sgoertzen

I'm the supervisor at a children's hospital in Central California and here are our indications for the transfusion of RBCs: Neonates: Term and near term neonates and infants < 4 months of age* Hgb/Hct < 7g/dl / 21% Stable anemia with no clinical manifestations Hgb/Hct < 10 g/dl / 30% Moderate cardiopulmonary disease Major surgery Increased oxygen (FiO2) requirement <35%, on CPAP lower setting Significant apnea or bradycardia, tachycardia or tachypnea Low weight gain Hgb/Hct <12 g/dl / 35% Fi02 requirement greater than 35%, on CPAP higher setting Recovering from major surgery Severe traumatic brain injury Significant deterioration of cardiorespiratory status Hgb/Hct < 15 g/dl / 45% FiO2 requirement > 35% Severe cardiopulmonary disease or congenital heart disease On extracorporeal membrane oxygenation (ECMO) *No clear transfusion RBC threshold guideline for low birth weight neonates (BW <1500gm) is available. Randomized clinical trial (Transfusion of Prematures) was started in 2013 and is ongoing. Pediatric patients >4 months old through adult Not bleeding Reasonable in almost all patients if Hgb/Hct < 7 g/dl / 21% Almost never indicated if Hgb/Hct >10 g/dl / 30% unless patient is on ECLS For Hgb between 7-10 g/dl (Hct between 21-30 %): Based on organ dysfunction and ability to handle inadequate oxygenation Respiratory or cardiac failure Chronic disorders of red cell production, severe platelet dysfunction Oncology patients Intra/perioperative conditions or significant bleeding Rapid blood loss exceeding >15% blood volume Intraoperative period as clinically determined by anesthesiology and/or surgeon Immediate postoperative period to restore hemodynamic stability We have built an alert in Epic with our "Prepare RBC" orders (both in mL and in Units) that warns the provider whenever they are placing an RBC order on a patient with a most recent Hgb value > 7 g/dl (or there is no recent Hgb value in the computer on that patient). This alert must be overridden with a reason from this drop down menu (below) in order for the provider to continue placing the order. We can run a report on all transfusions that triggered an Override when the order was placed (that also lists out the trigger value, the override reason, and the patient's problem list) and then the medical director performs an appropriateness review on only those outliers. BPA Overrides: RBC Orders (in mL) and (in Units): Warning if: No Hgb result or Most recent Hgb > 7 g/dl Appropriate criteria: Neonate w/Cardiopulmonary Disease Respiratory or Cardiac Failure ECLS Patient Sickle Cell Patient Thalassemia Patient Active Chemotherapy/Immunosuppressed Patient Hematopoietic Disorder Rapid Blood Loss HOLD for Pre-Op/Procedure Post-Op Hemodynamic Instability Other – specify as Comment

Here is our titer worksheet. We do a lot of prenatal titers for our Maternal-Fetal Center (high risk pregnancies). TO-300F01 Antibody Titration Worksheet.docx

We created this label (Shamrock): It's actually a brilliant orange color. Perhaps Shamrock would let you purchase this one that we already created for ourselves (Valley Children's Hospital)?

Re: We still have concerns about pre-op patients who aren't wearing any Epic band to scan when their pre-admit specimen is drawn. (I'm taking advice on how others manage these.) Likewise for outpatient transfusions. Epic told us that their system is not designed to use the process of banding outpatients and pre-op patients. WE INSISTED since 1) we've always banded any patient getting their blood drawn... especially for blood bank testing, 2) we were determined to meet AABB Std. 5.14.5.3) requiring an electronic (scanned) identification system, and 3) we decided that we were NOT going to go backwards after all these years and create a new system in Epic that was less safe just because they said that's their design. I insisted that PPID scanning be used for the specimen collection/labeling and that the same armband be presented on the day of their admission or outpatient transfusion. The patient is given strict instructions (an instruction sheet that they must sign and is scanned into the EMR) that they are to keep the band on or at least have it in their possession on the day of admission/transfusion. The original band used for specimen collection is replaced with their new encounter band only after the 2 bands are compared side-by-side and match exactly for Name, MRN, DOB. It was a bit of a struggle to get everyone on board to veer from the Epic "Foundation" methods, but we were finally able to convince people that this was a significant patient safety issue and was necessary.

I highly recommend you use this opportunity to discontinue using a separate BB ID band. Using the patient’s regular ID band works great. If you’re using scanned PPID from the wristband for specimen collection & labeling, adding another ID band into the process no longer adds any safety benefits. You’ve already created your closed loop system using the regular hospital ID band and scanning it for both specimen collection and blood administration in BPAM.

Here is our procedure. TO-480 Mixing Blood for Exchange Transfusions and CRRT.docx

When blood bank is called to release uncrossmatched blood, we specifically ask who the ordering physician is. The blood banker then places an order in EPIC called "Release of Uncrossmatched Blood" which is the statement (taken from AABB Standards) about the situation being critical enough to warrant the release of blood before compatibility testing is completed. This order must be electronically co-signed in EPIC by the physician that we name as the ordering physician. We have EPIC and WellSky (Mediware HCLL), but it shouldn't matter what blood bank computer system you have since this is all done (ordered/cosigned) in EPIC. I'm attaching our uncrossmatched worksheet that includes the instructions that we follow to place this order in EPIC and assign it to the ordering physician for co-sign. I check each day to make sure it gets co-signed. Once signed, I print the order with the co-sign tracking information, attach it to our worksheet, and file the paperwork for easy retrieval during future inspections/assessments. TO-381F01 Release of Uncrossmatched Blood.docx

We have a busy Fetal/Maternal Center for high risk pregnancies at our hospital. Our primary method of testing is solid phase (Capture) for antibody detection and identification, and our secondary method is PEG tube testing. The perinatologists are requesting antibody titers on all pregnant women with clinically significant alloantibodies. We have repeatedly seen clinically significant antibodies that react 3+ to 4+ with solid phase methodology that end up being "too weak to titer" when we move them to the tube for saline/37C/AHG titering. Even the non-diluted plasma reacts negatively in the tube at 37C and AHG without any enhancement. This is confusing to the perinatologists and I understand why. It doesn't make sense to them that a 4+ strong antibody can be too weak to titer. Does anyone else frequently experience this? I'm just curious whether anyone is routinely using any kind of enhancement when performing antibody titers on known clinically significant antibodies (such as CcDEe, K, Fy, Jk, etc). I know that the CAP ABT Survey choices for titer "diluent" are saline, 0.5% albumin, 6% albumin, 22% albumin and their "technique" choices include various versions of IS, RT, 37C, AHG, DTT (we're using saline w/ 37C incubation and poly AHG). With the exclusion of a gel titer, if you have a procedure (with criteria) for performing an "enhanced" titer, would you be willing to share it? For those of you using albumin for diluent, do you find this helps enhance the reaction of the antibody and what strength of albumin do you use?

Hi Sonya - yes, it's a custom label we had them make for us at Shamrock. If you like it, they may just let you order ours rather than create your own! Hope you are all well and happy in San Diego!

We apply this custom label to all PR platelets and PR platelet aliquots (see attached picture). We're a children's hospital and we've been giving PR platelets to neonates since March 2017 with no problems. PR Platelets.docx

We use Safe-T-Vue 10 indicators on RBCs/FFP issued in a cooler, and the Fluke 561 infrared thermometer to take the temp on products that come back that weren't issued in a cooler.

Our hospital went LIVE with Epic and WellSky in April 2020. The rest of the lab is Epic Beaker. We previously had MediTech house-wide. We have not experienced an interface delay between the 2 systems as David mentions above. We're a children's hospital with a level 2 trauma center.

For routine transfusions, each transfusion should include the volume of the product given. In massive transfusions, however, it is often common for them to track/document just the total cumulative volume of each type of product given during the massive bleed event.

In order for the vitals to “attach” to the product for various blood bank reports, the nursing staff must use the vital assessment within the TAR system (the Document button in TAR). If they choose to use a different vitals assessment outside of TAR, it will not attach to the product and you can only view those vitals by clicking on the “Vitals” button in the EMR of the patient and scrolling to the date/time of when the Transfusion was being administered. It’s a bit of a pain when you are doing Transfusion audits that appear to have “missing vitals”. They were often taken, but just entered outside of the TAR system in a different spot in the EMR.

I notified my Immucor rep but he wants to know what lot # CorQC is everyone having problems with? bldbnkr, Texas Lynn, David?