AMcCord

Very nice!

We send titers out to the ARC ref lab now. We were doing a lot of prenatal panels and doing the titers for the clinically significant antibodies for those patients. It got to be a burden considering our work volume and staffing levels, plus maintaining competencies for the procedure was becoming difficult. We have plenty of other work to do, so I don't miss doing them.

I quit doing titers years ago - and I'm not sad . Attached is the form I was using when I did do them. ANTIBODY TITRATION WORKSHEET.doc

I just answered this question. My Score PASS  

And we see this in surgeons as well.

We don't actually see many T&S orders from the ED. Those are usually patients who may be surgical candidates (like broken hips, bowel obstruction, etc.) and unless they are anemic, usually not transfused. There are more orders for 1 unit and transfuse, almost 100% look appropriate when reviewed. Instead we saw a pattern of ED providers ordering blood types in order to have a Blood Bank specimen available. We've persuaded them to use a BB Hold order instead of charging a patient for a blood type that was rarely needed - a specimen is collected but nothing done until they order a Prepare/T&S. We do use some discretion with the BB Hold orders. If the H&H is low or the patient is a really active GI bleed or it's a trauma case that looks bad, we put the specimen on the Echo just to get a head start. Nothing is reported until we get an order but it can definitely help the TAT. I've never actually looked at stats on ED orders, but I've wanted to (in my abundant spare time ). Another project I've wanted to tackle is to look at our emergency releases (especially on medical, rather than trauma, patients) and MTP orders to see what % of our patients we are actually transfusing or MTPs that only use a unit or two (or none), to see if we have any interesting provider ordering patterns. Also, how many times we ship blood with transfer patients vs how many times they are actually transfused in route or the unit(s) wasted. I would like to compare that information with the score ED assigns to the trauma patients to see if we are correlating well.

I've also seen this in an elderly K- male patient - he had never even been hospitalized in his life, much less transfused, until we saw him with his positive DAT and anti-K.

Not a Vision user, but can you use logic in your middleware/engine to remove the unwanted characters? Is there a setting in the Vision software for how the barcode is read by the analyzer?

Agree with Cliff. The alarm at the nurse's station would, I believe, be considered as a 3rd party under CAP as it is outside the lab's direct control. Years ago, before we had 24 hr staffing in the lab, we had a similar set up with the alarm in the telephone operator's booth. That position was staffed 24 hrs. The problem was that the operator didn't always respond to an alarm or didn't respond in a timely manner. During a CAP inspection the alarm was triggered in the blood storage refrig and the operator didn't respond. It was day shift and when asked, she said she didn't call because she assumed someone in the lab would respond to it. We were cited because we couldn't demonstrate adequate alarm response. If you are using nurses to respond, you could face a similar citation if they don't follow through with notification.

I've seen it a couple of times. Both were patients with WAIHA who were very actively hemolyzing their own red cells. DATs were 4+++ - like almost didn't need to centrifuge - positive. Sent both samples to reference lab and neither one could be resolved. I think they tried 12 washes on one sample without success (more than policy, but they were curious to see what would happen). Ugly cases, idiopathic as far as the experts could determine.

The Petz and Garratty book Immune Hemolytic Anemias has been very helpful tp me. There is so much between those covers!

We are using a small hang tag (purchased from Amazon, cheap - intended to tag clothing) with a sticker I print on a fluorescent label. See below (actual size).

Check your instrument manual carefully. Immucor has a statement in the manual for the Echo that addresses carry over. Maybe Ortho does as well???

We've never been cited by CAP, the FDA or TJC. TJC does come into Blood Bank because we handle the frozen/refrigerated tissue grafts and never a word said. Our saline in use is quite visible to anyone who walks into the department. That request is overboard and made by people that have never worked in the lab. Agree with the comments about safely handling the plastic blob, utilizing the reagent w/o waste, proper labeling w/ lot, etc. and the fact that it would look just like formalin and some of the reagents hemo uses.

Above is what we do with traditional reagents, including the fetal screen (lot to lot comparison as above). Automated reagents are QC'd when the lot is opened using the QC material we were using with the old lot. We inspect for appearance and shipping condition, check inserts, and document that for all reagents when received.

I would recommend getting the LIS. It will provide a level of patient safety that you can't get with paper. It improves workflow, especially if you are using automation. Decreases documentation errors and omissions. It will simplify billing. It will vastly reduce the piles of paper documentation that you would otherwise be storing for years - patient, donor and potentially QC (depending on the software). It simplifies inventory management, especially when you get look-backs and recalls from your blood supplier years down the road. We are a smaller hospital that went to an LIS just a few years ago. I can't imagine ever going back to paper (gives me nightmares actually!). It has definitely reduced my workload in terms of all the record keeping, reporting, etc. that is required. I am filling out fewer error reports and deviations from SOP. With staffing issues a 'normal' thing now, I need all the time I can find to do all the other things I need to get done, including working on the bench. Are you going to do the reaction workups or refer those?

And that transfuse order has to be from the same 'phase of care' where the patient will be transfused. If the transfuse order was entered in the ED or the OR, that order will not work for an IP on the floor - lets say ICU. BPAM won't work until a provider order is entered for that IP/ICU phase of care. Learned that one the hard way when we first went live with EPIC.

We do accept product from other ARC facilities. The contract each facility signs with the ARC specifies how products are to be handled and I would think that this would apply to any blood supplier. The transferring facility completes the ARC transfer form that includes an attestation that states that the product was stored properly. We verify that the products were packed correctly for shipment and that the temp of the units when received is OK. That inspection is documented on the packing slip that ships with the products, including date/initial by the receiving tech. I think another point hat can be considered is the fact that the other facility has been inspected by someone - state, CLIA, CAP, AABB, TJC, possibly their blood supplier, etc. - that inspection would include their blood storage records and practices. Maybe I'm naive, but I figure I can trust that unless I have evidence to the contrary. (I am not FDA inspected or I might give you a different answer.) If product comes in that doesn't pass inspection, we reject it and I notify the facility and our ARC hospital representative. Transfers that come in with another patient are an entirely different thing.

Check for work done by Mayo Clinic. I believe that they are sending out cold platelets w/ red cells on trauma flights. Maybe someone here can provide a reference for their trauma studies.

We manually entered results after a 9 day down time. Manual entries were verified before they were pushed from the LIS to the HIS. There was a special work group that came in on a weekend and worked long hours to do it, then worked charges after that. Nine days worth of data was a mountain. I can't imagine doing 2 months worth considering staffing issues. I would vote for scanning. We can scan into the lab results section in Epic. It wouldn't be graphed, but it would be accurate.

No

I had an OB patient with an antibody to anti-Goa that we picked up on prenatal screening. One cell was positive on the screen and nothing showed up on 2 panels, Because it was an OB case, I sent it to the ref lab and they identified the culprit.

My facility has never been cited by JC for therapeutic phlebotomies. Interesting. I handed that service over (quite happily) to the outpatient infusion clinic years ago. I did train them initially and give them copies of my forms as a documentation suggestion. My CAP checklist gets N/A for those questions and I've never been approached by a JC inspector. I would hope that they have yearly competencies, but I don't know for a fact. Might have to inquire.

We issue units for warm auto cases as 'incompatible, approved by pathologist'. We enter a comment in the patient Blood Bank record with the date/time we got the approval, from whom, and documentation of any instructions they give and any instructions we are asked to pass on to nursing. In some cases, the pathologist may consult with the ordering provider and request that he/she sign a 'Request for Release' form with one of two options selected: - incompatible units due to clinically insignificant interference (cold agglutinin, rouleaux, etc.) OR - incompatible units due to interference from a clinically significant warm reacting autoantibody. Although some units may appear compatible in vivo, it is impossible to rule out any underlying clinically significant alloantibodies that may cause a hemolytic transfusion reaction. The pathologist may also sign the release form in some cases, if requested by the provider.

We use the FinalCheck armband and lock system with Epic BPAM. We also use electronic patient identification for specimen collection. The armband code is not documented in Epic or anywhere else on the floor, only in Blood Bank. The blood product is locked in a bag at issue and the combination to the lock is the code the nurse takes from the armband at the bedside. No armband, no blood product (except emergency or MTP). Once the unit is removed from the opened bag at bedside, the identification process continues w/ 2 person verification and BPAM. It is not cheap, but it closes a loop for specimen collection. The process works smoothly. We lose very few armbands. There are more problems with BPAM, most of which are related to somebody forgetting to check a box in Epic to begin the transfusion, forgetting to enter a volume, or scanning the wrong barcode.