jayinsat

We use MEDITECH. We have an order built called EMISS (EMERGENCY ISSUE). We enter the electronic order anytime we have to give uncrossmatched products. The order requires the requesting physician to electronically sign off on the order. If they do not, their privileges are revoked and they are locked out. This is the same process used for any telephone orders from physicians. We have had 100% compliance with this for more than 15 years using this process. Our hospital compliance department follows up for signatures that are outstanding. The process works and is compliant.

Correct. That is why we typically use 5.5 as the upper set point instead of 6.0. If it alarms at 5.6, you are still covered and have time to move product before it reaches the upper limit. I think that is why I am confused by the OP's citation. I wonder if they have it set to 6.0

Well, the transfusion history was an important piece of this puzzle. I see this all the time on the ECHO Lumena. When a patient has more donor cells (group O) than autologous cells, the ECHO will often give a ? because of the mixed field reaction. When looking at the images, it looks like a clear 3+ or stronger. Tube is usually 4+ with mixed field. I should have asked transfusion history from the beginning.

That is quite concerning. Have you found a resolution? You may want to contact technical support and refer this to them. There is a significant issue going on. They will probably want samples to see if they can reproduce it on their end.

So, for example, your high alarm is set to 5.5C and it alarms at 5.6, that is non-compliant? Is that what your assessor is saying?

I agree with Neil above. I would challenge that deficiency and not change my process.

Very interesting. I would have recollected that specimen since it was contaminated. I have never seen anything like this though. Thanks for the share, and the pics.

I would argue that the DCLS program is probably your best route. Here in Texas, UTHSCSA (University of Texas Health Science Center San Antonio) has a PhD Clinical Laboratory Sciences program but it is residential only. The tricky part to any of these programs is how they will fit into clinical laboratory practice. It is unlikely that hospitals will want to pay laboratory experts to consult with physicians on appropriate lab orders, which is the main described goal of the DCLS program. However, perhaps both the DCLS and PhD CLS candidate could fill the role of Medical Director for a clinical laboratory? That is another goal of these programs. DCLS, like MD, is a practical doctorate. An argument could be made that either of these professional degrees could qualify the individual for the Medical Director role. Just a few thoughts of mine. I am finishing up my PhD dissertation in Biblical Studies. I have been contemplating doing the DCLS or PhD CLS afterward. I love both lab and ministry.

First, blood given pre-hospital is quite routine these days. Both ambulances and helicopters are carrying Low Titer O Positive whole blood that they transfuse on scene in response to traumas and hemorrhagic shock. In South Texas, the ambulances and helicopters receive their blood directly from our blood supplier. Who will be stocking your helicopter? Will it be your facility? If so, you have a lot of work to do. If your supplier, you have nothing to fear. Second, when a unit is given pre-hospital, our EMS techs give the empty blood bag and a record of transfusion to the receiving nurse in the Emergency room, who then sends them to the blood bank (theoretically, practically we seldom get them right away). Our emergency room physician orders a type and screen upon arrival. Only if an antibody is detected (or we have a history of a clinically significant antibody) will we perform any crossmatching with the unit. I would suggest you google the topic Low Titer Whole Blood. It will help you answer your question.

CAP recently revised these standards. It seems the new revisions are pushing towards more active monitoring of quality metrics and review of the same by medical directors which can be part of a transfusion committee. The new checklist items read: · TRM.41550 Intraoperative/Perioperative Safety and Efficacy. Phase II The intraoperative and perioperative blood recovery program ensures the safety and efficacy of the recovered blood components. NOTE: Safety and efficacy of recovered products can be measured through various mechanisms, such as through the review of data by institutional committees and monitoring of the intraoperative/perioperative transfusion practices. Evidence of Compliance: ✓ Review of intraoperative/perioperative blood recovery and reinfusion program records AND/ OR meeting minutes of institutional meetings · TRM.41600 Intraoperative/Perioperative Program Involvement. Phase II The transfusion service medical director is involved in establishing standard operating policies and procedures related to intra- and perioperative collection and reinfusion procedures. NOTE: When the laboratory is not responsible for the standard operating procedure manual for intraoperative/perioperative services, the transfusion service medical director's involvement can be achieved through review of such procedures or through meeting minutes of institutional transfusion committee meetings. The transfusion service medical director must be aware of standard operating policies and procedures to help the institution ensure efficacy and patient safety. Evidence of Compliance: ✓ Review of intraoperative/perioperative blood recovery and reinfusion program records AND/ OR meeting minutes of institutional meetings.

When you use extended sample expiration, how does this affect electronic crossmatch? The sample collection date would cause our LIS to reject the EXM rule. Do you just perform IS serological crossmatches?

My guess is we are all like you. We are not actively involved in their use and monitoring and kinda leave it to them. The only thing I have truly monitored is that they are being properly maintained by biomed. I get a copy of their report. Your post here has me thinking we need to implement a quality measure though.

I would add it to the title. For instance, I my blood bank collected donors, provided blood for transfusion, and participated in stem cell collection and infusion, my department would be called, "Transfusion Medicine, Donor Services, and Cell Therapy Laboratory."

I suggest reaching out to your director of the O.R. and to your Biomed Director. Start a conversation with them showing them the CAP standard and ask them how they are measuring the safety and efficacy of recovered products. Ask them to provide you a copy of their data to include in your records. Also, since your medical director has to actively participate in the program, they may need to officially report to them as well. Perhaps this could be covered in your transfusion committee, if you have one.

I do not have any remote refrigerators but, is there a way to have an automated comment added to the unit history when a unit is removed from the remote refrigerator that states it was visually inspected? That would give you documentation. Of course, you would need to have clearly stated in your policy that visual inspection is performed when units are retrieved, and nursing training would have to have that documented as well. That's how I would resolve that issue. That said, I think that the inspector may be improperly applying the checklist item to your situation. The checklist item states: TRM.40900 Blood/Tissue Sign-Out Phase II The process for signing blood and tissue out of the laboratory provides adequate protection for the potential recipient. NOTE: A person authorized by the transfusion medicine service must perform a clerical and visual inspection of each component immediately before it is issued. Transporters of blood components and tissue must be trained in prompt delivery. Training may consist of instruction at the time the product is dispensed. There is no blood bank staff that is "issuing" the blood so, technically, there is no "person" signing out the unit. I would argue that the inspection would have to take place when the unit is placed in the remote remote refrigerator. I would challenge the deficiency on those grounds.

I would consider switching to Immuco ECHO Lumena before going to Grifols. You could also look at Bio-Rad's IH system for gel alternatives. That said, I prefer Ortho for gel and Immucor for solid phase.

I just answered this question. My Score PASS  

I just answered this question. My Score PASS  

We discussed this in our transfusion committee. This was rejected primarily in concern to legal ramifications. Denying a patient life-saving treatment when the treating physician feels more blood is needed opens your medical director up to charges of malpractice and negligence. None of our M.D.'s were willing to stand behind that type of policy. The bottom line was, if the treating physician wanted to use up the entire inventory trying to save a life, we could not deny them the blood, even though it places other patients at risk.

I suggest you challenge that citation. CAP inspectors are not infallible as proven by the response from CAP above.

Meditech provided a validation guide that complied with everything @SbbPerson listed above. This was several years ago however. We kept all the screen shots of each validation step on a network drive in a folder to show inspectors. Still have them to this day. Most CAP inspectors will only ask for records for the period covering your last biennial inspection so no one ever asks to see that anymore (unless there was a significant change of course).

I use my calendar feature in Outlook to keep track of all this.

Theoretically, you could have in vivo binding. Practically, I've never seen it happen. We do not type for M antigen and give xm compatible here.

Hi @Clarest, The IgG is already in the card. It is that tiny amount of clear liquid at the top of the card. Rest assured, it is an AHG test.

Done. I can't tell you how many of my coworkers have mentioned needing something like this.