Townsend

We would like to start looking at this, but I didn't think it was FDA approved yet for titrations in the US.  Am I wrong Mabel?  We are just starting ABO titrations for incompatible heart transplants.  We are going to run in gel, and you are correct, that your cut off for gel will be 1+.  That being said, there is no weak+ defined for any gel reaction results (technically even if read by manual gel), so if we see any agglutination, we are calling it 1+ (and that would be our titer result).  Would love to hear back on how it goes for you. 
The note about requiring review if 1+ and lower; that is a setting that you can control on the Vision with your results cutoff on the analyzer, correct? 

We also have a request slip, which I've attached.  It is a 2-ply copy that the nurses complete when they are ready for products to be sent.  They complete the top section and send it to the Transfusion Service (TS).  Then we issue the blood and complete the middle section, sending the top copy with the product and keeping the carbon-copy in the TS for reconciliation.  Once the nursing unit receives the product, they complete the bottom section and return it to the TS.  This way we can keep track of the outgoing units and ensure that the nurse has received the product.  If we have the carbon-copy with no returned slip, we can call the floor and find out if they received the product.
 
It works really well for us.  We also used the AABB publication of the pneum. tube validation guidelines that were referenced in another reply.  We used a data-logger to get a near-constant temperature reading during our validation studies.  The inspectors really liked it, though it might have been more than was necessary - you would want to at least do the temp. before and after delivery during validation.  The nurses LOVE the pneum. tube delivery!
 
Request Receipt for Blood Products BLADM FS6.pdf

To say we are having problems is an understatement.  This seems to only be an issue for Vision users; the camera is very sensitive and is picking up weak reactivity that the instrument is calling "?" reactions.  Because the image is enlarged on the Vision screen, you can actually see specks in the column on reactions that should be negative (including negative QC).   Multiple reports have been filed, and we have gone through about half a dozen IgG card lots.  We are beginning to see these in our manual testing now as well (although you have to look VERY closely).  It appears that the problem is something that changed with the gel card production, although nothing official has been released by Ortho yet.  Older lots of IgG cards are fine, which proves that it is the gel cards.  Hopefully this is resolved soon...

At this time you can't put partially used cards back on the Vision.  This is something to consider if you are a smaller/med size hospital or if you are planning to use Poly IgG/C3 cards for DATs.  They are willing to give customers a credit for unused wells, so don't let that stop you from making a decision about using (or not using) the Vision for a specific card/test.  We are told that you will be able to put partially used cards back on the analyzer with the next software upgrade, so time is TBA.  There is also supposed to be a change in how long partially used cards can stay on the machine until they are "kicked off" - right now it is only 4 hours.
We are still validating, it has taken some time to get this set up for pediatrics and get the interface going with Sunquest.
Stephanie

At Nationwide Children's Hospital (Col, OH), we use single donor apheresis platelets at a standard dose of 5ml/kg.  Sometimes they will order a 10ml/kg dose if they need a larger bump or for the oncology outpatients.  So, for your 24kg patient we would usually split that apheresis unit (about half of a unit).  Since you can't aliquot the product yourself, I would get the Medical Director involved in the decision to give either the whole unit or a specific volume of that apheresis unit.  They can always give the ordered volume and discard the remainder.
If we have limited availability of plateletpheresis, we would make the switch to a pre-pooled platelet product (4 donors).  The total volume should be very similar to one plateletpheresis, so you could handle that volume exactly as I described above for the plateletpheresis.  We very rarely have to give a volume-reduced platelets here when given at that recommended 5-10ml/kg dose -just FYI.
Hope this helps,
Stephanie

We wrote in our policy that we don't expect 100% concordance, cited several publications regarding the differences between the methods, and made a note that the blood bank supervisor and medical director will both review the results to determine the significance of any observed discrepancy.

We can't compare it to HIV though - it is much more virulent and more easily transmissible. The fact that enough of a viral load to infect via sweat is quite worrying. Also the majority of cases of health care workers becoming infected aren't due to direct exposure, but due to failure in decontamination ie improper removal of glove. That, for me, is the worrying thing.

We are also giving group O rbc and AB plasma, emergency issued and no testing done in the BB.  I have attached our guidelines. Guidelines for Blood Product Support for Ebola Patients BLADM FS9.doc
 
After attending the AABB meeting, we have decided to perform an ABO slide test for blood type for convalescent plasma only.  This will be done in an isolation lab that we have planned to set up (would be in an adjacent room on the floor near the patient's room in ICU).  If we have a history of a blood type, or if we can obtain one from another hospital at which the patient was seen, then we would NOT be repeating it in-house.  ABO slide training for a select few volunteer lab staff is underway.  I have attached our procedure. COMPAT SER 38 ABO Type by Slide Method for Patients with Ebola.doc
 
Hope this helps... the plans seem to change almost daily!!!
Stephanie

We are also giving group O rbc and AB plasma, emergency issued and no testing done in the BB.  I have attached our guidelines. Guidelines for Blood Product Support for Ebola Patients BLADM FS9.doc
 
After attending the AABB meeting, we have decided to perform an ABO slide test for blood type for convalescent plasma only.  This will be done in an isolation lab that we have planned to set up (would be in an adjacent room on the floor near the patient's room in ICU).  If we have a history of a blood type, or if we can obtain one from another hospital at which the patient was seen, then we would NOT be repeating it in-house.  ABO slide training for a select few volunteer lab staff is underway.  I have attached our procedure. COMPAT SER 38 ABO Type by Slide Method for Patients with Ebola.doc
 
Hope this helps... the plans seem to change almost daily!!!
Stephanie

We are also giving group O rbc and AB plasma, emergency issued and no testing done in the BB.  I have attached our guidelines. Guidelines for Blood Product Support for Ebola Patients BLADM FS9.doc
 
After attending the AABB meeting, we have decided to perform an ABO slide test for blood type for convalescent plasma only.  This will be done in an isolation lab that we have planned to set up (would be in an adjacent room on the floor near the patient's room in ICU).  If we have a history of a blood type, or if we can obtain one from another hospital at which the patient was seen, then we would NOT be repeating it in-house.  ABO slide training for a select few volunteer lab staff is underway.  I have attached our procedure. COMPAT SER 38 ABO Type by Slide Method for Patients with Ebola.doc
 
Hope this helps... the plans seem to change almost daily!!!
Stephanie

Nationwide Childrens Hosp MTP Policy AUG 2014.pdfOur MTP started out as a 1:1:1 dose by patient weight. There were two factors that lead to us changing our protocol a few years ago: 1)Aliquoting of products to account for weight (like we do for our routine transfusions) was just too time consuming in a true MTP situation, and 2)Product usage was more like 2rbc:1plas:1plt dose at our facility.
This is what is in our current policy, which also states the standard doses we have defined at our facility as an aid (this is in chart form, but it didn't paste very well, so I've attached the actual policy) :
Patient weight Red cells per pack Plasma per pack Platelets per pack
<10 kg 1 unit 1 pediatric unit 1 plateletpheresis unit
10-40 kg 2 units 1 unit 1 plateletpheresis unit
>40 kg 4 units 2 units 1 plateletpheresis unit
Standard doses: 10 – 15ml/kg 10ml/kg 5ml/kg
There is also a multi-center, prospective data collection IRB underway for detailed MTP statistics in pediatrics. This information will be used to determine targets for future randomized controlled patient trials for use of MTP in children. Hopefully we will get some evidence-based guidelines out of these studies as to the best treatment for our bleeding pediatric patients!
Stephanie Townsend, MT(ASCP)SBB

Nationwide Childrens Hosp MTP Policy AUG 2014.pdfOur MTP started out as a 1:1:1 dose by patient weight. There were two factors that lead to us changing our protocol a few years ago: 1)Aliquoting of products to account for weight (like we do for our routine transfusions) was just too time consuming in a true MTP situation, and 2)Product usage was more like 2rbc:1plas:1plt dose at our facility.
This is what is in our current policy, which also states the standard doses we have defined at our facility as an aid (this is in chart form, but it didn't paste very well, so I've attached the actual policy) :
Patient weight Red cells per pack Plasma per pack Platelets per pack
<10 kg 1 unit 1 pediatric unit 1 plateletpheresis unit
10-40 kg 2 units 1 unit 1 plateletpheresis unit
>40 kg 4 units 2 units 1 plateletpheresis unit
Standard doses: 10 – 15ml/kg 10ml/kg 5ml/kg
There is also a multi-center, prospective data collection IRB underway for detailed MTP statistics in pediatrics. This information will be used to determine targets for future randomized controlled patient trials for use of MTP in children. Hopefully we will get some evidence-based guidelines out of these studies as to the best treatment for our bleeding pediatric patients!
Stephanie Townsend, MT(ASCP)SBB

No irradiation unless the patient is also getting a bone marrow transplant. After they are transplanted, we drop the phenotypically matched requirement.

We do the same (free-standing pediatric hospital) as jmm8427, with the exception of the genotyping.  We don't currenlty perform molecular typing in-house, so only select patients are sent out - who knows how this may change in the future!  This usually includes possible Rh variants (allo vs auto), warm auto producers, and some to look for GATA mutation.  We only give Fya neg for patients who type Fy(a-b-) as Malcolm mentioned.  We currently have a database of about 400 sickle cell patients.  Only a percentage are chronically transfused or exchanged, but it is becoming increasingly difficult to obtain fresh, matched units for all of them from our supplier.

I agree with R1R2 - at least show that there is a cold there (at least do a cold screen) before assuming an unclear panel is just a "cold".  Always check the heterozygous vs. the homozygous patterns first too.
 
I have seen way too many weak antibodies over the years that did not fit a perfect panel pattern, but were anything but "just a cold".  Prewarming is a weakened reaction system without any help from the current enhancement medias and it is perfectly capable of missing a bunch of stuff.  I did have a reference lab tell me once that you could "prewarm" with enhancement medias too - "just prewarm the media too" and we have done some of that over the years, but not everyone does. 

We do not add or calculate the volume of the anticoagulant for an aliquoted product label. This space is left blank or a line is written in the space. AABB standard 5.1.6A only requires the "identity of anticoagulant or other preservative solution" and does not require the volume to be stated.

This is consistent with CFR 606.121 (Container Label, section e) which states that Whole Blood labels must include the name of the anticoagulant and the volume of anticoagulant. The only other place I found the volume of anticoagulant in the CFR was for recovered plasma and source plasma.

Stephanie Townsend, MT(ASCP)SBB

1. Free-standing pediatric hospital.  Level one trauma center with approx 425 beds.  We do approx 500 samples per and about 1,000 products per month. All surgeries and transplants except liver transplants currently.
 
2. Published STAT Type and Screen is within 60 minutes.
 
3. Receipt to resulting of the antibody screen.  We spin sample after receiving it.  Most samples are received in central processing, but some come to us directly.
 
4. Manual gel for everything except blood type which is still tube method.
 
5. TAT is monitored as part of a QA monitor for Emergency Room samples only.  Target is at least 95% within 45 minutes of receipt.  So far for 2013 average is around 97%.  Historically probably averaged in the low 90s.
 
Stephanie Townsend, MT(ASCP)SBB

I added a document to the library that ICCBBA sent to me when I inquired about reconstituted RBCs. I put it under forms.
Cliff, if that isn't the correct place to file please move it.

We also have a request slip, which I've attached.  It is a 2-ply copy that the nurses complete when they are ready for products to be sent.  They complete the top section and send it to the Transfusion Service (TS).  Then we issue the blood and complete the middle section, sending the top copy with the product and keeping the carbon-copy in the TS for reconciliation.  Once the nursing unit receives the product, they complete the bottom section and return it to the TS.  This way we can keep track of the outgoing units and ensure that the nurse has received the product.  If we have the carbon-copy with no returned slip, we can call the floor and find out if they received the product.
 
It works really well for us.  We also used the AABB publication of the pneum. tube validation guidelines that were referenced in another reply.  We used a data-logger to get a near-constant temperature reading during our validation studies.  The inspectors really liked it, though it might have been more than was necessary - you would want to at least do the temp. before and after delivery during validation.  The nurses LOVE the pneum. tube delivery!
 
Request Receipt for Blood Products BLADM FS6.pdf

As a part of our hospital-wide patient safety initiatives, we have created "Distraction-free zones". These are areas throughout the hospital where the staff member is performing a critical step and should not be interrupted during the process. Applying that to the Transfusion Service, we have placed those signs at all of the workstations where blood products are issued. (the signs are attached)
Theoretically, every process from testing to issue could be considered critical, but we decided that this is the one area where catching a mistake would be most crucial. Issuing the blood is the last place where an error could be found. Since this is a hospital-wide effort of which EVERY employee has been trained on, it has actually helped out. Staff will often stop and wait until the process is completed to begin talking.
Stephanie Townsend, MT(ASCP)SBB
07-08-10 DFZ Signage PROOF.pdf
Distraction Free Zone Blood Issue.ppt