AMcCord

That's what I use in our ultra-low freezer. Works fine.

We have had similar problems with providers and nurses. The last statement is something we wrestled with when the policy was presented to us and my medical director is still not quite fully satisfied with it. Scott - I'm going to show him your suggestion to see what he thinks.

The grocery list below is what is in nursing policy at my hospital, with my notes in italics. This is their reference cited in the policy: Berman, A. & Snyder, S. (2012). Administering intravenous therapy. In Skills in Clinical Nursing (7th ed., 511-512, 516). Upper Saddle River, NJ: Pearson Education Inc. A. Recognize and report any of the following signs / symptoms of a transfusion reaction to the Physician and blood bank immediately for consideration of transfusion reaction work up: 1. An immediate hemolytic transfusion reaction may contain any or all of the following clinical presentations: a) Fever, chills, or both (specifically 1.5 F increase) b) Nausea or vomiting (also sudden onset of diarrhea) c) Headache d) Pain – localized to the back (also flanks, abdomen, chest, head, and infusion site) e) Chest constriction (also sudden onset of cough) f) Dyspnea and cyanosis g) Subjective feelings of distress – sometimes reported as a “sense of impending doom” (anxiety, agitation) h) Hypotension, tachycardia or both (significant change in BP) i) Hemoglobinuria (dark urine, anuria in extreme cases) j) Unexpected degree of anemia due to hemolysis of transfused RBC’s k) Shock l) Rash m) Feeling of heat along the vein used for infusion 2. Delayed Hemolytic Transfusion Reaction (24 hours to 2 weeks post-transfusion) may contain any or all of the following clinical presentations: a) Fever, chills, or both b) Jaundice (sclera) (increase in bilirubin) c) Pain-localized to flanks, back, abdomen, chest, head, and infusion site d) Dyspnea e) Sudden unexplained fall in hemoglobin 7-14 days post transfusion f) Continued anemia despite transfusion therapy g) Hemoglobinemia and/or hemoglobinuria 3. Febrile Nonhemolytic Transfusion Reactions (occur at the end of the transfusion or up to 2 hours later) may contain any or all of the following clinical presentations: a) Fever – occasionally b) Chills, colds c) Discomfort d) Rigors – occasionally e) Headache f) Nausea – some patients may vomit g) Dyspnea 4. Allergic Reactions (occur usually seconds to minutes after initiation of transfusion) and may contain any or all of the following clinical presentations: a) Intensely pruritic, localized or disseminated urticarial eruption (well circumscribed, discrete wheals with erythematous, raised, serpiginous borders and blanched centers) b) Generalized pruritis may precede eruption or generalized erythema or flushing of the skin. c) Angioedema, a more severe form, consisting of localized, nonpitting, deep edema of the skin. 5. Anaphylactoid and Anaphylactic reactions (occur usually seconds to minutes after initiation of transfusion) and may contain any or all of the following clinical presentations: a) Upper or lower airway obstruction or both b) Upper – laryngeal edema causing hoarseness or stridor (lump in the throat) c) Lower – Bronchospasm generates audible wheezing, tightness in the chest or substernal pain. Other associated symptoms include dyspnea, cyanosis, feelings of anxiety (“a sense of impending doom”) d) Profound hypotension e) Tachycardia f) Severe G.I. symptoms present from onset-abdominal cramps, nausea, vomiting, diarrhea. g) Erythema and urticarial eruptions are prominent and typically involve confluent areas of the trunk, face, and neck. 6. Transfusion Reaction Acute Lung Injury (TRALI) (symptoms arise in setting of recent transfusion of plasma containing blood components [ Red Cells, Whole Blood, Fresh Frozen Plasma, Cryoprecipitate, Granulocytes], always within 1-6 hours and usually within 1-2 hours of infusion): a) Acute respiratory distress which may first be manifested as dyspnea or cyanosis b) Severe bilateral pulmonary edema and severe hypoxemia c) Tachycardia d) Fever (1-2 C increase) e) Mild to moderate hypotension, usually unresponsive to IV fluid administration f) FDA regulations require all cases of TRALI to be reported. If TRALI is mentioned and/or charted by a physician as a differential diagnosis, the Blood Bank must be notified. Increase in temperature alone should not always constitute justification for a transfusion reaction work up. Nursing judgment should be used in evaluating symptoms and notification of physician.

We start with one panel (or cells 1-10 of Immucor's Panel 20 if doing tube testing). If a specificity is apparent when crossouts are done/the pattern of reactivity is reviewed, then we use selected cells (negative for the antigen the antibody reacts with) to complete rule outs OR if a number of rule outs are needed, run another panel on the Echo. If the patient has a more complex history or the antibody screen looks more complicated, we might choose to run 2 panels on the Echo right away. I require 3 antigen positive cells which are reactive and 3 antigen negative cells which are non-reactive to 'prove' specificity. The patient is antigen typed for the specificity identified if not previously typed for that antigen and if not recently transfused. Other common clinically significant alloantibodies are ruled out with 2 cells. This works well with straight forward, single specificity samples with antibodies like anti-K, anti-E, anti-Fya, etc., which are the majority of what we see. If the antibody screen on the Echo is positive in all three cells, which happens occasionally, we run a tube/PeG screen with an autocontrol plus one panel on the Echo with some questions in mind - is it an autoantibody? is it solid phase speficific? is it multiple antibodies? is it directed against a high incidence antigen? could there be a drug involved (anti-CD38, I'm looking at you!). If the auto is positive, we do a DAT. If the specificity is not readily apparent, then we run another panel, or two, or three as needed, based on what the first panel looks like. Almost all of our IDs start on the Echo and those panels are pretty well designed for rule outs of the common offenders. It is not uncommon to use only one panel for some specificities. I encourage everyone to look at the big picture, then narrow their search based on what they see. In the long run that will save them time (and reagents). And I will admit that on a busy day, we may put 2 panels on the Echo and push GO to expedite things a bit. If we are doing tube testing, running extra panels we may not need up front, is probably going to use more time and effort. Change is uncomfortable, especially for blood bankers, but give it shot. Think the steps through and work smart. You'll start to see problem solving in a way that you hadn't seen it before. Ask your work buddies for a second opinion if you're not comfortable. Review some cases with your supervisor to really get a good feel for what he/she is asking you to do. Once you've worked through the process it a few times, you'll feel better about it. And for those ugly case - the folks at the reference lab are your best friends!

Our policies say 'current edition' also. Some time again I got the same suggestion during a CAP inspection by someone who was an AABB inspector. It is an AABB commended practice. I do like the idea of a cover page listing the edition in use.

I used to have our thermometers checked in the same way. Then I discovered that the charge for that was actually more than buying new thermometers. It does seem wasteful, but it makes better financial sense.

My facility is 180ish beds in a rural area and I also have limited access to platelets. We stock 2 A Pos units on weekdays and 1 on weekends/holidays, if supply allows, and are thankful to have them. I do understand the issues about transfusing non-type specific product to patients and ideally we would transfuse only type specific. We do so if we have time to order product specifically for that patient (from blood supplier 150 miles away). My reality is also that we don't have the staff, space or the equipment to add that kind of procedure. We would have to maintain competencies on a lot of staff members who might wash a unit once or not at all over the course of a year, or call in staff to do it. Even with limiting the number of staff members that perform the procedure, we would still be trying to maintain competency for something done a limited number of times per year. It would be difficult for me to maintain competency and I'm the only full time blood banker. Who's going to check me off? Washing platelets would also require an FDA inspection, would it not? which opens another can of worms. It's a difficult situation. We can provide A Pos platelets for everyone, usually right away, or we can tell providers that we will order type specific platelets for their patient, but its going to take time, maybe hours or tomorrow. Providers rarely want to wait, including Hem/Onc.

In Immune Hemolytic Anemias Garratty suggests a warm saline wash to resolve the problem of a positive control for DATs. I've used that successfully for a patient with a pretty strong cold agglutinin, to report out a negative DAT IgG (after consultation with our medical director). It was unsuccessful for a couple of other patients with colds. It wouldn't resolve a problem with the control for IgG coated cells.

We use the name/MR# which is assigned by Epic when the patient is registered as an unknown. When the patient is officially ID'd and if he/she has an existing chart in Epic, the record of the emergency visit is merged into the existing chart. We use blood bank armbands, so even for those patients that are not yet in the system at all, as soon as a phleb reaches bedside (and that is pretty much immediately), we have a 'name' - which could be Male ER4, Female ER5, Male Red Hair ER3, or something similar plus the armband characters. If we have any kind of registration from the ED, we use that with our armband giving us 3 identifiers. The blood bank armband stays on all our patients until discharge, so we always have that to link us with the patient/specimen.

True, but we look at the request for uncrossmatched blood as an occurrence outside the norm, even though we have SOPs in place in Blood Bank to address that.

I've seen one baby with D antigen sites blocked by Mom's anti-D. Of course the DAT was 4+++++. It almost didn't need centrifuged in order to see agglutination. We perform the weak D testing. If the Rh control is positive, the weak D test is reported as invalid. If the control is negative, we report the test. There aren't a large percentage of samples that have a positive control.

I'm sticking with you, Cliff.

Below are the relevant CAP checklist items for emergency release of blood products. My viewpoint is that the emergency release is a 'deviation from SOP' and that is what the blood bank medical director must review. What I regard as a deviation is: our policies require us to perform compatibility testing for RBCs or perform a blood type for plasma (platelets) prior to providing them for transfusion. If we 'emergency release' blood, it is released uncrossmatched, and plasma (platelets) is/are released w/o a patient blood type. We are thus deviating from this policy. Our medical director is also looking for evidence that we followed the SOP for our emergency release process. We have an ongoing quality project to monitor documentation, how long it takes to provide product after request, and compliance with SOP. Quality improvement projects/processes are also part of regulatory compliance. For us the reviews are not a major problem because we don't have that many emergency releases. Our problem is maintaining staff competency to make sure that everything goes quickly and smoothly This is where the quality improvement part of the equation comes in and we've made some major improvements there. No inspection problems w/ Joint Commission, CAP or CLIA and we've been doing this way for years. I don't know if it's overkill, but it works, and it's good for our patients. TRM.40770 Life-Threatening Situations Phase II Adequate policies and procedures have been established for the investigation and handling of life-threatening situations (such as the use of uncrossmatched blood or abbreviation of testing) that include the written authorization of a qualified physician. NOTE: Written policies and procedures must be available to expedite testing for transfusion in a life-threatening situation. If an institution's procedure allows abbreviated testing in massive transfusion situations, records should indicate that the procedure was followed. Records must include the authorization by a qualified physician. (If approved by the institution and recorded in the laboratory's procedures, the physician responsible for the transfusion service laboratory may accept this responsibility.) If an incompatibility is discovered on completion of an incomplete crossmatch, the responsible physician must be notified in a timely manner and this notification recorded. 29 of 85 Transfusion Medicine Checklist 08.21.2017 Red blood cells released before testing has been completed must be conspicuously labeled as uncrossmatched on the tag or label. Records of completion of compatibility testing for units released uncrossmatched must be maintained. Evidence of Compliance: ✓ Records of emergency release authorization by a qualified physician REFERENCES 1) Food and Drug Administration. Current good manufacturing practice for blood and blood components. Laboratory controls. Compatibility testing. Washington, DC: US Government Printing Office, 1999(Apr 1):[21CFR606.151] 2) ibid. Records and reports. Records. Washington, DC: US Government Printing Office, 1999(Apr 1):[21CFR606.160] AND TRM.30900 Records of Deviation From SOP Phase II The transfusion service medical director or designee provides written authorization for deviations from the standard operating procedures. NOTE: The standard operating procedures constitute the approved procedures of the laboratory and are to be followed at all times. Any deviations from these procedures must either be authorized by the responsible transfusion medicine medical director or designee prior to their performance or, if detected only after the event, must be investigated through the laboratory's quality assurance process. A wide variety of routine procedures may, from time to time, require the transfusion service medical director or designee to authorize an alternative approach because of specific clinical situations. Among these, for example, might be the need to give Rh positive red cells to an Rh negative recipient because of inventory shortages, or to provide a unit of platelets that was not HLA-matched (or “crossmatch compatible” or “antigen-negative,” depending on the laboratory's routine approach) to an alloimmunized patient in an attempt to control hemorrhage. REFERENCES 1) Lam H-TC, et al. Are retrospective peer-review transfusion monitoring systems effective in reducing red blood cell utilization? Arch Pathol Lab Med. 1996;120:810-816 2) Shulman G, et al. Creating useful statistics to audit transfusion services. Lab Med. 1998;29:371-374

That's frightening! I will hold that thought as we move forward with OpTime.

CAP has been around since 1960s and TJC commission since 1951, causing lab staff grey hair for many years (in a good way). In the 1990's, CLIA put some bite in inspections because they brought a different type of quality focus into the inspection process, they verify inspections performed by other agencies, like CAP, and they cover labs that were not being inspected - like Drs offices.

I agree with Scott's assessment. TJC standards for blood bank say that the blood bank should follow AABB guidelines, not necessarily be inspected by AABB. (I should have used the word guidelines, not standards.) I believe that they see AABB as the 'gold standard' that facilities should strive to follow. And of course, the AABB Stds are aimed at meeting FDA requirements. I discovered long ago that if I made sure that I was following AABB standards as closely as I was able to, that I would have little to no difficulty in passing TJC and CLIA inspections. In addition, if I made changes based on new or revised AABB Stds, then I was going to be ahead of the game for new and changed CAP Stds.

One caveat I would add - if you are inspected by TJC, you are required to follow AABB standards.

LPNs can do vitals, but RNs must perform the verifications.

Malcolm, that is so wonderful! What a grand way to cap off a career. Well deserved.

We are using the FinalCheck armband and lock system. We use handheld devices to scan armbands/ID patients at bedside. Labels for specimens are printed at bedside and only lab draws blood bank specimens. Blood products are administered with BPAM, nurses have to scan the armband at bedside to ID the patient and 'match' it with the unit. With all that in place, we are not going to discontinue using FinalCheck band and locks. There are always some creative folks out there who don't think their little shortcut is a problem. I don't need more gray hair from thinking about scary things like that.

That's why Chemists won't come near Blood Bank -scares the pants off of them.

The wording on this one has changed several times since it first appeared in the standards - I'm sure they are seeking to clarify the intent. And every time they change the standard it just brings another angle to the debate about what they mean. That's why we all love the checklist (not!). Reading back through the thread, I think if we talk about this as 2 different topics, it would help. Confirmation of negative patient results with poly - David, thanks for inquiring on TRM 40200 and 40210. The package insert for the poly I use does not require the use of complement coated cells to confirm negative reactions for patient testing. IgG coated red cells are sufficient. Matches the response that David received from CAP. The package insert for the Anti-C3b, - C3d I use requires the use of complement coated cells to confirm negative reagents for patient testing. Also matches the response from CAP. Pretty straight forward. QC - the All Common checklist requires QC with a positive and negative control for every reagent, every day of use or following manufacturer recommendations . The package insert for the poly and anti-C3b, -C3d reagent I use does state that complement coated cells should be used to confirm that the reagents have sufficient anti-C3 reactivity - once a day. So, my interpretation of the standards for QC and the standards for patient testing are: If you are using a reagent with anti-C3 reactivity, you will need complement coated cells for QC. This would include poly and anti-C3. Performed once daily, when used. If you are confirming a negative patient test and you have used poly, you must use IgG coated cells, but complement coated cells are not required. If you are confirming a negative patient test and you have used anti-C3, you must use complement coated cells. So ejani should use complement control cells as part of daily QC for the poly AHG used for patient testing, but only needs to use IgG coated cells to confirm negative patient test results.

Our primary method is the Echo. I use PeG for tube testing, with LISS available for working with warm autoantibodies that love PeG and solid phase too much.

Unfortunately, we have weather extremes that sometimes affect deliveries of platelets. We don't have any issues when Plts are delivered by the blood service, but in the extreme temps of summer and winter when they are delivered by a contract carrier, we can have temps outside of the 20-24 C range when we receive them. It's all about how the boxes are handled. If someone with the carrier doesn't do what they have been instructed to do (keep the blood boxes out of the unheated/un-airconditioned warehouse), then we have the potential for temp variances. Doesn't happen often, but often enough that checking temps is a must. When you make your decision on whether or not to temp your Plts when received, consider the delivery method and your environmental factors. If you live somewhere without extreme temps, you are probably not going to have a problem.

I would definitely rule out other significant alloantibodies in some way. Assuming that the antibody present is 'only' RhIG is asking for trouble. 99% of the time, it probably will be, but the time it isn't could bite you in the tookus.