DebbieL

We print a report each night that tells us how many of each type of product are available. We just count the number of each and it almost always matches. We can usually get this done without the alarm sounding. If our counts doesn't match what the computer says we have, then we dig into the weeds to see which unit is missing. Then we print the list of all the ISBT numbers to find the one in question.

Sonya Martinez- You are welcome! I was horrified that we had to revert back to messy ice and thermometers when we paid extra for the Helmer alarm system. If you figure out how to "map" a fridge, please share with the rest of us. I would guess sticking thermometers all over to see where the warm spots are located but who knows.

Shelby56. Would you please give me an example of a "known" high titer commercial antisera? I'm thinking Anti-E or Anti-C since they usually give 4+ results. Or do you have something specific you order just for this evaluation? THX

I know when CAP revived the standard, I was upset because I also thought I had to revert back to ice and water to make the chart move on my Helmer fridges and PLT incubator during alarm checks. That was moving backward as far as i was concerned. I called Helmer and finally received a PDF regarding Helmer and TRM.42750. I was also sending email questions to CAP at the same time. Our equipment is older and doesn't have printouts but CAP stated a photo of when the alarm sounded should be OK to proof. (I am keeping that email for a future inspection, just in case.) I take a photo of the electronic screen showing the temp at which the alarm sounded and add to my Alarm Check QC sheets. I can't answer the part about Isenix so you probably need to contact CAP about that part but I have attached what I have from Helmer if that would be a help to you or anyone else. If you can't open the attachment, let me know and I will email it to you. 202001 TRM.42750 Helmer Solution for Alarm Checks.pdf

We also do a second type on all patients without a history in the computer. We try to use a stored Hemo specimen collected at a different time to save the patient another stick. If there are no previous specimens, we order an "ABO Recheck" in the computer. Only the Lab can place this order to keep nursing from ordering this by mistake which they used to do. We used to only do the rechecks on any type but O. We got a new Lab Director who didn't like that practice so we moved to retyping all new patients.

I searched the operator's manual for info and also contacted Immucor about carryover. They basically said there could be carryover but it would be extremely rare since the patient's titer would have to be higher than 5120 and humans do not reach that level. So I decided to use the CAP JAT or J series and test 2 or up to 5 in the same run. The positives are generally pretty strong (4+) and there is always at least 1 negative in the bunch. I also look thru the past patient testing and find at least 3 strong positive (3-4+) patients with either a negative patient in the same run or the next patient is negative and print their results. I write it all up on a form and attach the printouts to prove there is no carryover. I haven't been inspected since I came up with this but it seems reasonable, is not too hard to do. The only alternative is to use straight antisera and I'm not willing to do that twice a year. I would be interested in what others are doing to meet this standard.

Brenda, So glad you gave some possibilities about how to QC an expired panel. We actually have been doing something similar for several years. In your example, when we needed to use an expired panel to rule out E we would use the patient's plasma with a Jka+E= panel cell to prove the panel would detect the antibody we suspected as proof it was viable to use. Looks like it would be just as easy to use Jka antisera and officially meet the standard. I groaned when I saw they revised the standard because, at first glance, I thought we would have to QC the antigen we were trying to rule out or in and we don't have all rare antisera listed on a panel. I like the way you think about how to meet the standard but still have some wiggle room. Wiggle room is always a good thing

My hospital is not AABB but I will put in my 2 cents for what it is worth. The way I read this: The collecting/pooling facility will put a DIN on the product. The receiving facility will not change, alter, or remove the number (on that bag). Reading between the lines if you take those units and combine them in a different way with a NEW number, in a new bag, you are not altering the numbers on the original bags. You have a new bag with a new number and the next facility (should there be one) should not change your new number. Your computer system should be able to retain the original product numbers under the new facility number for posterity. You can locate who received either original number in the pool should there be a lookback in the future. It might depend on your computer system. Can you print a ISBT label with the new facility number? I would think that is the only number you would need on the new created unit. If you have several numbers on the bag it is going to confuse the nurses at the bedside and we don't need to confuse them. I do remember back in the olden days before computers when we made exchange blood, the bag and paperwork had both the plasma and RBC numbers on it because that was the only way we could do it and keep up with the DIN. We pool large quantities of plasma for Therapeutic Plasma Exchange. We just use the newly created ISBT facility number on our bag and paperwork. We have never been dinged for this.

I am also interested in how others are checking the Platelet incubator. Our probes are incased in some metal protective shield that makes them very difficult to get to. There are only some little nubs sort of sticking out about an inch or so.

Our hospital system pays a Cerner subcontract team to validate the big upgrades. I am SO GRATEFUL for this!!!!!. It would be overwhleming for one person to have to go thru everything associated with BB. We get a huge notebook for our records of what the did. We still have to test a few things. For small upgrades that affect BB, I perform some type of testing with screen shots during testing and also after it goes in. These are usually not too much. I always test the electronic crossmatch after every validation so I have it on record so I won't get dinged by an inspector.

We used to just document on the maintenance form and review at the end of the month. Then I read somewhere, it may have been on this site, that the software to read the backup disks on the Echo was proprietary and you must have their software to read the DVD backup disks. Our instrument was getting some age on it and I wasn't sure if we would remain with Immucor when we replaced it. So, I talked to Immucor and they said it could be read on Notepad even without the Echo computer. I tried reading it on my computer and it doesn't look anything like it does on the instrument. I sort of figured it out but it is a mess and it took a while. I even wrote a process on how to read the disks if we don't have the ECHO computer. I started having my people print the QC daily a few years ago so I will at least have it if asked by an inspector. I "review" and sign it within a month. I don't really review it because the Echo won't work if the QC doesn't pass but at least it looks like I reviewed it. I didn't want to be fumbling around trying to print QC for some random month during an inspection. Then to top it all off, our hospital came along about a year ago and switched out all our computer towers and took away the DVD/CD readers. I had to have a special one put in my office with a DVD reader in case we didn't have the ECHO and I needed to look at patient results. I guess what I am saying is pretend you don't have your instrument and see what your backup disks look like without the software to read it. Then make your decision on whether to print QC or not. I chose to print.

Our QC was minimal several years ago based on the fact that the first ABO back type would confirm the antisera. The standard says the Anti-IgG reactivity is checked during crossmatching. I think our QC only had about 6 tubes and 1 gel card. Very minimal! But I started thinking that we didn't actually have proof the AHG worked on a particular day. (If it isn't documented you didn't do it) I thought proof needed to be added or some tech working that day would need to remember to mark the form hours later. I knew this would get missed multiple times in a year so I added these to the QC form. I even had them add the lot numbers of items that aren't QC'd like the saline cube or the AntiC3b,-C3b. If asked, I have a record of the lot numbers in use on that day if we should need cough up the lot number. Later I read that all reagents must have a check against known positives and negatives so I expanded the QC. It now has about 13 or 14 tubes and 2 gel cards. It is overkill but like I said they can't ding me for not doing enough. I would rather do too much than not enough.

We have a dry erase board in an area that can be seen by all techs where we write general transient info such as 3 PLT ordered, # of available PLT, reserved PLT for heart surgery, etc. This info is erased as it is updated. Most of our issues seem to center around PLT. LOL I have a clipboard with basically a sheet with instructions on the top and basically lines and cues about date/time on the rest of the sheet. If we talk to a physician, nurse or blood center about an issue, we write the info on the clipboard. Some problems take up most of the page so they take as much of the sheet as they need to relate the issue. I'm sure some things are missed here and there but it seems to work for us. It is not perfect but nothing ever is. My techs are pretty good about writing on the clipboard.

Our hospital only did the minimum for years and was never sited. However, a few years ago it seems like the CAP standard changed to read that all reagents must be tested with positives and negatives. Or maybe I REALLY read the wording closely. So I redesigned my QC with pos and neg for all reagents. And we do check the A2 cells everyday. I know if I left that off, my people would forget to do QC on the rare occasion they actually needed to use the cells. I try to stay ahead of the issue. I will say, I was inspecting a hospital about 2 years ago and I asked the person in charge of the BB about the negatives he wasn't doing. He pushed back really hard so I called CAP to get a ruling. CAP said doing only positives was OK and she sounded exasperated that I would ask such a question. I got the feeling she thought I was reading it too closely. I didn't change my QC after that call and I still feel better about proving over and above what is the minimum necessary to prove the reagents work. No one can ding me for not doing enough. The reagent use is minimal and I don't feel I am wasting reagents.

I also called CAP in regarding this standard. It has been a while I was told we only had to compare kits such as the fetal screen kits. She said basically if there were positive and negative controls in a kit, we had to compare new with old. We did not have to compare elu-kits because there are no controls with the kit and all reagents used to test the eluate have been QC'd that day. I also heard this on a CAP webinar about the most common deficiencies a year or two ago. With regards to rare and not so rare antisera, we did not have to compare these at all because we do QC on day of use. I think she said something about FDA standards for potency. If they don't work, you don't use them. With regards to panels, we do not need to do QC on panels when they arrive or compare new to old. The new panels are made up of different donors from the old one, not a good comparison. Panels must be visually inspected for proper shipping conditions and documented this has been done. No other QC is required. She said if we use the panel cells as positive and negative controls when we perform antigen testing, you are actually performing pos and neg QC several times before the panel expires with no effort. A light bulb went off at this point. I have a new incoming reagent form we use and I added a column about the shipping conditions as acceptable or not acceptable with a legend below stating what is OK and what is to be rejected. We still use a paper form for rare antigen testing since it just works better for us. I added a column to insert the panel lot number used for controls and if the panel was visually acceptable when used. Bingo! I have documentation regarding visual inspections upon arrival and on day of use and can show panels used for antigen typing reacted as expected. It helps when you get to speak to a BB person at CAP.

You do not need to register with the FDA if you are just pooling, thawing, changing FFP to Thawed Plasma or splitting units like for pediatric use. The end product is basically the same as the beginning product. However, if you take a product and make a new product then you would need to register with FDA. An example would be combining RBC with FFP to make whole blood for an exchange transfusion. The end product is different from the starting product. I found a good explanation for this on the AABB site. 2012 ASK THE FDA and CLIA Transcript question #29. You can access and print these transcripts even if you are not a member of AABB. Hard to find on the site but persist. A CAP inspector once told me I had to register with FDA because we used Thawed Plasma. He had a VERY superior attitude that he knew ALL things BB and his mission was to impart his wisdom to someone so inferior to him. I knew he was totally wrong but I wasn't going to call him out during an inspection. I'm dumb but not stupid. LOL

We use the J series for antigen typing. The way I read it, the J series includes antigen typing and it is an CAP approved PT since they make it. They probably would like us to order the RCBCAT since all their PT are pricey but I think "J" meets the letter of the standard. We will be inspected in the sprig, I will see if I get called out on this.

Remember, you have to follow it to a "T" if stringent rules are written in a policy. You can be dinged for not following your policy. I would be a bit vague when writing the policy with a lot of wiggle room: wash hands after removing gloves or when leaving area, no lab coats outside of lab area, no eating or drinking or applying makeup, etc. All of our area is considered dirty, including phones, community pens, benches, door knobs and refrigerator handles. We couldn't swing a clean area and a dirty area here since everything is in one room with phones and computers scattered around. All it takes is one person with gloves answering a "clean" phone on a busy day to mess up everything. I agree with Ensis01, if it is too hard, your techs won't adhere to the policy and an inspector would notice. PPE is available to protect the tech and is readily available for them. If someone wants to be absolutely safe they should wear gloves all day no matter what they are doing and consider everything dirty. (I never thought of putting tape on paper with blood spots- good idea)

I am on the trauma committee where I brought up the idea of using A plasma instead of AB several years ago. The head Trauma physician was there and thought it was a great idea. He just wants plasma when he needs it. I approached our Medical Lab Director and had to provide him with documentation I found from Mayo so he felt better about it. Unfortunately, my pathologist limits us to only 2 until we have a confirmed blood type. I pushed for 4 but couldn't change his mind. I wrote up my policies and was done with it. I did not bring this up to nursing We keep 2 A thawed at all times. We rotate it by sending thawed plasma to surgery when they need it and thaw out more. We discard very little except around holidays when there is not much surgery. It works for us.

I just answered this question. My Score PASS

We have a process to extend the crossmatch that has worked for several years. It is complicated and involves 3 departments. Everything has to be exactly right. The patient comes in to pre-test. We have a form that is put with the pretest packet. On the top part of the form is the patients info along with today's date and expected date of surgery. The nurse asks the patient two questions- have you been pregnant or transfused in the last 3 months? The nurse signs her credentials and sends the form to us along with the specimen. We perform a T/S and write our info into a section for the BB. There is a spot on the form that we put whether we need a second type on the morning of surgery. We put a sticker on top of the tube to signify the tube has to be saved when specimens are thrown away. Two days before surgery, the night shift faxes the form to surgery holding so they can put the forms in the charts. The morning of surgery, the nurse scans the form to see if they need to collect the second specimen and they ask the patient if they have been pregnant or transfused since pretest. Nurse signs form and faxes to us and sends the 2nd specimen if required. We get the form, do the second ABORH, find the original specimen, look at form for all signatures, etc. If all the stars are alligned, we order a specific test in the computer which extends the crossmatch for 3 days, answer the specific things in the computer and perform an electronic crossmatch if the physician wanted blood set up. If the patient had an antibody, we request a new specimen on the morning of surgery to do a new T/S and crossmatch the units we antigen typed before the patient arrived. Works great. Most are only T/S done 3-5 days before surgery with the occasional cancelled surgery that tries to get in at the end of the month. We tried to do 14 days but extended to a month (30/31 days hard stop) because the physicians kept pushing the envelope. We did 30/31 days because it is easy to see if the surgery was canceled for too long. If there is any question about ANYTHING, a new specimen is collected and we start over. It works well for us and we have had very few problems after the nurses realized it helped them

We have one form- Emergency/Medical Release form. Top portion is Emergency release with one of 2 parts we check- Emergency O uncrossmatched or Emergency type specific uncrossmatched. An emergency situation exists and transfusion prior to completion of testing is necessary due to life threatening conditions. I have been informed and understand the risks blah, blah blah. The lower portion is the medical release with things we check, AB of undetermined, compatible units available, AB of undetermined- unable to find compatible, Rh positive product to Rh negative female of childbearing age, Blood Consent signature unattainable, Other. I am aware of problems encountered during compatibility testing. The medical status of this patient necessitates blah blah blah. I have been informed and understand the risks involved blah, blah, blah. Physician signs at the bottom. Our policy states that we do not have to have the signature prior to either of these conditions. If it is an emergency, we will get the signature when the crisis is over. If it is medical, we call the physician and tell them the issue and tell them they must sign the form. We will allow them to sign the next morning. If they don't sign I sic the HIM department after them when the patient is discharged. The physicians get in trouble here if they don't sign their orders. If it is something that is really out of the ordinary, I have my pathologist talk to the physician.

Sorry for the delay in replying. I am not receiving this newsletter in my email anymore for some reason. Yes we use Cerner. I don't think the baby and mom are linked. If they are, the lab can't see it on our side. We used to put the cord blood workup under the mom's number. That changed when the EMR came along to foul things up. Now the baby is ordered under their own medical record number. We have L/D wrap a mom's chart label sideways on the top of the cord blood and the baby label is placed up and down in the normal way. That way we have the mom's name and number when we are putting in the baby results. We look up the mom to make sure we have a current blood type. If current, we type the mom's type into the results. If it is not current, we get a new specimen. Blood Bank history is not always reliable. Unfortunately, the computer doesn't compare the baby type to the mom type, we have to do that. Talking about the history is not always reliable..... a patient came in to have a baby. The blood type didn't match the history. Had her collected again. It still didn't match her history. Started digging in the computer. Turns out, she had a baby 3 months earlier. (???) Called L/D to see if this was some type of weird OB case. No, it turns out the one that gave birth 3 months earlier had a Medicaid card and it worked so well when she gave birth that she loaned it to her friend. Just a little bit of fraud. Go figure. Never rely on computer history

Our previous computer system allowed us to put in the antigen typing QC when testing patients and donor units. It was horribly cumbersome. Our rule here is that we only do QC on antisera once in a 24 hour period, starting at midnight. We could never tell if QC had been done by an earlier shift on a particular antisera so we would do it again. My boss finally relented and went back to paper forms due to cost savings and we also saved tech time and frustration by using a paper form. Are you using a shared excel sheet that all techs use to enter QC? If I was inspecting, I would want to know how you could protect the info already entered, e.g. could someone change the entered information whether intentionally or by accident. In order for things to be added daily, you would need to prove that previously entered info is secure. If it is not secure, how would you know if something was changed on a excel sheet? Could you see a print out of the changes and who made them? I have had files disappear. Yes, our stuff is backed up but you have to tell the IT people when you thought it was deleted so they can look thru the dumped files of the whole system. I have lost files myself by moving them accidently to another file. I freaked out for a period of time. How would you document review within 30 days? You would need to add your electronic signature and date and it couldn't be changed or altered. If there is something wonderful out there, I am interested. Otherwise I will stick with the old fashioned paper forms. They don't take up much room in a file and I don't have to worry about them disappearing into nothing. I think I'll let the next supervisor do something wonderful when I'm gone. There are just too many questions surrounding electronic QC. (I sound like an old fuddy duddy. LOL)

We just use regular clear tape like you would use to seal a box. About 3 inches wide. I do admit the tape starts peeling up after a year or two, so she could have a valid point. I have typed up instructions for the outside and "laminated" with the tape. A lot of good it does since they don't seem to read what is in front of them. A different lady in Quality suggested we use the sticky pouches so we could put the patient name on the outside. I don't see the difference between a sticky pouch and sticky tape but whatever. I think I will redo all the coolers with new tape and see if I can get it past the next infection control person. We have had several in the last few years. One concentrated on corrugated boxes and upended the entire hospital.