Kathy

We are considering having our computer system fire off a corresponding blood product order every time a physician orders a transfusion. Does anyone see a problem with this (other than maybe getting a few too many blood product orders)?

We just went live with physician ordering and the EMR. We are having similar problems. I am wondering if it would be appropriate to have nursing orders to transfuse print to us. Does the doctor HAVE to order the blood product from us, or would that transfusion order be justification for us to place the order in the LIS ourselves? We have lots of cases where we have a whole unit of blood set up per physician order and then they want aliquots throughout the stay. We end up with orders for 5 units of blood when only one unit (five parts) is transfused.

I don't know what happened, but the link went down for this piece of equipment over the weekend and it is still down. Good thing it isn't in use yet.

I know what you mean about other things keeping you busy. We are set to go live with a new hospital system with physician ordering next week, followed by the lab system build, a physical move of the lab, and inspection. The platelet incubator has been up and running for about 3 weeks now and I was quite surprised when I went up there to do the alarm check and found that instead of being hard-wired, it is on ISENSIX. I am feeling a bit of pressure to get this thing validated so that it can be used, but I want to make sure I'm doing it right.

We have a new platelet incubator in a remote location and it has been hooked up to Isensix, but not hard-wired to Security (whose will make sure someone responds to the alarm). According to my operation manual, the alarm check on the unit needs to be done quarterly. Do I still do the alarm check on the unit's alarm even though it is not hooked up to security? Do I do the alarm check on the Isensix unit quarterly? If so, how is that check performed?

I did several checks on expired units of red cells. Using a calibrated infrared thermometer (Global Sensors Model AQA1721), I found that the units reached >10 C in as little as 10 minutes when left on the counter at room temperature. This prompted us to start placing the units on refrigerated gel packs during issue. When sending the units to monitored refrigerators, each unit has a Safe-T-Vue temperature indicator placed on it and they are placed in coolers for transport to the refrigerators. If any unit comes back with a red temperature indicator and/or temperature >10 C, it is discarded. Platelets are a little more tricky...as far as I know, there are no temperature indicators that would indicate if the unit went outside the 20-24C range. We will discard any platelet unit that comes back outside that range.

David, Since all of our specimens are collected in EDTA, wouldn't it be easier for us to only use Diluent 2? I would think that it would be easier to validate the ABO cards using Diluent 2 than to validate both the IgG and Polyspecific cards with positive (hard-to-find) DATs.

For those of you who use the Ortho MTS Gel system, do you use both the Diluent 2 (for the IgG and polyspecific cards) and the Diluent 2 PLUS (for the ABO/Reverse cards) or do you use one of the diluents for all of the testing? If you use only one diluent, which one do you use? What kind of validation testing did you do to determine that the one diluent worked for all of the cards? I want to do the validation testing. If I do it so that we use Diluent 2 Plus for everything, do I need to test for DAT (positive and negative, in both IgG cards and polyspecific cards) and crossmatches (positive and negative)?

I do not have the 9th edition of the Technical Manual, but I do have a formula from another institution that I worked at. Is the following correct? : Hematocrit of unit x volume of rbc unit / desired hematocrit = total volume of reconstituted unit. Subtract the volume of the rbc unit from the total volume of the reconstituted unit to give you the volume of FFP to add to the red cells. I did this on a few units of washed cells (HCT 70%) and it worked well.

Question to everyone: When you need to culture a component for a transfusion reaction, does the microbiology department obtain the specimen from the bag and innoculate the media, or does the blood bank do this?

When you get a patient who types weak D positive in tube, but strongly D positive in gel, do you only give them Rh negative cells?

My hospital currently does not have a SOP for the saline replacement procedure. How would I validate this? Also, we currently do anti-A, anti-B titers with room temperature incubation. How would we validate CAP's "Uniform Procedure", which includes an AHG phase?

I am now clear on the fact that split units must be billed and that you can charge the splitting charge for every part except the last part. How do I determine the split unit charge? I ran some numbers and determined that, on average, we split a platelet pheresis unit into 2.7 parts, but only transfuse 2.2 parts. Would I take the whole unit charge and divide it by 2.7 to get my split unit charge?

What is the proper procedure for billing products that are split (ie. red blood cells, FFP, platelet pheresis)? We have ISBT and our splits have the appropriate letter designations. Since I really know nothing about billing, please be detailed with the answer. I want to know what know what codes need to be billed and if the split units are billed, what the charge is compared to the whole unit charge. Is it ever appropriate to bill a whole unit if a split unit is transfused? I am not concerned about the charge for splitting the unit...only the charge for the product itself. I would very much appreciate any answers.

Great ideas! Very helpful. I have taken on the SOPs and that is one of the things that is causing me stress...it is going to take me forever to get them all updated. The former supervisor was too busy to do it. One of my problems is the tension that is caused when I ask the former supervisor (who was promoted) about changes I am thinking of making. Why not just make the changes instead of asking her first? She knows the place better than I do and is a great source of information. There might be a good reason why she didn't. By the way, we did pass that FDA inspection, no problem.

I work in a lab where we very infrequently encounter antibodies - maybe one or two per month. Some of our techs are not very good with antibody identification and problem solving when the antibody is not clear-cut. We don't have a SOP for when we would revert to the tube method, nor do we have a saline replacement technique in our procedure manual. I would like add the saline replacement to our procedure manual, and, since it means that we would be using the less sensitive method (tube) instead of the more sensitive method (gel), my medical director is appropriately questioning me how I know for sure that we wouldn't be missing clinically significant antibodies. He also wants to know how I would validate the saline replacement technique. I would would really hate to send a specimen with rouleaux to the reference laboratory, so I would like to give him some sort of concrete answer.

I worked in a pediatric hospital where we provided whole blood for cardiovascular surgery. I seem to remember that my boss would express the plasma of whole blood units that were not used and make them packed cells. I am currently working in a larger pediatric hospital with a very active cardiovascular surgery program but whole blood units are not used.

I am considering changing manufacturers of this product due to pricing. What do I need to do from a validation/documentation standpoint?

I think I am confusing people. I do have 2 Thermosafe coolers. When I validated them with 3 frozen packs I found that it made the blood too cold, so I have them validated for temporary storage of blood at 1-6C for up to 7 hours with 2 frozen rigid bottle refrigerants and 2 refrigerated gel packs. We had these first and are using them for traumas in the Emergency room. In May, we started using Safe-T-Vue 10 indicators on all blood that went to the areas with monitored refrigerators. What typically happens is that we send a bunch of blood up to the OR for surgeries. For the cardiovascular cases, that blood is then transported to the CICU refrigerator, where it is stored for a period of time and then returned to the blood bank. We were finding that too many units of blood came back with red indicators. The blood comes up to >10C in as little as 15 minutes, so the room temperature transport wasn't always working for us. Realizing that a cooler system that uses frozen packs won't work for us since the frozen packs won't stay frozen and ready for transport from the OR to the CICU, I decided to go with a refrigerated gel pack system (Transport-R Inc.) so that all of the blood and gel packs can be refrigerated when they get to the OR refrigerator and then the cooler can be repacked for transport to the CICU. The gel packs will be cold since they will have been refrigerated with the blood. The amount of time the Transport-R coolers come up to 6C and 10C is much shorter than the Thermosafe coolers, but that is fine with me since I don't need them to keep the blood cold for a very long time...mostly just long enough to transport between various locations in the hospital. I can put in the procedure that the Transport-R coolers are only to be used for transport, but I do have the data that indicates how long they stay at storage temperature. I am wondering how to incorporate this into the procedure, especially if the CICU wants to use the coolers to keep blood at the bedside for short procedures.

I wanted to see how long the coolers would maintain temperature. Per AABB Technical Manual, 16th edition page 284, "It is recommended that all red cell transport containers be validated to maintain a temperature for 1 to 6 C for a specified period to ensure compliance with the transport and storage requirements for Red Blood Cells." The only way to do that is to check the temperature periodically. I didn't want to do every hour because I suspected the coolers would not hold temperature for a very long time. I did do a process validation as well. The refrigerated gel system should work for us. If we used something with wet ice or frozen coolants, the coolants would thaw out or the ice would melt and not be available to transport the blood from the OR to the ICU. We do have Thermosafe coolers for traumas in the ER, since the ER does not have a refrigerator.

I have just finished what I consider to be a very thorough validation of some new coolers. I packed the each cooler with 1 unit of expired blood, then removed it every 30 minutes and took the temperature with an infrared thermometer until it reached >10 degrees. I repeated the process with 2 units, taking the temperature of each unit every 30 minutes. I repeated it with 3, 4, 5, 6, 7, and 8 units of blood. Per AABB suggestion/requirement, I now know the most amount of time I can keep my blood at <6 degrees (storage), which is 30 minutes, and the most amount of time I can keep it at up to 10 degrees (transport) - 3 hours. What do I do with this information? The coolers are really only meant for transport between monitored refrigerators within the hospital, but I know there is a chance someone might want to use a cooler to have blood at the bedside for a procedure (storage). I am very confused on how to word my policy in regards to storage and transport. Do I put "blood may be stored in coolers for up to 30 minutes and transported for up to 3 hours"? That is going to confuse everyone. They can walk around the hospital with a cooler full of blood for 3 hours but they can't sit it by the bedside for 1 hour? In case you are wondering why the short amount of time, I am using a system with refrigerated gel packs, which is sufficient for our needs since we have refrigerators in the OR and ICUs.

I spent 19+ years doing tube testing exclusively and am now in a hospital that does gel antibody screening/antibody ID exclusively (although we do have a tube procedure). You are right. We never killed anyone. I am on a learning curve from a management standpoint here, so forgive me if I ask stupid questions.

We typically issue 4 units for CV surgery and it would be really a pain to split all 4 units, not to mention the amount of blood we would waste by having a bunch of split units coming back from the OR. I do think it would be safer that way. I will run it by the medical director. It is ultimately his decision.

If you get a positive antibody screen in gel and do it in the tube and it is negative, how do you know which one is right? How do you know when you need to revert to the tube testing when your primary method is gel?

David, I am just going based on what we did in the blood bank of the last hospital I worked in. For our NICU babies, we would spike a unit with a filter, attach a stopcock, change the original bag's expiration to 24 hours, and pull syringe aliquots for all babies that needed <50 cc of blood during that 24 hour period. We sent one random bag for culture once a month. For that matter, we send washed cells for culture periodically. I would feel more comfortable at least initially culturing the bags every now and then.