sgoertzen

We are a children's hospital who started using TAR almost a year ago. The volumes of all of our products vary so much and are critical for our patients (they watch intake/output so closely), so weighing all of our products (as we receive them from the donor center and put them into our system) and also as we aliquot them into new split products has always been an important part of our procedure. My product dictionaries have no default volumes, and we enter the volume of each one as we weigh it. If you are off by a few mL and the nurse's pump shows that she transfused 257 mL even though the product was issued with the volume in the computer as 268 mL, it is fine. The entire unit gets the status of "transfused" as soon as the nurse hits the "End" button in TAR, and there are no pieces of product left hanging out in the computer somewhere. The nurse also has the ability to track in TAR additional saline flush volumes given at the Begin and End of the transfusion. We do not use a separate armband since our regular hospital armband has the patient account number in readable and bar code format. Prior to TAR, we did not pay much attention to the Acct # and used the name and Medical Record # for the issue process, but TAR is Acct # driven, so we've now incorporated reading the name, MR#, and Acct# as part of the issue process. If the patient was drawn under an outpatient Acct# and then gets admitted prior to transfusion (gets a different Acct#), you do have to use the "Move to Account" routine to move the products to the new inpatient account, or else TAR will not work. Please let me know if I can help you with anything. It "takes a village" to get it all put together, working correctly, validated, and everyone trained! Sheri Goertzen sgoertzen@childrenscentralcal.org

We are also a pediatric hospital and we do not allow anyone to order any products from CPOE - they can only place a request for products, which is basically a series of questions they answer so that we (the blood bankers) can edit/add the correct tests and products to the CPOE requisition to fill their request. We have an RBC Request, PLT Request, FFP Request, and CRYO Request. I also have a Type&Cross Request (just because that is the terminology so many doctors are familiar with using) but it is actually just a duplicate name for the RBC Request.

We require a second specimen only on non-O patients with no BBK history. It can be a microtainer sample. Since all of our neonates get group O blood, they are excluded. For group O patients and neonates, we simply repeat the ABO/Rh on the same specimen. Children's Hospital Central California

We are in the process of installing the Terumo Trucise system for our sterile connecting devices (TSCDs). I am hoping that some of you are expert users of this system and can offer some advice on how we might be able to build our system to capture the required "second check" of the labeling affixed to the aliquot bag we are welding to the original container (AABB Std. 5.1.6.3.1-5 &6). I know some folks have computer systems where the "label verify" is actually built into the aliquot/modify/pool routines, but unfortunately ours does not offer that feature (Meditech). I've reqested that Meditech add this as a customer defined option to these routines, but as far as I know, they haven't taken any action on this enhancement request. I'm hoping to completely eliminate writing anything down on a paper log, so we need to figure out a way to somehow document that second check within the Trucise system or "somewhere else" in Meditech. Any ideas would be very much appreciated!

This question was asked at the AABB meeting in San Diego a few weeks ago during the "Ask the FDA" session and it was stated by the FDA that if you want to use FFP post-thaw for up to 24 hours (rather than 6 hours), you must get a variance. Unless something has changed in the last month, a variance is still needed to use the 24 hour expiration. (I know... seems silly)

If your computer is set up for it, you can also use volume billing. We have ours set up this way, so that the computer bills a certain amount for each mL in the split product volume. We used to do it by averaging the number of splits made per product and assigning that adjusted split cost to the various split product codes. But when we moved to ISBT, the product codes no longer changed when we used the "Make Aliquot" routine to split the product (at least not in our computer system - MediTech). So we decided to move to the volume billing at that point. Our billing department hasn't seemed to have any problems with it, and it does make more sense that an aliquot of 10 mL would cost less than an aliquot of 100 mL. We are a children's hospital, so we split products all day, every day.

I'm at a pediatric hospital and our CT surgeons would love it if we could supply them with whole blood but they want it "fresh" - like less than 3 days old. Our donor center does not collect or prepare whole blood unless it is a specially pre-ordered (very similar to directed donation, prepaid, additional fees, etc.). So... we've told the surgeons that they can have it, but they have to do all of the ordering, pre-testing of the patient (for ABO/Rh/Screen), and pre-arranging with the donor center and the patient family. This is apparently too much hassle for them so they routinely opt to use fresh packed cells and thawed plasma.

I can totally relate. Like you, our BioMed department would not let us use the lightbox we received with the manual Capture workstation. We had to end up ordering a different type of lightbox. The one we bought is called an "Illuminated Viewer" (Model # BL1012/5000K) from "Hall Productions" which is a company in California (San Luis Obispo I believe). Our BioMed guys had no problem with this one and said it was much safer.

One big difference in the latest (July 2011) CAP checklist is that they no longer require annual procedure review. They've gone to a 2 year review cycle.

We are doing the same as BankerGirl. We use TAR which is great since the nurses at the bedside "Begin" and "End" the transfusion themselves which takes the product to the status of "Transfused" at the end of administration. For those few areas that still use paper forms (outpatients and surgery), we have the computer set to auto-transfuse those after 8 hours from issue. Those units end up with a "Presumed Transfused" final status.

Would you be willing to share your "Yearly Method Correlation" form? It sounds like you've come up with an easier system than what I am currently using (and we use the same methods as you), so I'm hoping your worksheet would work for us! Thanks! Sheri My email is: sgoertzen@childrenscentralcal.org

We are in the process of installing a temperature monitoring system for our entire laboratory, and being a blood banker, it is making me a bit nervous giving up some of the control we currently have, and of course... wanting to make sure we always remain in compliance with all regulatory and accrediting agencies. I would be interested to see how others handle this!

Sorry, no fancy references for our protocol. It is just something that the cardiac surgeons and our medical director decided upon years ago and it seems to work really well for us.

For our patients going to open heart surgery: We first perform a Cold Screen at 4 C. If this is Neg, Wk Pos, or 1+ Pos, we stop testing but report out the Cold Screen result. If the Cold Screen is 2+ Pos or stronger, we have our computer set to reflex order (per protocol) a "Thermal Amplitude Study" which includes a Room Temp (22 C) screen, a 15 C screen and a Cold Titer at 4 C. Every year or so, I ask our CV Surgeons whether we need to continue with this protocol, and they keep saying yes, that this information is valuable to them... so it looks like we'll keep doing it until something changes and they no longer want this testing done.

Are there any BloodBankTalkers who have MediTech Client Server who have already built and are using CPOE and TAR (Transfusion Administration Record)? We are just beginning to build these advanced clinical systems here at my facility (a children's hospital) and I would be so interested in talking to someone who has already been through the process and could share some experiences and insights! Thanks! Sheri sgoertzen@childrenscentralcal.org

I like Lisa's idea.... call the home page LabTalk.com, then name each of the sections accordingly as BloodBank Talk, Micro Talk, Pathology Talk, etc.

We have MediTech and have begged them to add a "Label Verify" (scanning system) at the end of the "Make Aliquots", "Make Components" (aka Modify), and "Pool Units" routines. Until they do, we are still documenting the required 2nd label check by a 2nd tech on a paper log. We are a children's hospital so modifying, splitting and relabeling is what we do all day and night. You would think our computer system could be built/enhanced to capture this required information.... especially now that this could be done with simple scanning. So infuriating!

Susan - where is that routine located? We are on C/S 5.62 and I am not finding it. Thanks! Sheri

Boooooooo!!!!! Why doesn't MediTech listen to us and build a label check function into the Make Aliquots, Make Components, and Pool Units routines?????? SO FRUSTRATING!!!! We have to use a manual log which is so NOT a part of the operational flow and is just asking for errors, incomplete documentation, etc.

We never formally QC'd our saline each day until we realized the manufacturer states you should do it right on the outside of the cube of saline. Ours details what needs to be done. Also, ours states on the cube that it should be given a 30 day expiration from the date it is opened. I came up with a daily Saline QC sheet for each workstation. Kind of a pain, but you don't want to get cited for not following the manufacturer's instructions.

I also supervise the Transfusion Service at a pediatric hospital and our procedure is very similar to Elizabeth's. Our donor center quit collecting whole blood derived platelets over 10 years ago and so we use only leukoreduced irradiated plateletpheresis units and aliquot them using sterile connecting devices just like we do PRBCs and Thawed Plasma. We rarely end up throwing away any left over "pieces" of a plateletpheresis. Our oncology doctors would much rather approve giving 3/4 or 1/2 unit to their patient than have us throw it away, and since we have all sizes of patients, it usually works out.

I would treat it like an "Unidentified" trauma patient - using downtime bands (like a Typenex), downtime forms, and uncrossmatched O neg blood. Once the newborn is born and registered in the computer, you can go back and enter all the information into the system, including a name change and ID band change (i.e. from the typenex number & band to whatever name they enter into the computer system and regular band they generate for the infant). At our hospital, they let us "Pre-Reg" 20 or so of these "Unidentified" typenex bands into the computer, so that when a crisis patient shows up with no ID or no time for registration, they only have to activate that armband account in the computer and attach the band to the patient, then everything can be ordered, entered, and issued in the computer, and then later... when the dust settles... everything can be reconciled to the patient's real name and information.

I believe this is the history: At the 2007 AABB meeting, the FDA inspector at the "Ask the FDA" session said that if a cooler is used for temporarily storing blood, then the FDA would consider that to be a "storage" device and would require the 1-6 C temp limits. (That is when I changed my temp limits on the coolers from 1-10 C, down to 1-6 C) At the 2008 AABB meeting, speakers from the AABB stated in variours sessions that if the FDA now considers temporary storage coolers as "storage" and not "transport", then the standards would also apply for taking the temperature at least every 4 hours. (That is when I changed the expiration on my coolers from 6 hours down to 4 hours so we could take & record the temperature every 4 hours.) Finally, at this most recent 2009 AABB meeting, speakers from the AABB are now back-pedaling (I think they had some major complaints for the very reasons you state above) and they are now stating that if you have validated your cooler to maintain acceptable temperatures for more than 4 hours, you don't need to record the temperature every 4 hours, but you would need to perform some sort of periodic QC to ensure it is still able to perform at the level it was validated. (So now I am changing my procedure back to allow the 6 hour expiration of the coolers, but now we will be taking the temp of each returned unit with the IR thermometer.) I'm still confused about the whole 1-6 C or 1-10 C acceptability limits. Its the same cooler and the same units ... if it is sitting still it must be 1-6 C and if it is moving it can be 1-10 C? That still makes no sense to me.

Exactly! This is especially true at our pediatric hospital where issued units come in widely variable sizes. That's why we are opting to just take the temp of each one that comes back before assuming its OK and re-entering it into inventory. I agree that verifying the HemoTemp AND taking the temperature with the IR thermometer is probably overkill (we could skip taking the IR temp if the indicator is OK), but talking with my techs, they would prefer to build a uniform method into the process and use it for everything that comes back. I don't want to give up using the HemoTemps because I don't trust that they won't take a unit out for awhile, warm it up, and then try to sneak it back into the cooler to send back to us. Added note: Based on our most recent FDA inspection, we also are now verifying the acceptability of the packing/transport methods used by our donor center by taking the temperature of units at the time of delivery using the IR thermometer. Our inspector said we didn't need to do it for every delivery, but should probably hit each type of product (RBC, PLT, FFP, CRYO) periodically, so currently, we are doing each one at least once per month.

We purchased two "Fluke 561" IR Thermometers from Global Sensors for $175. We are happy with them so far. They have a +/- 1 degree variability compared to many that advertise +/- 2 degree variations. At the AABB meeting in Oct., it was brought up both in the assessor training day and also during one of the sessions I attended about the 30 minute "rule" having no real foundational basis, and that there isn't (and has never been) any "rule" or regulation about this. There are however, temperature limits that are clearly defined and should be regulated. The 30 minute deal has been more of a widespread common practice over the ages that no one has challenged. They stated that if you want to use a 30 minute limit (or any limit based on time), then you have to show studies and evidence that proves your units are still within allowed temperatures at that predefined time at room temp (or outside temp, or where ever that unit traveled) after issue.