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sgoertzen

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Posts posted by sgoertzen

    Actually, we are STILL in the process of trying to get the Trucise system all built and validated. It apparently was not created to do a label verify comparison of all 4 quadrants of the ISBT label (as the folks at Terumo originally promised it could), so we are still working with them to create workarounds to get it to do at least the donor number and ABO/Rh. We're still having issues with the product code and expiration date/time. In preparation for using the Trucise, we switched to ordering and using only supplies (bags and syringes) that have barcoded lot numbers. We were using CharterMed which has no barcodes and switched to Fenwall that does have barcodes. The other option would be to print your own little barcodes and attach them to each set or box so you have something to scan.

    AABB Standard 5.25.5 requires a signed statement from the requesting physician.

    CAP requirement TRM.40770 also states that you must have records of emergency release (documented) authorization by a qualified physician.

    Neither make an allowance for a PA or NP or RN. It must be the physician, but there are no specified time frames for getting the signature.

    We also have a Helmer 8 slot and like it a lot. But... have you seen the new Genesis (Barkey) "Plasmatherm"? It looks to have a small footprint, thaws 4 units at a time, and the quote I received from Genesis is less than the new Helmer waterbath I was planning on buying. I just wish the product brochure gave estimated thaw times, because that is an important factor to consider.

    What do you consider customer complaints? Only patient or doctor complaints or all "write-ups"?

    Also, do you have a clear definition of a "near miss" or is it just based on your judgment?

    A customer complaint could be from anyone: doctor, nurse, nursing staff, or patient/family. They can come as email, phone call or through the hospital QA system. We also track the complaints we occasionally have with our blood supplier (delays, product shortages, mislabeled historical Ag negative units, etc). Those get reported back to the blood supplier in a report each quarter.

    Near misses are pretty much a judgement call on my part. I always consider... if someone would not have caught and corrected this mistake, would it have negatively impacted the safety of a patient? If the answer is Yes, I consider it to be a near miss. On our lab variance form, we have a grading key with these definitions:

    Grade (severity)

    0 = No Grade level required: Not Applicable

    1 = No clinical harm or injury to patient/staff. (Inconvenience, delay, patient redraw, customer dissatisfaction)

    2 = Potential for or actual mild harm/cost. (Self-limited, recovery complete, little to no discomfort, unnecessary expense)

    3 = Potential for (near miss) or actual moderate harm. (Definitive treatment required, prolonged hospital stay)

    4 = Potential for (near miss) or actual severe harm. (Life-threatening, permanently disabling, death)

    At my hospital, we split out our Blood Utilization monitoring like this (below) to cover each of these 10 AABB requirements:

    1. Ordering Practices: C/T Ratios (Total and by Service), Uncrossmatched Blood Requests, Compliance with MD signature completion on "Release of Uncrossmatched Blood" forms

    2. Patient Identification: Any Patient ID issues identified are reported

    3. Sample Collection and Labeling: BBK Specimen acceptability report (outliers are detailed)

    4. Infectious and Noninfectious Adverse Events, Incidence of Mistransfusion: Transfusion Reactions, Recalls, Notifications

    5. Near-Miss Events: Anything identified would be detailed along with root-cause, corrective action

    6. Usage and Discard: Units transfused, Units discarded

    7. Appropriateness of Use (for all Components):

    QA Audits performed by Medical Director, report pulls 100% products transfused (one type of product per month) and the most recent related lab data to when the product was issued. Outliers are investigated by the Medical Director. MDs receive follow-up letters on questionable transfusions.

    Jan/Apr/Jul/Oct = RBC compared to most recent Hgb/Hct

    Feb/May/Aug/Nov = PLT compared to most recent PLT count

    Mar/Jun/Sep/Dec = FFP and CRYO compared to most recent PT/PTT and Fibrinogen

    We also review any Autologous transfusions, Peri-Op Collection/Reinfusion (Cell Saver, Hemodilution, ECMO) and Therapeutic Apheresis and Phlebotomies performed during the quarter.

    8. Blood Administration Policies and Practices: Our QA department performs random audits on 75 transfusions per quarter (coordinated with the RBC, PLT, and FFP/CRYO schedule above) and audits for MD Order to Transfuse, Issue Checks Performed, Bedside Checks Performed, Vitals Recorded. Since we are using TAR, all transfusion data is now entered into the computer so this audit can be done using computer reports. We also audit 100% of all transfusions for "Duration Less than 4 Hours" by running a computer report. We also report on Bedside Blood Administration Audits which are performed by the blood bank techs (minimum of 16 per year) and Blood Warmer QC which is performed quarterly by Biomed.

    9. Ability of Services to Meet Patient Needs: We do Turnaround Time studies (Type & Screen, DAT, Crossmatch, Newborn Workup), report on any Customer Complaints and Cancelled Treatments. We also have a Bloodless Medicine and Surgery program so we report on the number of patients enrolled in the program who were treated without transfusion.

    10. Compliance with Peer Review Recommendations: Letters Written/Sent to Phsyicians from the Medical Director and/or Blood Utilization Committee Chair, and Responses Received

    I know, some of these do overlap somewhat, but "Ordering Practices" would be looking at how many and what kinds of products are doctors routinely ordering for various things (i.e. are they over-ordering or under-ordering for certain types of surgeries/procedures, do they order uncrossmatched too often because lack of ordering in advance) and "Appropriateness of Use" would be looking at whether they make the decision to actually transfuse those ordered products to their patients based on appropriate criteria (lab results, patient symptoms, etc.).

    We prepare small aliquots into ISBT labeled and tagged bags, and nurses pull the product into a syringe at the bedside using a small Y-Set (Baxter 4C2223, 13 inches) with an in-line filter. The labeled/tagged bag is NEVER disconnected from the syringe throughout the transfusion. The syringe simply becomes a part of the line from the bag to the patient. We've been doing it this way for years and it works very well.

    We've been using Meditech TAR for a little over a year now in all areas except outpatient (HEM/ONC) clinics and Surgery. We still issue paper forms to those areas. We had extensive hands-on training for every nurse in the TEST system prior to Go-Live which included creating mock products, tags, labels, & armbands so every nurse could go through the entire transfusion process (scanning, vitals, begin, reactions, end). It took 9 weeks to get everyone trained and was a massive endeavor. We audit every transfusion to ensure that begin to end times are no longer than 4 hours (wrote a custom report that pulls outliers) and I file a hospital QA report on each of these. Usually, they forgot to "End" the transfusion in the computer, but it still stands as the official transfusion record so its not OK. The number of these dramatically dropped after the directors realized they would be getting QA reports on every outlier and would need to write an explanation. We also audit 25 transfusions per month (75 per quarter) to ensure that all of the nursing checklist and vitals are done appropriately. I file hospital QA reports on each of these outliers as well, and again, it took about a 6 month learning curve and diligence with filing QA reports, but things have greatly improved and now we are only seeing a few fall out each quarter.

    Did you set up the nursing bedside scanning and checklist with the bypass option? We chose to not allow the nurses the option to bypass any of the TAR system, so if they are going to document the transfusion at all, they have no option but to use TAR (or if they are having trouble with scanning in TAR, they can always call the blood bank and ask for a paper form which must then be scanned into the electronic record).

    Those indicators sound really good, except for the "disposable" part. I wonder why someone has not created indicators like this that we could re-use over and over, that are good for a certified amount of time (like a year or two). They would be perfect for coolers and transport containers. C'mon manufacturers! This is what we need! You would sell truckloads of those things!

    To remedy this, and keep the nurses from having to think toooooooooooo much, we weigh our units prior to issue, so that is the volume that is charted in BCTA to finish transfusing the unit.

    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 a pediatric hospital, so the whole unit ordering is only a small portion of orders. Usually they are ordering by small volumes and each order they put in by volume, regardless of the volume, translates in SoftBank to 1 unit of blood. I do think it is interesting how you order the type and screen. If the docs don't order the type and screen, we call them and tell them to order it. It would be easier for us to order everything ourselves based on a written order, but I think that is what everyone is trying to get away from with physician ordering.

    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.

    Posted

    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.

    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.

    I use my 3 times yearly Automated Transfusion Survey specimens (5 specimens X 3 times/year), record the results from the Echo on a Yearly Method Correlation form I cobbled together and then test the same specimens on both tubes (all ABORhs) and 2 ABSCs and on manual Capture (3 ABSCs) - our two bench methods - and record on same form. Seems to work OK and is easy to document. :cool:

    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!

    This looks like a good protocol. Do you have any references in your procedure?

    We were required to bring back an old protocol where we screen an autocontrol at room temperature. If positive, then we test at 15 C and 4 C. As far as I know, this has no basis in the literature, unless there is a reference I haven't been able to find.

    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.

    Posted

    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

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