech and documented transit time and unit temperature on arrival.  Things happen even when we try our best.  One  time we tubed  a unit, got an order for another patient on same floor, received form for first unit back, tubed second unit - and nurse for first patient called upset because we had not tuned her blood. The nurse for the second patient had grabbed the unit for the first patient, signed the form without checking, returned the form, and started the unit on her patient, with two nurses signing off the bedside checks. 

The whole point of washing RBC products is to remove residual plasma, therefore to verify if said residual plasma was removed, you test the washed RBC supernatants for protein.
We have three COBE 2991s and we use Albustix protein dipsticks for detection. We have a positive control made from diluted donor plasma, and a negative control that is just saline. We sample a segment from the waste line post washing. For positive control you should have a set reading to match based on your protein detection technique, the negative control should be negative, and the washed RBC supernatant should be negative or near negative.

Have never had to do that (from 24 bed to 700+ hospitals)

I guess you can triangulate the data by checking several record sources but I am not sure that anything, including our own EMR, is perfect. Expired patients are still in our BBIS, we just move their ABID records to the deceased folder for another few years before discarding them.  You could certainly mix up two patients who live in your area and share both full names and DOB using something like BillionGraves.

The big thing is storage conditions and keeping the right temperature for each floor! My facility has 16ish floors, but we can only tube up to the 7th, otherwise products will get too warm on the way. So do bear in mind that tubing may not service every area

Kidd system antibodies can bind complement.
To investigate the reason, maybe you should do an elution, then test the eluate to see what specity /specities of the binding antibodies.
Add fresh serum can strengthen the sensitivity of testing Kidd antibodies.

For a product that is IRRADIATED, that attribute will print on an ISBT 128 label below the product name (see example) using HemaTrax software from Digi-Trax. No need for a separate label.

We use ziploc bags that have a large red stripe for blood products that go via pneumatic tube system to patient floors. They have the red stripe on them because nurses complained they could not tell if a tube held a blood product in it when glancing at the tube when it falls on their station. Therefore if they see the red stripe they are more likely to go empty the tube sooner knowing a blood product could be in it. We also use a Ziploc bag with a yellow label stating "PLATELET DO NOT PUT IN COOLER" when issuing platelets to the OR. You'd be surprised at how many platelets we still get back from the OR in the cooler even with this label on the bag!

If they have a historical type on file, you do not need a current T/S to issue plasma and platelet products. For RBCs you do need a current T/S.

We are persuaded that sending plasma and platelets in a first cooler harms more patients than it helps.  We actually wait to provide plasma and platelets/cryo until we are told this is a massively bleeding patient or 8 red cells have been sent.  First cooler is 4 red cells.  Second cooler is 4 red cells, if needed. Almost all the time, none or few of them are used. We are the only level I trauma center within 70-80 miles.  
Thus including plasma and platelets, which are highly toxic products, associated with nosocomial infection, multi-organ failure, thrombosis and mortality, will likely lead to the occasional patient receiving them along with one or a few red cells. A recipe for increased harm with no benefit. 
I realize this goes against the grain of what is being recommended, but the experts in surgical trauma are resolutely unaware or in denial about the risks of transfusion in patients in whom transfusions are not life saving.  Reasonable,  to my way of thinking,  to reserve plasma/platelets and cryo for patients who are truly massively bleeding and will die without transfusion. 
Even then, I'd recommend tranexamic acid and/or DDAVP, and possibly fibrinogen concentrate (or cryo) long before transfusing plasma and platelets to bleeding patients, based upon randomized trial evidence to date.
Remember that early use of plasma and platelets has never been tested against these other modalities in randomized trials.  Platelet transfusion in particular, has promoted bleeding and mortality in randomized trials to date, and should be avoided if possible.  Particularly ABO non-identical transfusions which almost certainly make bleeding worse, not better.  

If they have a historical type on file, you do not need a current T/S to issue plasma and platelet products. For RBCs you do need a current T/S.

This is something I found on the CAP website: (For some stupid reason I did not copy the URL.)
From the CAP website:
 
Optimum timing of post-transfusion phlebotomy is critical for ensuring meaningful laboratory testing results, and medical judgment is required in making this determination. Several factors must be considered, including the type and amount of blood product given, purpose of the test (that is, the question it is intended to answer), and clinical setting.
In general, it is best to perform phlebotomy when the patient’s circulatory system is in homeostasis. A patient who is bleeding or undergoing blood product transfusion, or both, is not in a steady state. Whenever possible, samples for laboratory testing should be postponed until bleeding has stopped and transfusion is complete. One obvious exception to this rule, however, would be the setting of massive transfusion, during which monitoring certain laboratory values, such as cell counts and coagulation parameters, is essential to guide ongoing therapy. Variables such as patient blood volume, cardiac output, renal function, and volume of blood products transfused affect how quickly homeostasis is achieved following transfusion.
For the evaluation of post-transfusion increments in hemoglobin, hematocrit, and platelet counts, a practical approach is to draw blood samples within 10 to 60 minutes after completing transfusion, as this time interval is aimed at measuring peak recovery.1 Results determined from blood samples drawn later than 60 minutes post-transfusion are increasingly affected by confounding conditions, such as splenic sequestration, sepsis, and consumption.1,2 If the intent is to determine the extent of such confounding processes on red cell and platelet counts, one should combine a 10-minute post-transfusion sample with sequential samples drawn at one hour and 24 hours post-transfusion.
Alterations in chemistry test results following transfusion are not usually a concern in the low-volume transfusion setting. However, assay results may be affected for varying periods following transfusion of large amounts of blood products, as seen in massive transfusion, red cell, or plasma exchange—particularly if the recipient has impaired hepatic or renal function. Banked storage of red cells results in elevated plasma levels of hemoglobin, potassium, LDH, and iron in the blood unit that may, particularly in the metabolically impaired patient, be reflected in the post-transfusion laboratory values. In addition, citrate anticoagulant present in blood products may result in transient hypocalcemia in the recipient.3 Therefore, following large-volume transfusions or exchanges, waiting 12 to 24 hours before drawing samples for chemistry assays will provide results that are more reflective of the patient’s underlying metabolic state.

I'm sure Malcolm can give you the hard numbers and details but keep in mind that not every D- person responds the same when given D+ RBCs.  Some will develop anti-D with as little as 100 microliters of cells or less while others will never develop anti-D no matter how many units of D+ RBCs they receive.  Then everyone else is scattered around in between these 2 extremes.  Then throw in the males and women who are beyond child bearing and it becomes even more complicated.  I fall into the category believing that try to prevent the formation of anti-D after a transfusion event, especially one of multiple units is counter productive and an effort in futility.   

We have a policy to offer RhIg if we have given Rh Positive Random Donor Platelets to an Rh Neg female of childbearing potential. The amount of RBCs in a platelets is normally less than can be covered by a single dose of RhIg unless the platelets were particularly bloody in which case we don't accept them from our supplier. Luckily these days our supplier is doing a great job of supplying only Single Donor Platelets so bloody platelets are not an issue. Giving enough RhIg to cover a RBC transfusion would not be a reliable or economically feasible option since the RhIg we have on hand only covers 15mls pRBCs. So a one (1) standard unit of packed RBCs would take in excess of 18 doses. As Malcolm said giving the RhIg would have the added downside of clearing the Rh Pos RBCs you just gave so unless you have additional Rh Neg units available you are just putting yourself behind again.

We don't ignore the "weaker" agglutinations -- we still record M reactions... however, the result of the titer is the last dilution that is graded >M (i.e. is graded 1+). We have a test result called "below titerable levels" for a titer that doesn't have reportable results similar to what you are describing.

We supply blood to a helicopter service with a contract with our hospital system.  We put Safe-T-Vue indicators on all of their units.  They provide us a copy of their in-flight chart when they transfuse anyone not coming to our hospitals.  If the patient doesn't come to us but has an account in our HIS, we create a bogus registration in our BBIS using a defined format account number.  If they don't exist in our HIS, we create a complete registration manually in our BBIS using a defined format for MR# etc.  Then we emergency issue the product in our BBIS and handle it just as we would those patients who expire before a specimen is drawn etc.  We charge the helicopter service for the products which they include in their flat fee to the patient.  We maintain the final disposition records for any lookbacks etc.  If we got a market withdrawal or lookback, we would notify the helicopter company to follow up with the recipient.  That duty is at least vaguely covered in our agreement with them, I believe.  We tell the helicopter crew to return any unused products to us and not to leave them at the receiving hospital but this isn't perfect.  We sometimes transfer products on paper to the receiving site if we can document handling sufficiently. It doesn't work easily if the receiving hospital doesn't use the same blood supplier.

Nursing policy for blood administration should include those type of guidelines, They have references available for infusion rate, etc. The medical director of blood bank should (ideally) then review all of those polices to make sure that what they have included is good practice. In other words, a collaborative procedure. We struggle with getting blood/blood product nursing policies reviewed when written. There is a constant rotation of new nursing admin staff writing policies who never seem to know that our medical director should review those new policies and they don't understand what the lab has to do with administration. I just tell them it's an FDA requirement and TJC expects those requirements to be followed.
Our nursing policies are accessible on-line so I search periodically for blood related policies to see if anything has been added. I put all of those policies in my SOP manual under blood administration. When I do biannual review, I check to see if the policy has been revised so I can upload a new version if necessary. I usually check at least annually as well. The policy format used by my facility assigns 'ownership', which is the VP of nursing, 'authorship' and also includes a line which indicates people who must review the policy. TJC requires policy review every 3 years, so that's why I include those policies in my manuals - to make sure they are reviewed often enough for CAP requirements. If I find a policy that does not have the medical director's name on it as a required reviewer, I reach out to the 'author' or the 'owner' to see about getting it added. I've also made a point of knowing who is responsible for the facility policy manuals and who is responsible for the Joint Commission compliance book. I have those 2 ladies on speed dial and they are very helpful.  It can be painfully slow to deal with all the committees/councils that direct nursing policy. I tell myself that persistence and patience is key (and patience is not necessarily one of my virtues!).