carolyn swickard

Yes to not wanting to worry about WB, but some of this is talking about actual transfusions in the field where fresh (<14 days) WB would be very useful and much easier to deal with for a field team. I have also heard that some Trauma centers have a procedure where FFP and pRBCs and all get mixed together as they are being transfused(?!!?) I have no clue how that works, but seems like it would almost be safer to give a WB unit than that procedure?!? Fresh FFP with more functioning Coag factors logically seems better, but maybe a fresh WB has enough to keep things going. I can't see us managing this though - the WB inventory, even with returning it for Packed RBC production, would kill us. Most of our "traumas" to date have used fewer than 4 units. It will be interesting to follow this trend. By the way - does anyone know if the WB is Leukocyte reduced? If not, still having white cells onboard the unit would cause problems too. Especially with WC degradation over time before packing and filtering. Would NOT want to go back to that!

Grifols is still doing our rare ones - through send outs from the United Blood Services, Tempe AZ IRL, but the price is now over $500. Also -- they prefer a tube that has not been opened (risking cross contamination) for other testing, including automated. Theirs seems to be a molecular test that leads to a RH Type decision (prediction?). I have not been able to charge our pts, but appreciate the new CPT code. Might get that to work, but the results take too long to get back for most of our outpt encounters. (about 1 week.)

"and cold-stored WB contains PLTs that appear to have equivalent or better hemostatic effect in both in vitro tests and in clinical trials, compared to PLTs that have been stored under conventional room temperature conditions." (quote) How long do the platelets in a WB unit last? Even 7-10 days still leaves half of the unit's lifetime without platelets. The rest of the benefits sound interesting - especially pre-hospital. We are not even close to having blood products in the field, but it is an interesting idea to work on. I wonder how this would change the Massive Transfusion Protocol" 1st response (usually a unit of pheresised platelets in 1st load)- if at all?

Plasma is hard to keep track of just by temperature alone. If you are in a hurry - there is a good chance the plasma is going to be warmer that 1-6C when it leaves the Blood Bank to start with. Even in a separate cooler, that means the temperature monitoring tabs won't work and there is no way to know what happens to the plasma that way. Data loggers wouldn't work either. Difficult situation. We will only accept plasma back if it is cold and in it's own cooler and will only keep it for 24 hours. We do not extend FFP (any type) that was issued and returned into a Thawed Plasma product either.

Coolers (Credo line) for more than one unit or across the parking lot, and by hand for single units. Tried clear bags for awhile, and the nurses hated that because it was just one more plastic bag that had to be thrown out and added to our mountain of trash. We already use a ton of plastic bags (biohazard and plain) for our specimen transport. Our tube system is too small, fast and old to transport blood in.

Dear God, you have my deepest sympathy. 1. Push the company to give details on their benchmark standards and where they come from. Chances are, you are not in the same boat. We had a similar problem here because our Micro and BB staffing for the weekends did not meet corporate standards (desires), but we were unable to cut staff because of the physical layout of our facility and the distance between the departments. 2. Your situation matches one hospital I know of, if you could contact them - University Medical Center, El Paso, TX. The Blood Bank is in the Main hospital and the main lab is way across the parking lot. They are a level 1 trauma center and a big surgical hospital, but the NICU is in a separate hospital next to them and did have it's own Blood Bank staff. 3. Do you have current FTE numbers that justify your current staffing? What is the difference in the "factors" in the staffing equations that are being used that lead to this new company coming up with their figures vs. your current FTE figures? Good luck. Patient safety arguments sometimes sway Administrations when nothing else will. If you can make a case for how dangerous it is for the staff of a Trauma center to be too little, too late - maybe it could help.

Oh - we have a Credo set of coolers for our OR and floor use - they have worked very well for us. But darn-- it never even crossed my mind about taking the temps every 4 hours - now we are going to have to look at that. We seldom get units back, except from OR, and that is usually within 4 hours, but still....... Thanks for the heads up.

I I thought the only reason we were driving ourselves crazy (in the US) trying to get everything down to 1-6C was because the FDA (at least) has determined that coolers moving blood around in the hospital are considered "storage" - not transport (1-10C). Have they changed their minds again - officially??

"Tube testing is notoriously variable, while gel testing is believed to reduce some of those nuances. " Yes, but it is also - according to years of CAP survey results - routinely 1-2 endpoints higher on every titration run. So, make sure you are telling your physicians that your facility is doing titers with gel and that the actionable titers for their patients might be at higher endpoints than those historically with tube testing. "It does need to be reliable/robust and give the same end point each time, even with the acknowledged variations in serological tests (reagents, test cells, techs, etc.)" I wonder if the inspector would have been OK with procedures with this kind of control if it was used when there was no retained sample (no control avail) and not used when the new specimen was run in parallel with it's retained pair (internal control avail)?? I guess we will have to see, because that is what we are going to try doing.

Further follow up. We did purchase the HemoBioScience premade DTT - very nice and really not too expensive for a small hospital - saves all the worry over the manufacture of an in-house DTT reagent. Works well to use 8-10 drops of your 3-4% RBC reagent cells to make one drop of "Packed" RBCs to treat with 4 drops of DTT. Once they are treated and washed, you remake to a 3% solution and get 8-10 drops of treated cells to work with. As hard as the DTT treatment is on the reagent cells - I don't think they are going to last very long for a small hospital - maybe a day or two for a reference lab?? (didn't see the results of that validation study.) We treat the reagent cells (I, II, III) and the first RBCs requested for crossmatch every 72 + hours (new specimen), but if the antibody screen was negative - we just continue with K neg , immed spin, type specific RBCs for the 72 hours (same specimen) for any add-on units. If the antibody screen is positive - a reference lab is going to get the workup. We only have one liquid panel, so I can't see us being able to work up an underlying allo antibody in-house. Dr still is not happy that it takes someone 3-4 hours to work one of these pts up - go figure. It is amazing that even an Oncology specialist thinks that just because we did an antibody screen 3 months ago - we should be fine with giving them "some of that least incompatible stuff"! oh well - will attach my SOP for DTT for anyone it might help. We can survive the simple pts with this procedure here - don't look forward to the 1st pt that forms an allo-antibody on top of the DARA. DTT SOP.pdf

Is this true for all of the pathogen reduction methods or only some of them? The new Circular of Information keeps qualifying the statements to say " if approved for GVHD prevention".

This also makes you wonder - still - if all of these studies on Patient Blood Management today were really done on patients with 100% leukoreduced blood products - especially the studies done in the US. It is not always listed in the controlled study parameters. Also - if my memory has not faded completely(!) - I seem to remember leukocyte reduction being touted to decrease the same problems they are now after us to just "not give blood" for - the reasons so well detailed above. We have been on 100% leukocyte reduced RBCs here (from our blood supplier - Blood Systems, Inc) for a couple of decades now - and we see VERY few transfusion reactions. While that is not the only reason not to give blood - why are the posited post transfusion complications still the same? Did leukoreduction not work? Or are we still fighting the same complications because some of the US still has not adopted universal leukocyte reduction? Leukocyte reduction seems to have helped our patients a lot. Just curious -

Our hospital did a good job of sequestering the available saline and saving it for specific uses last time this happened. Pharmacy kept track of it and did a good job keeping enough available for transfusion and other saline specific uses. They used some of the other solutions to replace saline use for reasons other than transfusion where they could. Maybe that would be a better/safer way to go?

Yeah - those darker ones are sneaky...

Thank you so much for this - very useful. (And for once.......we have the right reagent!!! - Go Immucor!)

Nursing picks up their own "Transfusion Order" in the Nursing system (Meditech - I don't know what it looks like). Then they bring a copy of the signed consent form with them for every unit. It is cumbersome for the RNs to always find the consent form and photocopy it off (and we do suspend that in heavy use) but it has succeeded in getting us to and keeping us at 100% compliance with signed Transfusion Consents on the charts. The only exception to this is the O.R. (no easy access to photocopiers - they say) and an Emergency Release (where the DR has to sign for the blood). Each unit is confirmed by a 2 RN read and check, at this point.

This is roughly what our current procedure is too. We call them Rapid ID packs, but they are only in our ER. I wonder if L&D would ever need them here? Have to check into that.... Just to hijack this thread farther - does anyone have an extensive Disaster Plan that covers both internal disasters, external disasters and (God help us all) Mass casualty events?? I have been trying to write something for quite a while - but everything seems to be just too little or too much. What do you put down on paper and does it ever help anyway? What do you practice/drill? We have 2 100 bed hospitals, two E.R.s (about 20 beds each), 2 college campuses, 4 High schools and a few dozens mid and elementary facilities. Our blood center is about 1 hour away. Can anyone share what they may have? Can anyone from Las Vegas, NV, USA share anything?? Can't imagine what your night was like at all.... Carolyn.swickard@lpnt.net Thanks for any help.

Our last Meditech revision was to 5.6.7 and there was no change to unit lookups. Meditech 6.whatever is a long way ahead of that, but I don't understand why they would change such a long-standing, NECESSARY part of the Blood Bank system. Please keep us informed on this subject if you discover this is a real change and not just a new version Glitch they have to fix before Go-live.

Also - examine your Joint Commission Standards if your Lab happens to be under Joint Commission accreditation. QSA .05.18.01 - section 2 and 3 state in part: 2. The requirement that suspected transfusion reaction-related adverse events are reported immediately to the laboratory, whether or not the physician responsible for the patient deems it necessary to report the event. 3. Policies and procedures for nursing services related to blood and blood component administration do not conflict with the laboratory's policies and procedures. That is fairly definitive about what they want to see and it differs from CAP. We had to change from " what does the physician want to do" to "we need the Transfusion Reaction Workup" if we hear about it at all. Curious as to what Hospital Joint standards say about the whole thing - I have never seen that set of standards. And most hospitals are accredited by Joint Commission, even if their Labs are not.

We purchased the HemoBioScience DTT - premade also. It worked very well in parallel testing and seemed to completely decrease the reaction of DARA with the treated cells. It is frozen and can be thawed up to 3 times (I think), but you will use it up before that as only 2 mls comes in each tube. Much faster than a send out. Gives you a clean screen and then you can just crossmatch treated K neg units. (barring the production of anti-k, that is!) Used a combination of the AABB procedure (recommendations and limitations) and the manufacturer's procedure to get a clean procedure that worked here. I can not get a file copy of our procedure from our system (Policy Stat) to this system but would be able to email a copy if anyone cares for it. If anyone notices a problem - please let me know. This was a scary stretch for us too.

Have you considered getting your system programmed for electronic crossmatch/release). At your size - that could be your best option to have zero units tied up on your shelf in "crossmatch" status. It is a lot of work, but Cerner has the programming for it and it would be the best answer for you in the long run. Especially if you get any bigger or busier. Getting the Dr's to change their ordering patterns would be just as much work and wouldn't be the most efficient way to handle your overall problem - looking towards the future. Just an opinion......

It would be so nice to have the luxury of giving, at least, ABO identical pltphs. We really don't have that here, we have too few pltphs to choose from in this region. And washed pltphs would have to cross state lines and our distribution system does not have them FDA licensed, so they don't get to come up here. But thank you for the information - we can simply try harder.

We have a canned comment that says " Anti-D detected is presumed (you might want to make that "possibly" or something less) to be due to Rh immune globulin given...." and then we input whatever date is given to us from phone calls, computer searches, questions to the pt, etc. Some of my techs are now also putting in the source we receive the information from ("chart", "computer", RN's or clerk"s name, etc.) The computer puts the comment on the chart. hope this helps.

Some of our cancer patients are transfused while febrile. They can go with a fever for days, so rarely, they have to transfuse in the face of the fever. Impossible to determine if they might have a febrile reactions on top of the fever. The RNs look for the rest of the signs and symptoms possible in transfusion reactions.