Deny Morlino

Welcome Amelia!

I have had the same experience with strength of reaction that David describes.

We divide the clerical investigation between nursing and lab. The reaction form has a section for nursing to complete with verification of the clerical piece associated with the unit at the patient bedside and any documentation in the chart associated with the transfusion. Nursing signs this section and forwards this copy to the lab. They are VERY conscious of the turn around necessary for this process to work. The observed signs and symptoms triggering the reaction call are also included in the nursing section. Lab takes care of the clerical checks associated with the process in blood bank and this is noted in the lab workup section as well and signed by the tech completing the workup. As for the AABB standard 7.4.1.2 (3), if the unit will be restarted, it is not possible to have the items listed in hand. If the unit is not restarted then we receive all of these items from the nursing staff. When the unit qualifies for a restart the tech physically goes to the bedside to examine (again) the unit for any signs of contamination and to double check identifying info. Your post did not strike me as confrontational at all!! You are just looking for information was my assumption. Hope this helps.

We are required to report these as well.

We operate the same as David with the reaction investigation. To answer the physician override question, no the physician is not allowed to override until we have completed testing and reported results to nursing. This is accomplished ASAP to allow continuation of the transfusion if results allow. Our frequency of reaction called is higher than David's. We pushed education (repeated every year) to lead nursing to pay very close attention. The hope was to catch more potential TRALI reactions and anything even slightly questionable as the potential reaction occurred. It has taken several years to increase the nursing comfort level with liberally calling reactions. We have about 5-7 reactions per 1000 called. More than half are determined to be legitimate reactions after the pathologist has completed his investigation. I would rather have a few that were "false alarms" than to miss a reaction.

Same here... I hunt the physician down. Compliance with this has not been an issue here ever.

When a new lot is received a new lot verification of performance occurs. I must review all of these documents and sign them as reviewed. There is a comment stating that the technical supervisor's signature indicates that the package insert has been checked for updates / changes. This puts the "burden" on my shoulders, but this way I am assured that the t's are crossed and the i's dotted on this issue. When we receive a new lot of reagents, it is tagged with an orange sticker from a "dating" gun (sort of like the guns the supermarkets used in the past to place prices on items). This color indicated that the item has been received, but a new lot verification and QC need to be performed prior to the lot's use. Once the new lot verification has been performed, a blue sticker (3/4" Avery round stickers) is placed on all items in the lot indicating that the new lot verification has occurred. When the lot goes into use a green sticker (same as the blue stickers) is placed over the blue sticker on the entire lot and a date placed on each item as the bottle or rack of cards, etc is placed into use. This is the system we have used here for over 20 years and it works well for us. The lot changes are documented in the workbook as appropriate to allow tracking of reagent change down to the specific specimen a lot was started upon. The change of lot number is documented in red ink in the workbook to make it easier to find.

Same here. We use cards until the reaction columns are exhausted in a card. Again, this is the way Ortho trained our staff.

As we wander along in our day to day duties attempting to solve problems and answer questions it is easy to forget the effect our comments may have on others. Thank-you Cliff for posting this letter. As you said this is a true international community where we manage to avoid politics and other hot topics allowing us to focus on our true passions for blood banking.

That was exactly the first thought that came to mind when I was looking at the number of units involved.

Same here as Likewine99

I have another question regarding warmer use. A member of anesthesia was at a recent seminar where the recommendation was made to transfuse all blood through a warmer. I guess I could see the reason in the surgical suite where the temperature is kept lower, but for every single transfusion I am not sure this is appropriate. Thoughts and references appreciated.

Best of luck!! If the push is for evidence based transfusion in medicine today would this not qualify as an attempt to provide the entire picture for the appropriate decision to be made? Just a thought. Again good luck.

Brenda, The hospitals involved with this transfer procedure are located across 7 counties I believe. We are the largest of the hospitals sending blood to the bigger hospitals and operate at around 75-80 beds. The hospital we transfer to is about 250 beds and does perform open hearts, etc. In the same city of 45,000 is a 400 bed hospital. My understanding is that the two large hospitals exchange blood back and forth as needed. Neither is listed as an official overstock center although we request units from both as needed if they are able to help us out. If they can't, ARC is about 60 miles from us (a good 80 minutes as their is not a direct route). The hospital that is closest to ARC is about 40 minutes away. If the large hospitals are short on units because of bleeders they would source from the distribution center if they are not able to help each other. I know the ARC tech support looks at the numbers on a rolling 6 months for each hospitals use to see if any adjustments in stock levels are recommended. Are you supplied by ARC? If so I could put you in touch with my tech rep. She could either offer suggestions or describe the process in more detail than perhaps I am able. Our outdating is very low (mainly AB positive LRBC) and the process seems to work here. Maybe there are some details or questions to be answered I have not thought of as of yet. Let me know how I can help.

Brenda, Yes we keep adding to the signed form. A nurse signs the form for each unit as we issue the products. The physicians here do not seem to have any problem with the process. The signature on our form is an acknowledgement of the statement that they feel the situation is a life threatening one requiring blood without delay prior to completion of cross match testing and/or antibody screening / identification.

Brenda, Are you supplied by ARC? We are here and have similar issues with stock levels. The arrangement ARC has made is that a 250 bed hospital located about 35 minutes from us takes the shorter dated units. This larger hospital performs open hearts and uses far more blood products than the 6 or 7 smaller hospitals they receive shorter dates from. This hospital receives blood deliveries 6 days per week from ARC. One day per week the smaller hospitals send a transfer list to the larger hospital with a transfer list for the following day of units that have a minimum of 10 days until expiration and a maximum of 17 days. The larger hospital adjusts their order for the following day with the expectation of receiving the units from the smaller hospitals. Net result is lower wasteage numbers for several smaller hospitals than they could reasonably expect to achieve on their own. We have been doing this for several years and it works very well.

The name remains the same on the blood bank band. Often a notation is made on the blood bank paperwork indicating that the patient was a "John Doe" with name change to their correct name to aid in the identification process. As we are a small hospital these patients are frequently transferred to another larger facility, so the length of time they are a patient is to our advantage. Yes nursing is to check the patient name on the blood bank band as well as the hospital ID band. This along with the above mentioned works well for identification purposes.

Ours has been by practice of the surgeons. Just listened to an AABB webinar yesterday covering Orthopedic blood use reduction strategies. The speaker seemed strongly against autologous blood use due to the reduction in hemoglobin of the patient prior to surgery, and higher frequency of transfusion of the autologous donors with not only auto units but allo units as well. He stressed better preparation of the patient approaching surgery as one part of the strategy to reduce use.

1. ONLY our lab staff!! We had the ED try it for a very short time and non-compliance with the "rigid" labeling requirements put a stop to this practice. 2. Yes and there are too many positive aspects to discontinue for now. 3. The only time nursing would draw the sample is if a specimen collection was through some sort of port and lab staff must be right beside the nurse during the collection to assure proper identification of the patient per lab's protocol (NO EXCEPTIONS). 4. By our staff, not in my almost 20 years. Phlebotomy performs the vast majority of the blood collections. The importance of patient identification on a normal specimen collection has been stressed to the nth degree. Identification assurrance for blood bank is beyond that and the phlebotomy staff tow this line. I have had question over the years about "banding the patient we just drew without a redraw". The answer is always a definitive "NO". Rarely is the question asked anymore.

Liz I will come back to the first question in a moment. For newborns at our facility they are identified with their last name, boy or girl (if twins boy A, boy , date of birth and medical record number. This remains unchanged through discharge. On any return visit the medical record is altered to include the patient's first, middle, and possible last name changes. Here we use a blood band system. This along with the medical record number allow us to maintain the identity. The blood bank band remains the same for the duration of the admission and has the medical record number on the band as well.

One form, one physician signature. Each unit is a line item and is accompanied by a nursing signature when blood is issued. Works well here.

Fine here. The few times we have had tornados in the immediate area the sky has had a particular look to it. Same look on Friday, but nothing local reported. South and west of us by a couple of hours however they had their hands full. Thanks for the concern Malcolm.

I do not disagree with the above posts, but did have an inspector several inspections ago that would not allow us to accept ARC's massive validation of the transport boxes they use for shipping blood products and required us to document product temperature on the invoices upon receipt. Seemed like overkill to us, but it was an easy adjustment. For the record, there has not been a single product out of temperature specifications upon receipt for over 6 years since this was implimented at our facility (go figure).

I am assuming that this indicates a unique blood bank identification band? If so, is there any reason this band could not remain on the patient throughout the stay as the safety identifier for blood bank? That is the process we adhere to for the duration of the stay after a trauma admission without identity. The hospital identification band is a separate item and can be changed to serve the other purposes you list. Maintain the blood bank band with the numbers associated with blood bank and you should be fine. Once the patient is discharged a merge could occur without interruption of service.

Sorry for the double post. Internet acting flakey.