Mabel Adams

We require a signature be in the record because it is a requirement of standards. We don't require it to be completed before we will issue uncrossmatched blood so there should be no delay in care. We will issue uncrossmatched on a simple verbal request or the order (it is built into our trauma order set). Our uncrossmatched order in Epic does not send product orders to the Lab; it is a communication order that gives us permission to create the supporting product orders in the BBIS. Our process is partly for the above situation and also because they sometimes decide they need uncrossmatched units before the antibody screen is complete even though they have already ordered RBCs. We do request that either the computer order be placed or a paper be signed so we can have that in the record, but it can be done after the patient is cared for. It seems like just asking if they need uncrossmatched blood will halt the ones who just think that calling the lab repeatedly will speed up the process but remind those who really need it that it is an option. I am inclined to agree that getting the order/signature doesn't really accomplish much. I've never even heard of any litigation arising from a case where a patient was harmed from an emergency issued unit. I've seen a few antigen positive units issued to patients with antibodies who still didn't show evidence of harm so maybe the lack of litigation is because I've never seen harm. I have seen harm from not transfusing a patient with a strong anti-D during an O neg shortage where they attempted to avoid giving Rh pos blood by just using blood salvage during his emergency aortic aneurysmectomy and he ended up needing dialysis. I think this is what ended up being our final wording in Epic: The question “This patient’s clinical situation is sufficiently urgent to require release of uncrossmatched blood.” – must select YES. Where is the requirement that the medical director review them? Is that CAP?

We built an uncrossmatched blood order in Epic that includes the statement from the AABB standards almost verbatim. The MD orders it and has to click yes to the statement to finish the order. We just went live and expect TJC next week and AABB in the next 6 weeks so we will see what they think.

A few years back I heard that TJC wanted to just state that we had to comply with AABB standards but the AABB pushed back. Something to do with them owning those standards and TJC couldn't just adopt them as their own per se.

We are debating the proper use of PPE in the lab so we are looking for anyone who has a pretty granular policy or procedure for this that they would be willing to share. The debates are around things like whether you should wear gloves to touch a keyboard or phone that someone wearing gloves has been using. Then it progressed to refrigerator door handles. If anyone has strict policies like this, then how do you deal with units of blood and paperwork? If you touch papers wearing gloves or let them sit on workbench surfaces, can they then go to a clean section of the lab? If you touch a unit of blood while wearing gloves then you send it to a patient's room is that a problem? No I don't want to try that CDC recommendation from a few years back when they wanted us to disinfect the blood bags at issue. The FDA said that wouldn't fly so it went nowhere. Or is a policy that allows us to touch blood units sufficient for the rest of the lab and we should just be sensible and not lick our fingers when touching items in the lab like keyboards and door handles and papers? Are there any evidence-based studies on what approach is required for adequate worker safety? I appreciate your collective wisdom.

This workflow is supposed to work anywhere we have an MTP--ED, ICU, OR and OB. Our regular, routine transfusions in OpTime have dual sign off turned off because they had trouble finding space for the nurse to get to the anesthesiologists' computer to document dual sign-off. Again, they do it, but they don't document it in Epic. We actually still provide them with paper downtime transfusion records just so they can document that the nurse also checked the ID when they gave blood. I hope to get OpTime to create an easy way for them to note that the nurse did it and who it was but it hasn't happened yet and may require an enhancement. Definitely still hitches in the process there. Also, there is an option in OpTime for uncrossmatched blood and they can hang anything they want if they click that button. They used it once to hang blood that was, in the computer's brain, for a different patient and it let it happen. It really was for the same patient, but they were using his real ID in Epic but the original uncrossmatch request had come into the BBIS under a trauma alias which to Epic was a "different patient".

We were the first Epic site in the country to do MTP in BPAM with matching turned on. Be aware that the Epic "foundation" way is to document the transfusions but with the ID checks that are on for routine transfusions turned off. We still use a separate blood bank band because certain patients do not wear hospital bands (e.g. pre-ops drawn in advance of surgery) and I don't trust everyone's workarounds when they aren't playing nice with Epic. I find that SafeTrace Tx and Epic are like two spoiled toddlers--each wants everything exactly its own way and they aren't very good at communicating exactly what that is. We made some significant decisions about using BPAM for MTPs that let the computers do what they are good at (recording numbers accurately) and the humans do what they are better at (thinking) and left out some of the verbal checks of long unit numbers that are still required for routine transfusions. We turned off dual verification in Epic for MTPs. They still do it, but don't have to take the time to document it. Our MTPs require 2 people pretty much dedicated to the process of giving blood. We do about 1 a month but a "real" one who gets more than about 6 RBC units only happens every few months so we are still seeing if this works. We went live in April. We did extensive training on the MTP BPAM process before go-live. We think it is faster than paper, although they still drop back to that if there are any problems. Like others above I had to argue intensely to make them understand that the whole MTP is not universal donor, uncrossmatched blood. Some of the lines I heard from nurses-turned-IT people like, "it's an emergency, you don't check anything" just made my blood run cold. You can contact me directly if you want to see what we came up with and what problems we have faced, although it is still a work in progress--especially at our smaller hospitals that are expected to use the same process once a year.

The Vision prints a barcode of the specimen number on the results page. In our BBIS (SafeTrace) we must scan the specimen number before entering results and if it is not the specimen recorded for the patient it won't take those results. That said, in the year we had our Vision before it was interfaced we always rechecked that the manually entered results had been entered accurately.

We can't justify keeping the monoclonal anti-D that picks up category VI partial D at IS for using it twice per year. We don't want to pick those up on the mom because we want to call category VI Rh negative. We don't test donors so don't need the reagent for that. We wouldn't want anyone to mistakenly use it as a normal anti-D. We usually turn them out as unknown and give RhIG. Sometimes the weak D test does a little heat elution on a weak positive DAT and the control and test are both negative at AHG so you can call it negative. We also have a procedure for doing a heat elution on these so we can then test the cells through AHG.

We are a very popular place to move (Central Oregon) and we are having trouble finding people to hire. To answer the original question, we have one dedicated first shift BBer and everyone else is a generalist. We have capped the number of people trained in BB (about 24) so that they get enough shifts in here to stay competent. They do pretty well. We have evening shift coordinators who are a bit more advanced and staff can always call me.

Can your Haemonetics project manager tell you how to join the STTX user group email list so you can ask there?

My mistake. Keytruda is not the name of the anti-CD47 drug. Does it have any name besides anti-CD47 or HU5F9-G4? Is it still in clinical trials in the US?

I just saw that the FDA approved the use of Keytruda (anti-CD47) for a type of lymphoma so wondered if anyone has newer information for managing these patients if they need transfusion. Does the Immucor AHG work reliably? How are you resolving typing discrepancies?

We turn out a negative DTT-treated screen and do electronic crossmatch. If the screen has gone out as positive our computer won't allow EXM so we would do IS as Malcolm suggests. More complicated if there are alloantibodies but we haven't seen that yet.

Catherine, I am looking for a reference lab that can do this testing for around $300. If you wouldn't mind letting me know who yours is, I would appreciate it (PM, email, or phone call are fine).

I have a note: AABB 2015 (Ask the FDA... question 18) that issued plasma must be stored in a container that maintains proper temperature but that it is acceptable for return regardless of its temperature if properly stored. You are really debating the "properly stored" question but I found the above interesting and useful for those units issued warm and brought back promptly before they cooled down. I will be defining some circumstances in which we will accept them back. This is a more common problem now that the "trauma packs" with plasma go out more routinely.