jalomahe

We have a log book that we use to keep track of coolers. We indicate what cooler went where, when so we know when they are approaching 4hr being out of the department and if they go missing we have a way to track it down. When the cooler is returned it is cleaned and that is documented on the form also. COOLER LOG.doc

Nursing policy states they are to begin transfusion within 15 minutes of receipt unless the unit was issued in a cooler and if they cannot they are to immediately return the unit to the blood bank. Our nurses are very good at following this policy. That being said, there are times when the unit doesn't make it back to the blood bank in that 30 minutes but it will be back in less than 45-60. Red Cells obviously will not be within temp range so if returned they are discarded. Any other product, if it's within temperature range yes, it will return it to inventory for re-issue. As for Red Cells if they unit can't be returned in <30 minutes and the problem is they blew the IV and they are working on starting a new line started they are told to keep the unit at room temperature and transfuse BUT they MUST complete the transfusion within 4 hours (maximum allowable transfusion time) of when the unit was released from the blood bank. Any time a unit of blood/component is wasted an electronic Safety Report is completed that goes to multiple people to review: patient safety, nursing location manager, transfusion safety officer, laboratory manager, etc. for follow-up.

DANSKET I am confused as to why you discard the unit if it passes all other inspections but was out greater than 30 minutes? Are you saying that a Platelet or Cryoprecipitate that has a storage temp 20-24C comes back at 35 minutes with a temp of 24 will be discarded? Ditto with plasma that was issued immediately after thawing so accept range is 1-37C but if it came back at 35 minutes and it's temp was 24C it would be discarded? I understand with the RBCs because chances are that at 30 minutes the temperature would not be within acceptable range. At our facility We dropped the 30 minute rule completely and go completely by appearance and temperature for all products regardless of whether they were issued in a cooler or not.

If the patient had a pre-delivery Type & Screen performed then we only do the fetal screen post delivery.

The IT department should not be able to NIX instrumentation selection for the lab. If the ECHO is the best fit for your lab then that's what you should go with. I suggest having Immucor Sales Rep get the Immucor IT folks to talk to the hospital IT folks so they can speak the same language and understand what the issues and whether or not they can deal with it until the new W7 version is available.

I'm not sure what IT has to do with it. They usually balk at versions for PCs that are used for normal PC use. That's because they are required to support those PCs when there are issues. Since the ECHO PC is only used to interface with the ECHO and the IT is not who has to provide technical support for the PC they shouldn't even be involved other than providing access for an interface and to an internet connection for the cisco box. Any problems with the ECHO PC will be handled by Immucor, not IT. I think they've overstepped their bounds on PC requirements.

If you switch to RhoPhylac talk with the Rep, they will be happy to send in training staff free of charge to help train nursing in any location that will be administering the product. The nurse educators at our facilities really appreciated the help and it allowed all of the staff to get all of their questions answered.

Question. How likely are you to be doing titers on maternity patients that might have titers performed at another location? Since the sensitivity of Gel is higher than tube methods might you give the pt's caregiver confusing information if your titer is elevated due to method vs true rise in titer? I only ask since this was a question in our region where there are multiple hospitals that do prenatal testing and sometimes patients/physicians don't stick to one lab. The consensus was that for prenatal titers the standard of care within the area hospitals is to perform the testing by the Uniform Tube method so that there weren't variations in titer strength based solely on methodology.

So I'm guessing you are a really small lab without many resources? What is your plasma usage? How likely are you to need plasma during the outage? ----You could thaw one or two prior to the outage to have on hand in case they are needed. You'd have up to 5 days to use them. That would give you more time to thaw using cold water if you needed more. ----Ask supplier for liquid plasma for use during outage? ----Is there a water bath anywhere in the lab that you could use? ----Microwave water and keep it in a large thermos would work and then mix with cold water to get temp you need. To late now but for future..... if you are not a high volume blood bank, Helmer makes a really nice plasma thawer that does 2 units at a time. It's not terribly expensive and has a small footprint. Would be a lot better/safer than a bucket with running water.

It's really an experience thing. The more experience they have with ? results the more comfortable they will get. We've had Echo for 3 years, before that we had Galileo. I would say that techs who are in the department on a regular basis and are comfortable doing blood bank as a whole (good understanding of theory and process) get comfortable with it within a year. Techs who do not like or are not comfortable in blood bank may never be completely comfortable with ? results. We train with and use the example reactions that Immucor provides. The cards are kept at the bench for quick reference. Also as the techs come across ? results they can get a more experienced tech to review the result with them and explain why they graded it the way that they did. We also teach the techs that if they are unsure and have no one to ask then they should treat it as positive and follow the workup SOP/flow sheets. Better for them to result out a "Clinically Significants Ruled Out" and do coombs crossmatches than to miss something important. HOWEVER, having said that, when the tech is new you may see a slight up tic in the number of panels being performed. Hopefully not too much unless you are having problems with a lot of unexpected ? on your results in which case you need to do some troubleshooting on your Echo.

Without seeing the well images and/or the reaction strengths the Echo uses for grading reactions I can't say. Did the "0" result look at all grainy? Since the reaction strength for a "0" (Neg) is 0-2 and for a "?" is 3-9 perhaps your patient might have fallen at the upper end of "0" and the lower end of "?". I like reproducibility in instrumentation also but you will get variation at the low/high ends of cut-off ranges in all instruments. Would you have been as concerned if the difference was between a 1+ and 2+ reaction? Also remember that Immucor recommends reviewing all reactions prior to reporting your results just to make sure that it's not reporting a very weak reaction as negative. I'm not saying that happened in your case but it has been reported to happen. And remember, if the instruments were perfect all of the time they wouldn't need the techs LOL!

If the tube testing showed 2+ or less reactivity with anti-D reagents (same as used on Echo) I would suspect that the reason for the negative results on the Echo is that the reaction was shaken away during the resuspension step of the testing. Remember that Echo has an algorithm that it follows for resuspension. Shake so many times, swirl so many times etc. This can cause weak reactions (their limitations and warnings state 1+ or less) to be interpreted as negative by the instrument. Techs who are resuspending a button in a tube are visually looking for an end point and immediately stop shaking the tube when the cell button is resuspended whether that takes 5 shakes/swirls or 15 shakes/swirls......Echo can't read for an endpoint in that same way, it must follow it's algorithm. Additionally techs consciously or unconsciously will adjust the intensity of their shaking in response to what they are visualizing. A good way to demonstrate this is to take that same specimen and have a tech who doesn't know what the reactions have been resuspend it with their eyes closed. Tell them to shake it for say 15 seconds and then see what the reaction looks like. It's a fun experiment. Having said all of that.....if you see this often you can always have your FSE come in and adjust the resuspension step.

Is the old system vendor still around? If yes you can check with them to see if they maintained any retrievable records from that time frame (our vendor downloads all records to storage at their home site in case the entire system crashes to the point that all data bases have to be reloaded). If they do you can possibly get them to search the file for you OR you may be able to get them to work with your current IS vendor to migrate the information ... for a price. Otherwise you will need to reply to the lookback as information no longer available.

Our reference lab recommended doing the eluate if patient transfused within 3 weeks.

We are using Echos and prior to that we had a Galileo. There's an interesting phenomenon that can occur with automated solid phase that can cause a positive screen and then a negative panel. I have personally seen it happen at least twice. If there are bubbles/foam on the top of the specimen the instrument will pipet the bubbles/foam and this underpipetting of specimen can actually cause the absc to be look positive. When the panel is performed, the bubbles have already been removed and the instrument pipets the plasma correctly, the panel is negative. All of our techs are taught during training to inspect the specimen for bubbles/foam prior to placing on the instrument but sometimes it is a step that is overlooked when it's busy. Another cause of false positive can be using cold undermixed indicator cells. If a new bottle of indicator cells is placed on the instrument without allowing them to warm the cells may not resuspend completely prior to being pipetted. Since the instrument pipets from just below the surface of the reagent it's possible to not have the proper amount of cells. This also occurs when bottles are loaded without a stirball having been added to the bottle. Just a couple of other ideas for troubleshooting.

I am assuming you were freezing plasma for pre-admit surgery patients. How long were you allowed to use the frozen plasma for crossmatching? How long are you now allowed to use the non-frozen/refrigerated plasma for crossmatching? Are the time limits different depending on whether the patient has an antibody or not? I'm curious because I'd like to move away from the frozen plasma hassle also but we allow patients to have their type/screen drawn up to 30 days pre-surgery.

Devil's advocate: So if the product was shipped appropriately however you suspect that there was possibly a temperature failure anyway (for whatever reason) ... you wouldn't check the temperature? Our blood components are transported from the supplier by an independent courier service. There have been rare occasions where we have received platelets that although they were packed appropriately they "felt" cooler or warmer than we would have expected (usually during our extreme weather extremes). SO wouldn't it be prudent to check the temperature to make sure they are okay? BUT if we do take the temperature .... what qualifies as "As close as possible to 20-24"? Any AABB inspectors out there?

The question was about the ambiguity of the AABB published temperature requirements for transport. AABB Stds state storage is 20-24C and Transport "As close as possible to 20-24C" What is considered to be "as close to possible"? If it is received from the supplier and the temperature is 18C is that okay? What about 16C? or on the upper side of the range....Is 26C okay or how about 28C? How do I tell techs what "as close as possible" really is for transported platelets?

What does everyone use for acceptable temperature of returned platelets and cryoprecipitate? AABB Stds state storage is 20-24C and Transport is "As close as possible to 20-24C" We have had platelets that when they were received from the supplier had been riding around in the back of the courier's car for awhile and felt warm to the touch. Another time in the winter, they were cold to the touch. So how warm is too warm, how cool is too cold? Similarly we've had cryoprecipitate issued during an MTP that was returned in the cooler with the RBCs, they were still in the padded transport bag they were issued in but they were cool to the touch so again, how cool is too cold? Thanks for your input.

EPIC does have an FDA Approved module for Blood Administration. It is called Blood Product Administraton Module (BPAM) That was cleared in 2014. It can recognize whether or not a unit of blood/component is for the correct patient when the unit is scanned. Epic Systems Corporation 1979 Milky Way Verona, WI 53593 Blood Product Administration Module, version 0.9 BK130037 03/06/2014 When transfusing a unit the patient's barcoded arm band is scanned and then the unit is scanned. Epic checks for the unit number in the patient's blood bank results. If the unit is not one that is resulted to the patient it gives an error. Nursing also uses an electronic blood administration flowsheet for recording that all information was checked (just like they do on paper) then they scan their id badges to sign off that everything was checked and correct. The flowsheet is customizable to fit your facilities requirements. We currently use a Sunquest as our LIS, interfaced with Epic.

I'm the Lead Tech of my department and I have my phone number posted in the department so the techs can call if they have questions. I tell them I'd rather they call me and I solve their problem/question quickly (hopefully) instead of them either spending a lot of time dithering about it and delaying results/care or doing something incorrectly, especially in the LIS, and it taking me hours later to sort it out and make the corrections. Additionally I live close by and have told techs, especially on evenings/nights that if they have something come in that they are having trouble handling to call me: example trauma/massive with antibodies. Some techs are comfortable calling me so will be more likely to call, others not so much and won't call even when they should have. I am never upset with someone calling even if they wake me from a sound sleep because if they are unsure enough to call me I don't want them to hesitate because they think I might yell at them. If it's something that they should have known how to do or should be able to follow the procedure I take that up with them the next day/shift that they work. But at the time they're calling me it's all about patient care and getting done what needs to get done. I was a third shift tech for many years so I know what it's like to be having a problem in the middle of the night and needing someone to ask for help. Luckily no one abuses the courtesy of having me available 24/7 so it's never been an issue for me.

We do not remove the plasma to a separate tube for the very reasons that you mentioned (labeling errors) and in worst case scenario if the plasma tube was mislabeled you could be using the wrong specimen for crossmatch. So by only keeping your original tube you are increasing patient safety by eliminating a step for an error to occur. Plus if your lab is into LEAN processes this is making your process LEAN. The techs her are anal-retentive enough that if they are using a specimen for xm or any other test they want the original plasma in the original tube. We also use electronic crossmatch so we don't have to use the specimen after the initial testing too often. If we do need to use the specimen for xm or additional testing and it has been refrigerated we will let it come to room temp and then respin just to get rid of any stuff that the cold might have generated. If it hasn't been refrigerated yet then as long as there is clear plasma there's no need to respin.

We do not use a sticker either, we did away with it many years ago when we got our LIS system. The LIS will not allow units to be used that have not been confirmed. We confirm type our units when we receive them from our supplier. While in the process, the units are NOT put on the shelves with units that have already been confirmed. That way no one accidentally grabs them to use ahead of time.

30 days for pre-surgical patients. They must have answered NO to pregnancy and/or transfusion. We aliquot off the plasma and freeze it for use when the patient arrives for surgery. 3 days for all other patients with day of draw being day zero and expiration occurs at 23:59 on day 3.

The techs just interpret by visually looking at the test wells under the Edit function. When in doubt they are told to go ahead and run an appropriate Capture panel based on what they are seeing and follow up in accordance with the flow sheets. The new techs usually get an experienced tech to look at the wells with them the first few times then they get comfortable fairly quickly.