John C. Staley

We are not able to irradiate in-house so we get the unit irradiated from the blood supplier and use it through the life of the unit. The corporate transfusion medical director decided that all neonates would get irradiated and the neonatologists went along with it which makes inventory management easier. One baby per unit is our standard. We use a standard 4x4 base label duplicated to match the original label with 2 exceptions. The component modified by label has our name on it and the component lable is a divided product label. On a 60cc syringe we put one side of the label on each side of the graduations and then seal the lable around the syringe from there. There is a little fold left but it is no problem with the pumps. There are a few more details involved like how old a unit can be when we set it up on a baby and thing like that but this is the reader's digest version of what we do. I can't imagine trying to support our NICU without a SCD.

I've never heard of that protocol before. Any idea where it came from?

We use a syringe set from Charter Medical. It has an inline filter so the nurses don't need to use a filter for transfusion. We attach the syringe set to the blood bag using an SCD. The syringe is 60cc. Check with your NICU and see what pumps they use and what size syringes they can use. The 60cc seems to be somewhat standard. We add 5cc to the order for the transfusion set.

We document what arrived, when it arrive, how much arrived and if the package insert has changed. If there is something wrong like broken bottles or anything thing else that is immediately apparent steps are taken as outlined in the reagent receiving SOP. No testing is done until the lot is first put into service, then daily QC is performed. Maybe it's just a matter of semantics but to me when some one says "acceptance testing" then some form of testing is involved and that entails test tubes, centrifuges, etc.

I'm curious, who did this "Quality Inspection" and what did they base their citing on? We haven't done acceptance testing for years and it was our corporate transfusion QA group who told us we could stop and they are the most conservative bunch you would ever hope to meet.

Personally, I say challenge the deficiency. I'm beginning to think that this whole proficiency thing is a good idea mutating into a monster.

Linda, why not make it simple. Let OR use a simple computer spread sheet like excel and set it up with columns for all the required info. An other option would be a data base like access that could have a simple form developed with reports and queries if needed. (No I'm not a real microsoft fan they are just what I'm familiar with.) Why would you need it to interface with your Meditech computer system? All they need to be able to do is to track it. It would take a little effort on their part to keep the info up to date but there is no reason you need to get drug into their problems.

Immediate dismissal without additional information would probably not be a good idea. I agree with most every thing stated by Lcsmrz. As long as humans are involved human error will occur. All we can hope for is to minimize it as much as possible and learn from it when it happens. Our current computer system generates so many warnings that many of the techs suffer from warning overload. (It actually warns us that A+ FFP is not the same type as an A= patient). They get meaningless warnings all the time and if they are expecting one and a different (important) one comes up they may not even read it. Is that acceptable, no, but it is human. I suggest that you weigh all the factors involved before making such a dramatic decision.

I've been using the biologics system since 1979 in 2 different facility. It is simple and it works. I have asked for scissor proof bands but haven't seen them yet. The system works very well as long as everyone fully understands the principle of DON'T CUT OFF THE ARMBAND. I have not seen any significant problems in all of these years but then it could happen tomorrow. Remember a system is only as good as the people using it make it.

We are finally considering dropping wD testing on our patients (excluding newborns for mom's RhIg determination). One of the more conservative medical directors is concerned about wasting Rh neg units and exposing women to RhIG who don't need it. Can any of you who have dropped routine wD testing provide any data or references to address her concerns? Thanks John

We utilize a single armband system (Biologics). About once a year our lab Qa folks undertake an audit by visiting every patient in the hospital once per week to make sure they have an armband attached. They aren't here this early so I don't have access to the data but when I get it I'll share it with you. I do remember that it got a lot better after the first couple of audits showed administration how poorly we were doing and the nurses were intensively retrained. From a patient ID standpoint the most dangerous situation in the hospital is a nurse with a pair of scissors.

I have never seen a unit of blood hung with out a sterile bag of saline attached to the "Y" set. The bag is spiked anyway to get it into the the patient. Running a little sterile saline (about 100cc) into the blood will cause no harm and if it improves the smooth flow of the transfusion all the better. The nurse will know their patient and if input/output is closely monitored they will take the saline into account. As far as affecting the hematocrit, I think that is far less of a concern that being able to get the blood into the patient in a timely, stress free manner. If you think about it, all they are doing is duplicating an additive unit at the time of transfusion. I see no difference between adding about 100cc to a CPDA-1 unit and hanging an AS-5 unit.

This was fairly common practice back in the olden days when CPDA-1 was the best thing around. We used to tell nurses all the time they could dilute with upto 100ml of saline to help it flow better. It's pretty simple, they always hooked up a saline line to the Y set any way. All they had to do was to run some saline into the blood bag and mix it up. End of the sluggish flow problems. Find some nurse over 50 and I'll bet she can tell you all about it.

I don't know if you would say we have delt with this successfully or not but this is how we deal with it. As long as the anti-D is detectable we consider it as we would any other anti-D to include full AHG crossmatches. When it finally goes away we we remove the anti-D from the patient's computer record. Our contention is that it is still anti-D and it is detectable, you must acknowledge it. Now on the flip side, what's the chance of transfusing an Rh neg women of childbearing years with Rh pos blood? Pretty slim I would hope so I really can't justify our approach logically. It was just the easy way out.

We've had a patient coming in at least one a week for a transfusion (2-4 units). He has a warm auto antibody with no underlying alloantibody. We don't perform absorptions at my facility and send them to a reference lab. My question is how extensive of a work up do you do for each transfusion episode? This has been going on for about 6 months and he has never produced an alloantibody after many units.

Thanks for the responses. You have pretty much confirmed my suspicions.

Question Cathy, is the MLT that applies for advancement and works under the same job destription and pay as an MT eligible to apply for a supervisor position if it requires an MT? Just wondering how far it goes. All in all I think it is a great idea.

Just an FYI, I had an OB doc come unglued when we reported "Anti-D due to RhIG". Their contention was that we could not know that and had no business reporting it that way. Consequently we chose the waffle language of "Anti-D possibly due to RhIG" and let the doc decide what to do from there.

Couple of suggetions. If you have a history of a negative antibody screen at 28 weeks don't do an antibody screen at delivery. Just confirm the Rh and give the RhIG. If you are compelled to do an antibody screen and discover an anti-D with a record of antenatal RhIG injection then report something to the effect of "Anti-D possibly due to RhIG". Let the physician decide if you need to do any more.

While I answered yes to the poll it is not becasue I believe in the policy. It is currently a corporate policy (unwritten I believe, I've never seen it written) that only MT/CLS can perform technical work in the transfusion services. Non-MTs are allowed to do other things but not bench testing. At a previous place of employment one of the best bench techs I have ever met was an MLT. She stopped at MLT becasue the chemistry requirements for MT were just more than she could deal with. She was very capable in all areas of the department, which, at the time was a hospital based blood bank. For an MLT to pass the registry they have to know enough bloodbanking that would make them a valuable asset for most, if not all routine bench testing. I think it is foolish to restrict MLTs from the transfusion service. There are not enough techs out there to be over looking these qualified folks.

It sounds like just their way of trying to address the patient ID issue. Congratulate them for recognizing that it is not just a blood bank/transfusion serivce issue but one that encompasses the entire lab. Maybe it will work well for them. We couldn't afford to double our phlebotomy staff so there is not much chance of us trying it.

Unless you are using a technique very unique to your setting (2 day room temp incubation in 65% albumin or some such) and half the country is already doing what you want to do, why all the extensive validation? The reagent manufacturer says you can use plasma and the FDA has given it's blessing to the reagent. Run a few parallel tests to see if there is any visible change in what you are used to seeing. Why do more? Obviously patients are not dying right and left all over the country where facilities have already switched to plasma and been using it for years.

You are most definetly not alone. Much like the OR and ER, L&D seem to be the universal problem children. They like to think they function only in crisis mode and there fore should be exempt from all rules, regulations and policies. I actually had one L&D nurse tell me that it was impossible for her to transfuse the wrong blood to the wrong patient regardless of the status of any patient identification and she was serious. Just to help you understand my perspective, I'm married to a L&D nurse. She has no explanation why this particular group has such a difficult time truly understanding our fanatical obsession with proper patient identification. She understands but can't get the others to understand at anywhere close to the same level but then she's had me nagging her about it for 30 years. One of the ways we (the hospital not the transfusion service) worked with this is to preadmit most of the L&D patients so the armband and everything is ready when they arrive. Another thing we have done was to work with admitting and get them to fast track the L&D admissions that are not preadmitted. The one thing we did not do is allow "work arounds" to circumvent the patient identification policies. Also, if a L&D patient come in in serious bleeding trouble they can use the same emergency identification/issue system we use in the ER.

We consider blood in our emergency coolers to be in transport between the OR/ICU and the transfusion service. If this transport takes a few hours we see no difference than sending them to another facility or back to the supplier other than every unit is monitored with a HemoTemp II just in case they are removed and then returned to the cooler. I know it's a matter of semantics but that's how we define it here.

We don't get anything back. Also you could remove the vital signs from your crossmatch tag and have them charted in the nursing part of the chart. It is a nursing responsibility let them monitor it. I review charts for one month every six months for proper documentation of patient identification and then file a report with administration. This seems to get more attention than when we were reviewing every bag tag and trying to adress each rpoblem as it came up.