Tissue: BB Involved or Not

[THintz]

In light of the recent updates to JCAHO standards last July, our facility is looking at some changes to our tissue management program. I was wondering how many Transfusion Services are involved with any aspect of tissue (bone, skin, veins, etc.) management (i.e purchasing, storing, tracking, vendor qualification, distribution, lookback, etc.) We are an AABB/CAP accredited facility so those standards would also apply if brought into the TS. I realize we have the expertise to share with this process but not sure this is truly a function of transfusion services. I did attend the Tissue presentation at the recent AABB annual meeting and Seattle and can appreciate both points of view. Your opinions?

1. Who has "general oversight" within your facility? Transfusion Service, Other area of Lab, Surgery, combination?

2. Do you have a Tissue Utilization Committee?

3. Do you have any FTE's specifically for tissue management, such as a "Tissue Coordinator"?

4. Who is directly responsible for reporting adverse tissue events and performing lookbacks?

5. How large is your facility?

[adiescast]

We are a hospital system with about 800 beds. Surgery is responsible for tissue. We have a committee that works on compliance issues. The committee does not do utilization review. The point of care coordinator and I (transfusion service manager) are on the committee. Surgery has a "tissue coordinator" who also has other duties. The tissue coordinator is responsible for reporting adverse tissue events and performing lookbacks.

[Mary]

Surgery is in charge of tissues. We tried to manage the tissue inventory, but it was a nightmare trying to stock what they needed. The "quality" issues were difficult to communicate to nursing.

[labgirl153]

MUSC (Medical Univ. of SC) in Charleston, SC has their transfusion Service handle the tissue bank...I don't recall the bed # but assume it's >1,000 beds. They've only started this in recent years.

[Jane]

Our OR is responsible for the tissue but it is stored in one of the lab's (not blood bank) freezers. I hope no one decides this would be better handled by lab. In fact, during a recent JCAHO survey, we got asked a lot of questions about tissue even though we don't order, issue, track, etc. I would like the OR to get their own freezer and move it away.

[Kathy3171]

We had a JCAHO inspection recently for our point of care, and the inspector focused in on tissue storage. At our hospital, about 350 beds, the surgery department is responsible for tissue procurement, storage, handling and lookback. They have a tissue coordinator that handles all of these functions in addition to other duties. Because of the inspection, the lab was cited because according the JCAHO the lab is ultimately responsible. So.... I have written into the Blood Bank policy that states the Surgery department is responsible for Tissues with oversight by the Medical Director of the Blood Bank. I have been working with the coordinator in surgery to get their procedures written that comply with the standards. This is not an easy task, as we are on different wavelengths, but we are making progress.

[kate murphy]

Surgical Nursing staff has ultimate ownership, though the BB Med Dir wrote their policies. We were cited by JCAHO last inspection, as there was no overall coordinator and nobody overseeing product monitoring, final disposition, storage temp etc. JCAHO was so displeased, they came back 2x, 3 mos apart, to check on this. There was a strong push to put it in the BB, but we had valid issues - space, tracking system, QA, etc. So, for now, it still resides in the OR.

[sgoertzen]

I'm at a pediatric hospital and the "latest" is that DHS considers breast milk to be a "tissue" and is now requiring hospitals that store mother's breast milk to be fed to their own baby to have a Tissue Bank License. Our surgery department already has one of these licenses for the transplantable tissues they control in surgery, but the other pediatric hospitals we've contacted recommend getting a second license just for the breast milk program (so that problems during an inspection with one program doesn't jeopardize the other program). They have enlisted me, as transfusion service supervisor, to help them try to come up with a method to "control" all of the bottles of breast milk in a way similar to the way we control/inventory/issue blood units. In a pediatric hospital that encourages breast-feeding for all newborn patients (extending out to all of the floors - not just NICU), you can imagine how wide-spread this program is and how many people it involves. I have heard that many hospitals are really struggling with this since most institutions don't have a breast milk repository bank that accepts/labels/stores/issues all the breast milk for feeding these infants.

I would be interested to hear what other hospitals are doing to "control" their bottles of mother's breast milk in their refrigerators and freezers as a "tissue".

sgoertzen@childrenscentralcal.org

[Geriann]

General oversite within our facility is now the Transfusion Service Department (TSD) as a response to JCAHO inspection. All frozen (autologous and allogeneic) tissue products are inventoried, dispensed, and monitored by the TSD. All refrigerated and ambient tissue are inventoried, dispensed, and monitored by the surgery dpt. FTEs for tissue management...good idea...i will work on that one.

The TSD will be responsible for LOOKBACKS, Adverse Reactions, and Product recalls.

Facility is about 400 beds.

We are just beginning to implement these practices and have applied for a Tissue Licence...Policies and Procedures are now in place and I am beginning training for my staff and the OR.

The surgery dpt will still do all the ordering.

I have not even begun to deal with the breast milk....however i see it in the near future.

As per the track record of the surgery dpt i think all tissue will eventually be stored, issued, etc in the TSD.

There are so many AATB, AABB, fed regs, and of course I am in California...California regs to incorporate.

I can let you know how it goes.

Geri

[rfm]

In light of the recent updates to JCAHO standards last July, our facility is looking at some changes to our tissue management program. I was wondering how many Transfusion Services are involved with any aspect of tissue (bone, skin, veins, etc.) management (i.e purchasing, storing, tracking, vendor qualification, distribution, lookback, etc.) We are an AABB/CAP accredited facility so those standards would also apply if brought into the TS. I realize we have the expertise to share with this process but not sure this is truly a function of transfusion services. I did attend the Tissue presentation at the recent AABB annual meeting and Seattle and can appreciate both points of view. Your opinions?

1. Who has "general oversight" within your facility? Transfusion Service, Other area of Lab, Surgery, combination?

2. Do you have a Tissue Utilization Committee?

3. Do you have any FTE's specifically for tissue management, such as a "Tissue Coordinator"?

4. Who is directly responsible for reporting adverse tissue events and performing lookbacks?

5. How large is your facility?

we can provide a SOP you can follow to make your life easier! Robert_mayes@mtf.org

[Sheila]

I'm at a pediatric hospital and the "latest" is that DHS considers breast milk to be a "tissue" and is now requiring hospitals that store mother's breast milk to be fed to their own baby to have a Tissue Bank License. Our surgery department already has one of these licenses for the transplantable tissues they control in surgery, but the other pediatric hospitals we've contacted recommend getting a second license just for the breast milk program (so that problems during an inspection with one program doesn't jeopardize the other program). They have enlisted me, as transfusion service supervisor, to help them try to come up with a method to "control" all of the bottles of breast milk in a way similar to the way we control/inventory/issue blood units. In a pediatric hospital that encourages breast-feeding for all newborn patients (extending out to all of the floors - not just NICU), you can imagine how wide-spread this program is and how many people it involves. I have heard that many hospitals are really struggling with this since most institutions don't have a breast milk repository bank that accepts/labels/stores/issues all the breast milk for feeding these infants.

I would be interested to hear what other hospitals are doing to "control" their bottles of mother's breast milk in their refrigerators and freezers as a "tissue".

sgoertzen@childrenscentralcal.org

Thanks so much for pointing out another positive aspect of my job at a VA Medical Center: No breast milk! (Along with the no cord bloods, no pediatrics, etc)