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mcgouc

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Posts posted by mcgouc

  1. We used 14 days. We chose that number mainly because of specimen storage space. Preadmit nurses were required to ask and document the recent transfusion and pregnancy questions in the computer on all their patients. These showed on the blood bank requisitions from preadmit and had to be answered “no” to extend the specimen. Patients signed an overall form regarding the accuracy of their history and that was part of it. Years ago, we once had an autologous unit on the shelf for a patient and the ”transfused in last 3 months” question was answered “yes”. On checking, we learned the patient lived in another state, had a unit of autologous blood drawn when he had a doctor’s appointment in our city, had returned home, and gotten a transfusion there before the surgery.  

  2. The BB supervisor sent a certified packet to the physician on record. We included a letter documenting the transfusion, a copy of the current FDA requirements for notification, and a form for them to complete and return by a certain date with the notification information. The Medical Director’s name and phone number were in the letter as the contact person for the physician. The Medical Director was copied on this info in case he was called.  If the completed form were not returned, the Medical Director called the physician.  Every phone call, etc, was documented.   There were problems, as mentioned above. We had hospitalists who only treated the patients in the hospital who might not work there anymore or did not feel responsible for follow-up.  What if the patient went to rehab and never went home?  If we could not reach an end point, we sent to risk management for resolution. 

  3. Years ago, we kept the segment used for the crossmatch in a covered tube rubber banded to the patient’s specimen.  When we went to the electronic issue, we switched to pulling an extra segment when we received units.  It was bulky keeping the segs with the patient specimens. Plus, we did a lot of add on crossmatches and had to keep all the specimens organized and spaced in case we needed to rubber band more segments to the tube.  It was about 600 beds with a busy OR. In the decades we kept the crossmatched segments, we never found one time where a crossmatched segment did not match a segment from a unit involved in a transfusion reaction.  When we started pulling and keeping an extra segment on receipt, I thought we might miss keeping some segments, but we never had a problem finding a seg for a work-up.  Our specimen refrigerator looked a lot neater and specimens took up less room. You could check your reaction work-ups to see if there has ever been an error found when doing the reaction work-up. If not, you could demonstrate the extra time and supplies involved in keeping the crossmatched segments was not justified. .  

  4. We inspected and checked manufacturer’s directions on receipt.  For the reagents we used daily, we did “duplicate” QC on the old and new lot of  any reagent expiring or running out that day and switched to the new lot. Our policy described exactly what was required from our regular QC to run on the old and new lot for each reagent to get a positive and negative control.  All new lots were segregated until tested.   Since we did not use the fetal screen daily, we did the double checking on arrival so we did not forget and let the old lot expire before doing it.  

  5. If you set a time, such as less than 30 minutes, and they start the transfusion at 30 minutes, you can be cited by Joint Commission or FDA if they do a trace of that unit - unless there is a deviation from policy report on file.  The 30 minute start time may be in the nursing policy, but when a tracer is performed, the deviation will fall back on the transfusion service to correct.  Although we did ask that the nurses do the preparation before picking up the unit, there would be a phone call saying the start of the transfusion was delayed for some reason. (IV infiltrated while picking up blood is one I remember).  When we started taking temperatures of returned units, we learned they were usually only acceptable to be returned for 15-20 minutes, depending on how they were handled after leaving the Blood Bank.  After much debate, we changed the policy to start the transfusion as soon as possible with the emphasis on completing the transfusion within four hours of leaving the Blood Bank.  We did require them to return the unit to the Blood Bank immediately if, for some reason, the transfusion were cancelled.  

  6. When we started extending, the patient had to provide the mother’s maiden name when collected and when returning. We had that documented on our paperwork along with the no pregnancy/transfusion in three months information  The extending and not requiring the bracelet to be worn continuously  had to be approved by the Transfusion Committee and that was what the doctors approved.   When we went to the electronic crossmatch that required a second type, we would check when we did the pre-admit work-up and order a second type for day of admit and attach a note on the chart for pre-admit to collect a type when the patient returned. 

  7. Having a readily available back-up for the ABO and any antibodies, ABO discrepancies and special needs (such as irradiated) is required. Ours was done to a  PC in the transfusion service in the background at 0400 every morning.  It was a hassle to get IT to make that program for us, but I kept giving them documentation that the info is required to be available when the computer goes down.  Had we not had the back-up, we would have had to keep making cards to check during downtime. 

  8. Many years ago, I was told by a consultant that if I modified a form, I needed a new revision number and a track of what was revised and when it went into effect.  The form was an attachment in a policy so I did have the Medical Director sign off on the change.  Something I considered minor might have been considered major by someone else. It would have been great to have a compliance review but I did not have that resource.  

  9. QC-97-13 - procedure for issuing not performed or documented in accordance with specifications. If your policy states the form needed to be signed prior to issuing, this is a general code to cover that.  As stated above, they will let you know if it isn’t necessary. 

  10. I had in my policy that we would review the Changes to Standards document published by the AABB and document on each change whether it affected us or not.  (We did not draw donors so we just reviewed and put those changes as not applicable.). If we were already in compliance with the change, we would document no change in policy required with the policy number. If a policy had to be updated, we documented when the updates, training, etc were completed.  The Medical Director signed this review and we kept it with our policies. 

  11. Our blood center could provide units with one or more bags attached.  (We did not perform many neonatal transfusions and ordered these for the neonates).  The empty bags had labels and our computer was set up for the aliquots.  We were fortunate that this only took a few hours.   If an urgent need, your process sounds acceptable. 

  12. I am retired but volunteered several years as an AABB assessor. Both CAP and AABB send the deficiencies from the previous assessment to the assigned assessor with the submitted plan of action to correct the previous deficiency. Most plan of actions have a time frame documented to correct the issue.  We were supposed to make checking completion of the plan of action a priority. My first question would be if this individual had completed any work before his training records were completed. Then, I would ask for his competencies that were completed during the allowed time frames.  If I performed a tracer on your FDA reportable, could you provide completed training and competency records for all the employees who worked on that patient?   Your pathologist may be young, but he does not want repeat deficiencies.   Document everything!  

  13. Before getting an ECHO and using the pHix recommended for that, I did buffer the saline using a powder. It was several years ago but I think I got it from Hemobioscience.  I started because some (Immucor) manufacturer’s directions specified a saline pH around 7. Our unbuffered saline did not always meet that pH. We checked and documented pH daily and when we made a batch. We also had standards to check the pH paper daily.  We QC’ed the saline daily as before.  We continued the pH checks after switching to pHix.  

  14. We also only tubed to certain floors. We sent a form with patient and unit  stickers with the unit that the person who removed the unit was supposed to time, initial, and return.  We called when tubing and they had 10 minutes for us to receive the form before we followed up.  If we tubed  to a floor, we had to have the form back before tubing for another patient.  To validate and to do QA checks, we sent a tech to each location  and tubed  an expired unit to each location with a temperature monitor. When we tubed, we called that tech and documented transit time and unit temperature on arrival.  Things happen even when we try our best.  One  time we tubed  a unit, got an order for another patient on same floor, received form for first unit back, tubed second unit - and nurse for first patient called upset because we had not tuned her blood. The nurse for the second patient had grabbed the unit for the first patient, signed the form without checking, returned the form, and started the unit on her patient, with two nurses signing off the bedside checks. 

  15. I am retired but our corporation had set up a program and dashboard before I retired.   We were using Cerner.  We lowered the acceptable HGB level for transfusion in a non- bleeding patient to 7.  We started physician blood ordering in computer and the physician had to select a reason to transfuse (as above).   They could only order one unit at a time as they were required to do HGBs between units.  At first, we pulled the dashboard and met monthly but, as we became more compliant, we met less often   However, it took daily monitoring to become more compliant. Blood bank techs checked HGBs on all transfuse orders.  We issued blood for fall outs (unless HGB was really high where we called Medical Director), but sent all outlying  patient and doctor info to QA for chart review and follow-up on a daily basis. We also had hospitalists, but some doctors were having nurses enter the transfuse orders, so we started monitoring who was entering the transfuse orders.  It was a lot of work for the techs in Blood Bank and there should be someone who is not working a bench available to control this program in-house and communicate with the nurses and physicians.  For example, our corporation regarded order entry to be under the nursing educator and the Blood Bank had no input into it and was not formally trained, but guess what department the physicians called when they had no idea how to order blood.  That made sense because the nursing educator was usually not available for phone calls and someone was always in the lab.  However, the result of the monitoring wasgood and  our transfusions decreased by 40%. Our numbers looked great on the dashboard after a year or so. 

  16. We supposedly had physician order entry for transfusion orders. The order printed n Blood Bank and the nurse brought a copy to obtain the blood. We had instituted a blood management program with stricter reasons for transfusion. The reason was required on the order and we double checked the entry - if they marked HGB less than 7, not bleeding, and the HGB was 7 -9, we usually completed the order, but sent the transfusion for review.   They could only order one unit at a time in a non-bleeding patients with HGBs between units.  HGBs greater than 9 would require approval, if non-bleeding. We also documented whether a nurse or physician actually entered the order and that was reviewed -with doctors having nurses enter transfusion orders being contacted.   There were other reasons for transfusing and we had a paper transfuse order for OR or downtime.  Instituting this process was a lot of work at first, but we cut transfusions by close to 40%. 

  17. We switched to using two samples drawn at a different time if there was no history several years ago.  I had previously worked at a place that required two signatures, but we received a WBIT from ER  with two signatures so I knew that had problems.  There were different challenges in different areas of the hospital hen we added the second specimen type. We trained labor and delivery nurses to draw and label a tube when they started the IV. We were able to use previously collected (within 24 hours) Hematology tubes and most in-patients had those.  When pre-admit patients needed a second type, we ordered the test for the morning of surgery, and called day surgery to flag the chart. The main problem was getting a second sample from ER, but getting a properly labeled sample from ER was always a problem.  I learned nursing policies at my facility were changed a lot and the nurses appreciated getting notices and being trained on the change prior to the change.  We did one type on an analyzer and a tech did a tube forward and reverse for the second type.  

  18. We had a log book and white board also. Each shift had to sign the book, but, I think, the most important aspect is overlap between shifts in the department.   If the next shift doesn’t arrive on the bench until 15 minutes after the previous shift has ended, what was written in book 15 minutes ago may be out of date. 

  19. On 3/28/2019 at 3:11 PM, mpmiola said:

    We have already thought about releasing red blood cells from group O until a confirmation, but it was not well accepted at the time. Do you have problems with stock due to red blood cell release "O" until confirmation? How do you do for underweight children? Do you wash the red blood cells to remove antibodies?

    Surprisingly, the change had little effect on our group O usage. We did not wash cells.  We were allowed to use properly identified Hematology samples collected in the last 24 hours, at a different time from the BB sample, for the second type. We started a blood management program about the same time where Hgbs or Hcts had to be documented prior to issuing blood so Hematology samples were usually available, even on children.  We did the second sample type on all type and screens so if they decided to transfuse we were ready.  Different areas of the hospital had to be treated differently. For example, when we had a pre admit patient who needed a second sample, we did a type and screen on the preadmit sample,  ordered the second ABO, called and had a note placed on the chart not to send patient to surgery until that was collected, and left a note in Blood Bank.  By working with surgery, ER, and the floors, the change was not nearly as bad as I had feared.  

  20. On 3/28/2019 at 3:11 PM, mpmiola said:

    We have already thought about releasing red blood cells from group O until a confirmation, but it was not well accepted at the time. Do you have problems with stock due to red blood cell release "O" until confirmation? How do you do for underweight children? Do you wash the red blood cells to remove antibodies?

    I thought it would increase our group O usage, but it only increased it a couple of units a month. We had to work with different areas of the hospital. We could use properly labeled Hematology samples collected at a different time within last 24 hours for second type. That covered most in-patients. (We had a blood management program where reason for transfusion had to be documented and if the reason was anemia, we had to document the hemoglobin). We did the second type on all type and screens so if they decided to transfuse, we were ready.   If a pre-admit patient needed a second type, we ordered it for morning of surgery so it would be on our pending and had them put a note on chart. ER was a problem, but we worked through the managers and they adjusted.   Even there, they usually got a Hgb result before drawing the Blood Bank sample. 

  21. We used to do pre-transfusion, 15 minutes, every hour, at end, and one hour post transfusion.  Then the lab was inspected and the Blood Bank was cited because the nurses were not documenting close enough to the specified times.  They noted one hour vitals at 45 and 75 minutes on a transfusion and said that was not acceptable for one hour.   It got too complicated with so many vitals to specify a tight time frame for one hour.  We researched and dropped the every hour and one hour post transfusion and added checking the vitals documentation as a QA monitor.  Whatever you do, just make sure the times are specific and being followed.

     

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