mcgouc

When we dropped the 30 minute return and went to taking temps on returned units, we started issuing units in padded mailing envelopes that we kept in the refrigerator. We were able to lengthen the return time 5 to 7 minutes with those.   We asked that they return the padded envelopes so we didn’t have to buy a lot, and they were good about returning them.  
 

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.  

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. 

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. 

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. .  

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. .  

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. .  

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. .  

We leave them in the shipping box and take only 5 or so out at a time, then directly into the refer.

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.  

Could the unit be a weak A or B?  How was its ABO performed and confirmed?    Try crossmatching with an A and B patient if you don’t have a lot of different reagents. 

For our Ultra low freezer we change the chamber temp to the alarm range. For the freezer we are able to place the chart probe and chamber probe in alcohol and add rt water until it alarms. 

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. 

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. 

It was so hard when teaching students not to reach over and flip open that lid. Remember changing broken clips on the immufuges?  Or the Dade Cell Washer that added the antiglobulin?  I think that is why manufacturers started makng green antiglobulin. 

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!  

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. 

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!  

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!  

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!  

You can use either. For products with an expiration of less than or equal to 72 hours, you must use the exact time. For products with an expiration of more than 72 hours, you can use the number of days @2359 (Technical Manual, 16th ed, pg 219). We have been using the 120 hrs but are in the process of changing to the 5 days @2359.

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.  

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. 

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. 

I would definitely run the panel - weak reactions are not all junk. Tube testing is taking a step down in sensitivity so obviously you are running the risk of ignoring a true positive. We've ID'd newly developing anti-Jka on screens/panels where the reaction strength was '?'.
 
My rule is  ...  Before you dismiss weak reactions as junk - always run a panel to make sure you are not wrong. While that panel is running, repeat your screen with tube/PeG. Once you have the results of both, then you can make a decision about what you are seeing.