Refrigerators in Open Heart O.R.

[mwlister]

We are scheduled to open our Open Heart program and we met with the surgeons today. One of the primary area of interest was putting a refrigerator in the Open Heart room and stocking it with blood to support two hearts at a time, in addition to having blood on hand for the nearby unit for the post hearts for three hours. This would require stocking the refrigerator with multiple units of blood for several patients.

I would appreciate any input anyone (who currently performs Open Heart Surgery) could provide for the following:

1. Do you support having a refrigerator as discussed above?

2. Have you experience any errors in personnel selecting the wrong units?

3. If you had a refrigerator and removed it could you explain why?

4. Can you provide any references for error rates associated with refrigerators in the Open Heart OR?

5. Any other comments.

Thanks, MWL

[pdavenport]

In 1999 Joint Commission issued a alert regarding the use of remote blood refrigerators that contain blood for more than one patient. If you go to their site, it's still available. The reccommendation that comes to mind is:"Environmental redesign issue such as discontinuing use of an operating room refrigerator for multiple blood units or adding laboratory workstations." Coolers that go into the OR are one alternative. There are also blood refrigerators on wheels that can go in the room. If you can avoid one refrigerator that contains blood for multiple patients you'll sleep better at night.

[donellda]

I don't have answers to all of your questions but I have worked at 2 different facilities where open hearts are performed. Where I currently work, we do have a blood bank refrigerator in the heart room. We have 3 heart rooms but only 2 are routinely used for hearts. OR personnel come to the blood bank to pick up the blood for the surgeries one patient at a time. In most cases, they return the blood back to the blood bank before starting the next case although there has been 2 hearts going on at one time. There has not been a problem as of yet. They keep the units on separate shelves.

At my former place of employ, there were 3 heart rooms each with their own blood bank fridge. The blood bank was responsible for bringing the blood to the OR and putting the blood in the correct OR fridge. In cases where the room changed, blood bank went back to the OR and moved the blood themselves. We were also responsible for returning the blood back to the blood bank. There were no problems with this system, at least not while I was there.

[Lcsmrz]

I never liked the idea of OR Refrigerators, but the proximity to the blood bank was always an issue. Even one place where it was next door, the surgeons felt an OR refrig was required because of time. They say that when a patient goes bad, everything needs to be in place -- and fast!

Another issue was re-do's in the evening or on weekends with minimal available staffing. There was simply no one available to run blood products. Physicians tend to distrust tube systems for stat blood delivery.

I like to cooler idea, but the FDA ruling on the 1-6C storage has complicated the issue and made this option expensive to implement and maintain.

[rcurrie]

I have coolers that will keep blood at 3-4C for 48 hours with no ice added. I use them on my helicopters. They are the Minnesota Thermal Science GH4 (Golden Hour, 4 units) containers developed for use on the battlefield. I have considered using them for my heart rooms, but at the present I have a full-size BB refrigerator in the OR. The refrigerator is 12 steps from my issue window in Transfusion Services. Go figure. I used to have a smaller BB refrigerator in the CCU. I finally drug it out of there one day after another report of noncompliant usage. As I was rolling it out on a dolly, one of the nurses said wait- my lunch is in there! It is now my MT student refrigerator.

As far as the OR refrigerator, the biggest problem I have is getting unused blood returned to the BB. I know of no patient mixups that have occurred.

Larry, it is a 30-second trip through the tube system from BB to the OR, and a 1.5 minute trip to my trauma bays. I have validated the system twice. I can't get them to use it.

BC

[Cathy]

We have been doing open hearts for a little over four years now. We have a small refrigerator in the operating room, in the hall, in between the two cardiac rooms. There are two plastic bins in the refrigerator, to help keep them separate. The OR staff calls for blood prior to the start of the case. We send up two units via the pneumatic tube and they place them in the refrigerator.

A little while before the case is done, an OR staff member comes to blood bank to sign out a cooler. The blood goes from the refrigerator into the cooler to accompany the patient to his room. The cooler used to stay at the bedside for several hours, until it was felt that the patient was stable. The trigger was supposed to be when the patient was stable enough for family to come in, the blood could be returned. That didn't work all that great. The coolers were staying up on the floor for hours. Now we have attached timers to the coolers and the nursing staff returns the blood and cooler to us after two hours. If they need any products after the two hours, we send it via the pneumatic tube. This system has been working pretty well for us.

[Mabel Adams]

For places still using blood fridges in the OR (with blood for several patients in the same fridge), what are you doing to make sure the right blood gets taken out of the fridge and other regs are met? Do you have some sort of sign-out procedure at the fridge that captures who took it and when and that the confirmed patient ID? Or is it enough that they check patient ID in the room when they hang the unit?

Do you allow blood to be taken from the fridge to Recovery? If so, do you add any checking/tracking steps?

[adiescast]

We have a refrigerator in the OR for the cardiac surgery cases. The refrigerator has a magnetic lock on it that is controlled by a release button in blood bank. The OR sends a runner to pick up blood for one patient at a time. We record the patient and unit information on an issue log and move the units to the refrigerator in the computer. They call us when they get to the OR and we open the door for them to put the blood into the refrigerator. The release button has a light on it that stays on when the refrigerator door is open (so we know if they do not get it closed). When blood is needed for a patient, the OR nurse calls the blood bank and gives his/her name and the name and ID of the patient. We open the door and they read the donor number(s) of the unit(s) they are removing. We record the issue time and name of the nurse on the issue log next to the donor number(s). At the end of a case, they call us to release the lock so they can return the unused blood to us. That time and nurse name also go on the issue log, along with the time they actually show up in blood bank.

We have had very few problems with this. One time someone put blood for a vascular case into the refrigerator while another nurse had the door released for a cardiac case. They did not tell us and apparently the cardiac nurse didn't notice that they had put it in. Their problem was that they had to call us to get the blood back out, so they had to admit that they had done it. That has not occurred again. If someone ever calls and does not tell us what patient they are taking blood for, we don't release the lock. If they don't tell us what units they took, we call into the room to obtain the information and report the problem to OR management. They will take care of it because they know we will pull the refrigerator if they are non-compliant.

[Brenda K Hutson]

I have worked in 6 different Institutions (large and medium sized); all performed open heart surgery. I have seen about every scenario possible and I personallly would NOT recommend blood in refrigerators in the OR for the following reasons:

1. When things go bad (and we all know they do), they are quick to just start grabbing (and you mentioned having

more than 1 patient's blood in there at a time). Yes, I do know of occurrences of grabbing blood on the incorrect

patient and transfusing it.

2. You will still be responsible (to whatever degree you agree to with the OR) to ensure the compliance of

temperature documentation of those refrigerators. At one place I worked, we changed the charts each week but

an OR employee was responsible for documenting the daily temperatures from an internal themometer and from the

chart, on a Log attached to the refrigerator. After several instances of "falsification of documentation" of temps.,

the refrigerators were removed.

3. At one Institution, we had the Tissue Bank in the Transfusion Service (I know you are not inquiring about Tissue

Banking but I promise I have a point to make....). The resaon it was in the Blood Bank was that the OR did not feel

they could comply with the strict temperature documentation regulations. Now to me, there is a difference between

"can't" and "won't." It is definitiely not of the same high priority for the OR staff as it is for the Transfusion Service.

4. Could allow only 1 patient's blood in any given OR refrigerator at one time, with the stipulation that you will now

Issue blood for the next patient until any extra units on the first patient have been returned, but you still have no

guarantee that will always happen.

All of that being said, is there any foolproof way to prevent the OR from transfusing blood to the wrong patient in an emergent situation? Even if you send the blood in a Cooler; even if the Cooler has a specific OR Room# on it; even if a Transporter comes for the blood and takes it up to the OR as needed; etc., things happen. You just try to minimize the possible scenarios as much as possible.

In a perfect world where ALL Proctocols were followed ALL of the time, yes, your scenario could work.

Brenda Hutson, CLS(ASCP)SBB

[tricore]

Maybe your institution should investigate the Neoteric/Haemonetics BloodTrack system. One of our hospitals uses it.

[L106]

I'm pretty much with Brenda Hutson on this topic!

When we started doing Open Heart Surgeries just a few years ago, it was decided (totally without my input) that they had to have a blood refrigerator in the Open Heart Surgery area and in the Cardiac Intensive Care area (where they swore they would only need to keep the donor units for the first 6 hours following surgery.) I have to admit, the CVU Surgery personnel do a pretty good job of recording the refrig temp daily and properly transporting the donor units up to the CVU ICU area with the patient.

The CVU ICU area is another story. They routinely insist of keeping the donor units in their refrig for 24 hours (not 6), frequently refuse to return unused donor units to the Blood Bank for 2 or 3 days, & did a lousy job on recording the refrig temp daily. So we have to call them every morning and ask them what the LED temp display says so we can document the daily temp. Some even tell us that the readout says "36 degrees Centrigrade" (instead of 3.6 degrees Centigrade!) (I wonder what they think normal body temp is??)

[BB001]

Mediware (www.mediware.com) has secure remote blood storage refrigerators installed at several locations across the country.

[Mabel Adams]

I'd sure like to talk to someone using the Neoteric system. From the website it looks like you could attach it to an existing fridge. I wonder how expensive it is?

You can send a private message with an email address if that is better. I always worry that email addresses posted on this public site will become huge spam magnets.

And is anyone using it with McKesson, Horizon, Wyndgate computer systems?

Edited April 16, 2010 by Mabel Adams
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[Brenda K Hutson]

So just to clarify, are the last 2 responses in reference to remote documentation of temperatures? Sorry, it just wasn't real clear to me what you were referring to. While that might deal with 1 issue, I would still have these concerns:

1. Even if the refrigerator temperature is acceptable, what is to stop them from having units out of the refrigerators for

an extended period of time; then just put them back? Would you be putting temperature monitors on the units?

2. There is still the "very real" risk of blood from previous cases being left in the refrigerator where only 1 patient is

allowed at a time, and/or, grabbing the wrong patient's blood in a refrigerator where they are allowed to store

multiple patients at one time.

All of that to say; I have been under the impression that the movement is "away" from having refrigerators in the OR?? I have just "seen and heard" too much in my 27 years.

Brenda Hutson

[Mabel Adams]

These 2 posts refer to the equivalent of Blood vending machines (or thereabouts) that require pt. ID, operator ID & captures time unit entered or removed. Some of them can be set up to open only the drawer with the correct blood type in it or for the right patient. Others can be used on an existing fridge to document who put a specific unit in or out when and if out, for what patient was it taken. Still not foolproof as long as humans are involved, but maybe a step in the right direction.

[Brenda K Hutson]

These 2 posts refer to the equivalent of Blood vending machines (or thereabouts) that require pt. ID, operator ID & captures time unit entered or removed. Some of them can be set up to open only the drawer with the correct blood type in it or for the right patient. Others can be used on an existing fridge to document who put a specific unit in or out when and if out, for what patient was it taken. Still not foolproof as long as humans are involved, but maybe a step in the right direction.

That does sound like an improvement!

Brenda

[tbostock]

Every Joint Commission inspector that I have ever dealt with asks if we have a remote refrigerator in the ED or OR. When I say "no", they say "Good! Because if you did we would have you remove it".

For all the reasons that Brenda stated above, it is a bad idea in my opinion. Much better to send by pneumatic tube, one patient at a time. If they don't trust the pneumatic tube or want to use it, they can use the backup method (their feet).

[NANCY F]

Our hospital does keep a refrigerator in the CVOR area. However, we have a small stat lab, manned by laboratory personel located between 2 surgery suites. The refrigerator is in the stat lab. If CVOR needs blood they go to the stat lab which is only a few steps. The laboratory tech issues the units to the CVOR staff, much the same as we issue units to the floor. When the case is over, and the tech leaves, the tech returns unused products to the blood bank.

This tech also does some point-of-care testing for the CVOR patients.

[L106]

Our hospital does keep a refrigerator in the CVOR area. However, we have a small stat lab, manned by laboratory personel located between 2 surgery suites. The refrigerator is in the stat lab. If CVOR needs blood they go to the stat lab which is only a few steps. The laboratory tech issues the units to the CVOR staff, much the same as we issue units to the floor. When the case is over, and the tech leaves, the tech returns unused products to the blood bank.

This tech also does some point-of-care testing for the CVOR patients.

Wow, Nancy.....That's a really nice setup!!

May I ask....Is that small stat lab strictly for lab work ordered for the CVOR patients? What tests does that stat lab offer? Do you only staff it during active CVOR cases? Do you staff it if there's a CVOR case going on during off-hours/holidays? Thanks for the info!

[NANCY F]

Yes it is for CVOR only, currently they do testing on an ISTAT --we call it a Stat 9--like an ABG with Hct and Lytes, and ACT's --I know it' a coag thing, but that's about all I know about ACT's. We have staffing for days and evenings, and have a call schedule for night shift. When the cases are finished, the tech comes back to the lab and helps out as needed. Typically most cases are finished by early evening--but one never knows for sure. Hope this helps

[macarton]

We send large igloo coolers up to our surgery unit. We have a refrigerator in the unit where they keep blood after surgery until the next morning and returned. Due to an incidence in which a unit was spiked, we have bins in the refrig and the blood is put in zip lock bags and sealed before going in the cooler. We had a refrig in general surgery, but due to an anesthesiologist giving a unit to the wrong patient, compatible type thank goodness, we send coolers up for all cases labeled with the patient's name and dob.

[Lea Tolzmann]

We issue our blood in coolers with Hemotemp II temperature monitors. They can only pick up one patient at a time. The cooler moves with them to CVICU after surgery. We set a time limit of 6 hours for the return of blood. We have not had any significant problems with the blood being out of temperature.

[Ann Viernes]

This is an amazing list of testimonials since 2007 regarding refrigerators in the OR! We are in the process of studying blood delivery options for our new ORs scheduled to open sometime next year, a block further away from our blood bank. We currently rely on a dedicated tube station, a satellite dispense station with a refrigerator staffed M-F 7AM to 7PM. The refrigerator is locked when our tech is not on duty. We also use coolers for large cases (liver transplants) and for cases where blood is needed when our dispense station is closed. This works for now, with all the ORs on one floor. The new ORs will be on 4 floors and we can't have a satellite on all 4 floors. We are debating strategically located tube stations, refrigerators, and coolers. Transport will be an issue. AABB News recently had an article on the use of robots to transport blood to the ORs. The person that mentioned a refrigerator with a magnetic lock operated from the blood bank is intriguing. More information on that would be appreciated! Thank you all for the information in this thread!

[adiescast]

The person that mentioned a refrigerator with a magnetic lock operated from the blood bank is intriguing. More information on that would be appreciated! Thank you all for the information in this thread!

I'm not sure how much more I can tell you about the magnetic locks. They were installed by our Engineering staff. They are very powerful magnets that are attached to the outside of the refrigerator. The release is wired to buttons in the blood bank. When we press the button and they open the door, the button stays lit until the door is closed again.

The magnets are designed to fail "open" if there is a power failure so we can get the blood out if the refrigerator temperature is lost. The one trick that we do not share with the staff in these areas is that the magnet requires electrical power and is actually plugged in behind the refrigerator. If someone discovers that, we could have a problem...but we have been doing this for 9 years and no one has discovered it yet!

This method is far less expensive than purchasing the (admittedly very neat) computer controlled refrigerators. The tracking is manual, with all of the inherent possibilities for human failure. It works here and I stole it from someone else who had it in place for several years before that.

I hope this helps!

[rravkin@aol.com]

I have worked in 6 different Institutions (large and medium sized); all performed open heart surgery. I have seen about every scenario possible and I personallly would NOT recommend blood in refrigerators in the OR for the following reasons:

1. When things go bad (and we all know they do), they are quick to just start grabbing (and you mentioned having

more than 1 patient's blood in there at a time). Yes, I do know of occurrences of grabbing blood on the incorrect

patient and transfusing it.

2. You will still be responsible (to whatever degree you agree to with the OR) to ensure the compliance of

temperature documentation of those refrigerators. At one place I worked, we changed the charts each week but

an OR employee was responsible for documenting the daily temperatures from an internal themometer and from the

chart, on a Log attached to the refrigerator. After several instances of "falsification of documentation" of temps.,

the refrigerators were removed.

3. At one Institution, we had the Tissue Bank in the Transfusion Service (I know you are not inquiring about Tissue

Banking but I promise I have a point to make....). The resaon it was in the Blood Bank was that the OR did not feel

they could comply with the strict temperature documentation regulations. Now to me, there is a difference between

"can't" and "won't." It is definitiely not of the same high priority for the OR staff as it is for the Transfusion Service.

4. Could allow only 1 patient's blood in any given OR refrigerator at one time, with the stipulation that you will now

Issue blood for the next patient until any extra units on the first patient have been returned, but you still have no

guarantee that will always happen.

All of that being said, is there any foolproof way to prevent the OR from transfusing blood to the wrong patient in an emergent situation? Even if you send the blood in a Cooler; even if the Cooler has a specific OR Room# on it; even if a Transporter comes for the blood and takes it up to the OR as needed; etc., things happen. You just try to minimize the possible scenarios as much as possible.

In a perfect world where ALL Proctocols were followed ALL of the time, yes, your scenario could work.

Brenda Hutson, CLS(ASCP)SBB

Brenda,

Thank you for this info and your experience. I have seen similar. Has anyone had any experience where each OR suite would have it's own refrigerator? An expence I'm sure, but I wonder if this would not be a practicle circumstance.:)