sgoertzen

At this pediatric hospital, we routinely give partial units to patients. In fact, that is how they order blood here ... either in mLs or units. We have our aliquot system set up to bill per aliquot - not per mL. We do aliquot studies every 6 months for the previous 6 months and adjust our billing accordingly. Currently, we are routinely making 2.8 aliquots from each split leukoreduced PRBC unit ($202), so each aliquot is currently being billed at $72.50 - regardless of whether the aliquot is 15 mL or 150 mL. In the example you gave above, at my hospital, each patient would be billed the $72.50 for a partial unit (plus the split fees). We rarely waste much of any blood or platelets, even from the units that have had small aliquots removed from them. I understand how it gets more complicated at an adult facility where you have an NICU population and an adult population and nothing in between. When I used to work at a facility such as this, we would try to make those rarely ordered aliquots for babies from the heavier PRBC units, leaving them with about the same volume as many of the smaller full units. Since PRBC and PLTPH units often vary quite a bit in volume and Hct or Plt count, we felt justified billing the patient for a full unit even though a small part of it had been split off and given to another patient. Since we are a pediatric hospital, we do have an on-site irradiator and we always try to irradiate each aliquot as close to the time of issue as possible. When freshly irradiated units get issued and come back to us from surgery, we try to use them for > 4 mo. non-cardiac, non-NICU/PICU, patients where potassium is not a concern.

Just wondering... from all of your experiences... what percentage of group O plateletpheresis have an Anti-A titer of less than 1:200? How about the anticipated titer values of Anti-B in a group A or O plateletpheresis? I'm at a pediatric hospital and we spend a lot of time volume reducing platelets when we do not have plasma compatible available - which is often for group B and AB patients. We are using >45 kilos as the limit for which we no longer have to volume reduce incompatible platelets, but I am wondering whether maybe titering the product would be a better (maybe even safer) way to go. Even though we use the methods suggested by AABB, I always wonder about the final quality of the platelets after we take them through the volume reduction process. Please e-mail me if you have some experience with this. Thanks! Sheri Goertzen sgoertzen@childrenscentralcal.org

Is anyone out there using the hand-held bedside ID system that has apparently been built into the latest versions of MediTech? My hospital wants to use some sort of hand-held bedside ID system for specimen collection/ID/labeling and also for administration of blood products. I have been told MediTech has developed such a system, but can't seem to find much information on its capabilities (not even from our MediTech consultant). Do any of you have some information on this system you could share? Thanks, Sheri

I am the transfusion service supervisor of a children's hospital and our policy for irradiation is: Irradiated packed cell units are no longer returnable to the donor center so it is important to utilize these units on appropriate patients prior to their 28 day expiration • RBC products and aliquots should be irradiated as close to the time of issue for transfusion as possible to avoid red cell storage lesion. • Do not issue RBC products more than 7 days post-irradiation to any patient in the NICUs or PICU due to possible problems with high potassium values. • If a DD unit or antigen specific unit must be used for a NICU/PICU transfusion after 7 days post-irradiation, consult a pathologist to either obtain a Deviation from SOP to use the unit “as is”, or to wash the unit to remove the anticipated higher levels of potassium in the plasma. • Attempt to use older irradiated PRBC products on larger pediatric patients without hyperkalemia concerns. • If PRBCs need to be washed and irradiated, perform the irradiation after the washing whenever possible to prevent excess potassium leakage which can occur in pre-irradiated cells that are subsequently washed.

I supervise the Transfusion Service at a Children's Hospital and we use the weight limit of 45 Kg to determine when ABO plasma compatible platelets must be given. We will volume reduce ABO plasma incompatible platelets for kids that weigh less than 45 Kg.

I'm at a pediatric hospital and the "latest" is that DHS considers breast milk to be a "tissue" and is now requiring hospitals that store mother's breast milk to be fed to their own baby to have a Tissue Bank License. Our surgery department already has one of these licenses for the transplantable tissues they control in surgery, but the other pediatric hospitals we've contacted recommend getting a second license just for the breast milk program (so that problems during an inspection with one program doesn't jeopardize the other program). They have enlisted me, as transfusion service supervisor, to help them try to come up with a method to "control" all of the bottles of breast milk in a way similar to the way we control/inventory/issue blood units. In a pediatric hospital that encourages breast-feeding for all newborn patients (extending out to all of the floors - not just NICU), you can imagine how wide-spread this program is and how many people it involves. I have heard that many hospitals are really struggling with this since most institutions don't have a breast milk repository bank that accepts/labels/stores/issues all the breast milk for feeding these infants. I would be interested to hear what other hospitals are doing to "control" their bottles of mother's breast milk in their refrigerators and freezers as a "tissue". sgoertzen@childrenscentralcal.org

We use the Cell-Safe igloos (ISC) packed as per manufacturer's instructions: 3 plastic Freezer Bottles stored in a freezer between -10 and -20 C for a minimum of 24 hours - one at both ends of the igloo and one along the wall. We place up to 6 units of blood inside of the plastic tray/tub along with a thermometer. Then we put a large Polar Gel Pack (from the 1-6 C refrigerator) over the top of the blood units in the tub. We have validated each igloo to maintain a temp of 1-6 C packed like this for up to 6 hours (they actually are OK longer than that, but we set the 6 hour limit so that surgery, the ED or PICU have to return the igloo for re-packing with new freezer bottles if they want to keep the igloo out longer.) The Cell-Safe igloo system comes with the freezer bottles and the plastic tray/tub. They also come with the manufacturer's validation report, but then of course, you need to do your own validations as well. For the packing method we use, you cannot keep the freezer bottles in your plasma freezer... it freezes them too cold and takes the temp too low in the igloos, so we purchased just a regular inexpensive upright home-type GE freezer for the bottles. We've numbered each igloo and it's 3 corresponding feezer bottles, so that we know to check the igloo issue log and not to re-use that same igloo with the same freezer bottles for at least 24 hours from the last time it was returned. We keep several sets of frozen "back-up" freezer bottles in case we cannot wait the full 24 hours before re-issue of that igloo. Note: we also attach HemoTemp II indicators to the units so that we can verify that the units were not removed from the igloo and warmed to 10 C.

We use a SCD to attach multiple pedi-bags to the original container with one weld. When an aliquot is needed, that volume is then pushed off into one of the pedi-bags and the pedi-bag is irradiated. (The blood irradiator cannister can accommodate the 30 ml syringes, but the techs prefer to irradiate the pedi-bag). Then if the aliquot is less than 50 ml, we enter the bag with the syringe and pull it into the syringe just prior to issue. We label the barrel of the syringe with the crossmatch or assignment card (which we print on a label instead of paper) and we attach a tag to the end of the plunger of the syringe which holds all the remaining labels (facility, product type, irradiation, etc.) The syringe pumps do not have a problem with this attached tag and it does not get in the way. I would be happy to share my procedure if you would like to see it. sgoertzen@childrenscentralcal.org

I agree with everyone else. We can't have a PT for every kind of antibody ID technique we use in blood banking. How about things like prewarming, adsorptions, neutralizations, or enzymes??? I work at a pediatric hospital, so getting enough specimen to do all of the investigational testing just once is a challenge. There is no way they are going to let me get another set of tubes from those little anemic patients to send to another facility just to reverify the established techniques that we use are working.

From Children's Hospital Central California: We use both the 30 ml (REF 309651) and 60 ml (REF 309654) BD Syringes for making our aliquots. We don't prefilter, but rather, we issue a 33 cm 80 Micron Filter Blood Component Infusion Set (Y type for saline flush) Baxter (4C2223) along with the syringe aliquot. Our hospital uses the Medex Medfusion pumps 3010a, and the Trilogy multichannel pumps. Any small aliquot (less than 50 ml) is automatically placed into a syringe prior to issue. Anything larger than 50 ml is issued in a pedi-bag or the original container.

Rather than saline, we use 2 drops LISS reagent (N-Hance) for the Rh neg control on all AB Pos patients. The N-Hance idea was suggested to us by our Gamma rep (who had her SBB) many years ago since it is very handy to use directly from your regular reagent rack.

We are also a pediatric hospital with an extensive oncology and surgery department. We coordinate our platelet orders and inventory by logging this info on a write-on/wipe-off white board any orders placed by physicians for platelets (even the ones scheduled for an outpatient txn a week from now). We've drawn a grid with colored tape on this board so there are 5 titled columns to log on each row the patient's name, product needed, order date, expected txn date, and current status (i.e. "to be ordered", "ordered", "on rocker"). When ordered platelets arrive, we do tag them with a piece of tape with the patient name as we place them on the rocker, BUT, we often juggle products around to ensure we use up the shortest date platelets first. We don't "assign" the platelet in the computer to the patient and tag it with the official computer generated tag until we receive the order to issue the platelets. The techs are diligent in referencing and updating this inventory board throughout all shifts of the day. We rarely expire platelets. We also keep track of our special ordered phenotypically matched units for our chronically transfused hematology kids on this board as well.

Dose mapping annually (done by Nordion) and a RadSure indicator on each product.

We have a table top MSE, Mistral 3000i. It is quite old (>15 years) but works well. It may no longer be available for purchase. What surprises me is the number of volume reduced platelets you prepare. I supervise the transfusion service at a 300 bed pediatric hospital with a full NICU, PICU, heme/onc department and cardiovascular surgery department. We transfuse approx. 100-120 platelet transfusions per month, but we only volume reduce platelets maybe 10 times per year. We really try to discourage physicians from ordering spun platelets and most are happy with giving small volume aliquots made from the leukoreduced plateletpheresis units. I've copied (below) the "principle" section from our procedure for volume reducing platelets: PRINCIPLE Random platelets or plateletpheresis must sometimes be spun in order to reduce the total plasma volume of the product. There are only three conditions where spun platelets are warranted: 1. No ABO compatible platelet units are available for a patient weighing less than 45 kg. It is acceptable to give ABO incompatible platelets unspun if the patient weights over 45 kg. DO NOT CALL PATHOLOGIST if you must spin platelets due to ABO incompatibility. 2. Patient in fluid overload due to heart or renal failure. Even in these conditions, it is better to divide the product into smaller volumes using the sterile connecting device than to spin the product. 3. Patient has repeated severe allergic/anaphylactic reaction to plasma proteins in platelet products (even after pre-medication with Benadryl). Take these platelets down as “dry” as possible and add back 25 mL of Lactated Ringers prior to 60 minute rest incubation. • QUESTION ALL ORDERS FOR SPUN PLATELETS The use of spun (volume reduced) platelets is strongly discouraged and REQUIRES APPROVAL BY A PATHOLOGIST.

I went to Office Max and just bought plain white business cards on a sheet (perforated) that you can print up using your standard colored laser jet printer at work. I created a template for the sheet of business cards with our hospital logo (address and phone) and a place to hand-write the patient name, birthdate, medical record #, blood type and identified antibody and date. It was pretty easy and seems to work great! If you wanted to get more sophisticated, you could create each one in the computer and laminate it for your patient before you send it to them.

We use the Immucor "CorQC" kit. We QC each reagent vial used each morning and whenever opening a vial with a new lot number.

I am the Transfusion Service supervisor of a 250 bed pediatric hospital. We are AABB Accredited and CAP Accredited. Because we have an on-site blood irradiator and COBE washer (for washing rbc units), we are also FDA registered and have a state license for the manufacture of biologics, so we also get FDA and State inspected every other year. I am responsible for the clinical training and competency of 28 med techs who rotate through my department 24/7. I have 2 "lead" techs on the day shift who also rotate through hematology and chemistry, but whose primary department is transfusion. They do most of the training and they both help me quite a bit in maintaining my QA program, but I am responsible for all of the technical, personnel and QA oversight of my department. I don't have a QA/Compliance person.

Has anyone investigated the possibility of switching to the new Olympus reagents? What does their pricing look like and do their reagents and reagent red cells look like they could compete with either Ortho or Immucor? My administration is NOT HAPPY about the major price increase with Immucor and as someone said above, Immucor's reason for price increases doesn't square up with their stock reports over the past few years that brag about the huge return profits they are making for their investors.

For syringe aliquots, we also use the 24 hour exp. for RBCs and FFP, a 6 hour exp. for cryo, and a 4 hour exp. for platelets (aliquoted using a sterile connecting device). I couldn't find any published data on how long these products maintain acceptable viability after being moved into a sterile hard plastic syringe, but it sounds like we are pretty much in line with others. We do a lot of syringe aliquoting since we are a pediatric hospital and everything ordered with a volume of 50 mL or less for patients in NICU or PICU automatically gets aliquoted into a syringe.

We are a pediatric hospital. If we have a historical blood type, we only do one ABO/Rh. If it is a new patient to us, we repeat the ABO/Rh a second time on the same specimen. It would be nice to have a second separate specimen drawn, but with our baby and kid population, each draw is a major ordeal and we try to minimize blood draws as much as possible.

We are a pediatric hospital so volume is of great importance to our transfusing nurses. We weigh and write the volume on every product issued.

We are a pediatric hospital and we have a 2 tier matching protocol for all chronically transfused patients: (e.g. sickle cell, thal, hgbopathies, etc.) We initially match for Cc,D,Ee,K. If the patient makes an antibody in spite of this basic matching, we then move them into the 2nd tier where we also match for Kidd, Duffy, and S.

We use the regular hospital ID band (which is bar coded), but currently only medications are being given using the hand-held bar code readers at the bedside. We will be converting to this bar code system for printing specimen labels and administering blood products over the next couple of years.

We are also a 300 bed hospital and our chart reviewers perform the routine 30 chart retro-transfusion reviews each month (rotating month from month through the various components to audit). We do, however, perform an additional ongoing prospective audit at the time of issue for every transfusion by linking the most recent Hgb/Hct result with all red cell products, PLT count with all platelet products, and PT/PTT results to plasma and cryo products. We have the Meditech system which allows those most recent lab results to pop up and display to the BBK Tech at the time of issue. Anything that looks suspicious for appropriateness is brought to my attention and I request my pathologist and QA to audit that specific transfusion for appropriateness. We also have boxes and fill-in the blank fields on the issue form for the nurse to complete as she/he is doing the pre-transfusion ID check as to the reason for transfusion. We have very good compliance and rarely do audits fall out becuase there is no indication for transfusion documented.

We are a pediatric hospital, so we send the family a simple letter and an antibody card for their wallet explaining that it is important that if their child is ever treated at a different hospital than ours, they need to show this card to the physician and nurse taking care of their child and ask them to make sure they relay this information to the laboratory blood bank at the new hospital.