When does the clock start.....

[Brenda K Hutson]

We are having a little disagreement with our Nursing staff (first time in my 26 years I have heard this). In my 26 years and 6 Institutions, we have always started the clock for the 4 hour transfusion time, from the time we issue the blood from the Transfusion Service. However, our Nursing staff has in their protocol, that the clock starts when the transfusion starts. In looking in the Technical Manual, it just states 4 hours; it does not say at what point that clock starts.

I told the Director and Educator of Nursing that I would "throw the question out" on this website for input. So, I would appreciate your feedback.

Thanks,

Brenda Hutson, CLS(ASCP)SBB

[KarenJ]

We consider the clock to start when the unit leaves the blood bank. I have worked at 3 hospitals and that seems to be the standard. Good luck

[tbostock]

When it leaves the Blood Bank (the issue time), not when the transfusion starts.

[John C. Staley]

The clock always started when the blood was issued.

That's why the nurses have in their manual that the IV must be flowing and the consents signed before they request the unit from the transfusion service.

:disbelief

[Brenda K Hutson]

Well, I think part of why that is in their Protocol is that they know they cannot return the unit after 30 mins.

After 26 years and 6 different Institutions (large and small), I would have been surprised to have been doing it wrong all this time.

Thanks for the "data" to present to Nursing,

Brenda Hutson, CLS(ASCP)SBB

[Likewine99]

When the unit is issued from the BB.

Our SOP is written to reflect this and since we are responsible for monitoring compliance for transfusions, nursing

(for once!) follows our guidelines.

30+ years expereince and five different places of employment.

[L106]

As everyone else says, 4 hours from the time it is issued from the Blood Bank. (Let's just say "lots" of years of experience!)

[Brenda K Hutson]

And in addition to all of your experiences, one place I worked actually monitored this as an Audit. We had a 2 page Transfusion Form that attached to the Units. We signed out on the Form, and the Nurses signed the Form and documented Vital Signs on it. One copy stayed on the chart, and the other came back to the BB. I would then look at the time frame from when we issued it, to the completion of the transfusion. If > 4 hours, I wrote an Occurrence Report.

Thanks again for all of your "documentation" for me to give to our Nursing Dept.

Brenda Hutson, CLS(ASCP)SBB

[Malcolm Needs ☆]

Bit late on this one, I know.

I would agree with all of the posters, and the reason that I would agree is that from the moment the unit of blood leaves the controlled fridge in the Blood Bank, it is no longer in a controlled, monitored environment (unless, of course, it is taken from one controlled, monitored fridge to another, whilst in a controlled monitored environment - such as a delivery van from the Blood Centre to the Hospital Blood Bank - that has been validated).

As soon as the unit leaves your fridge in the Blood Bank, its temperature will start to rise (albeit the core temperature will remain stable for a while).

Do the nurses take into account how long the blood may be at ambient (room temperature) before the transfusion begins? I would suggest not.

[Brenda K Hutson]

The Nurses know that they must return the blood within 30 mins. if they cannot tranfuse at that time (though of course they should not have sent for it if they were not ready). So basically they think they can start the transfusion anywhere in that 30 minute time-frame, and that the 4 hour clock starts when the transfusion starts.

There have been occassions where they send it back > 30 mins. We then call them and tell them we cannot take it back,and that if they think they can transfuse it within 4 hours (and for us, that meant from the time if left our dept.; but now finding out that it meant something else to the Nurses), then they should come back and get the unit and transfuse it. Now their argument is: but we would not transfuse something that had been out > 30 mins. HELLO! You are always transfusing something that has been out >30 mins. in that it could be hanging for 4 hours!

Anyway, thanks,

Brenda

[David Saikin]

Ditto . . . when signed out.

[Ramir]

We are having a little disagreement with our Nursing staff (first time in my 26 years I have heard this). In my 26 years and 6 Institutions, we have always started the clock for the 4 hour transfusion time, from the time we issue the blood from the Transfusion Service. However, our Nursing staff has in their protocol, that the clock starts when the transfusion starts. In looking in the Technical Manual, it just states 4 hours; it does not say at what point that clock starts.

I told the Director and Educator of Nursing that I would "throw the question out" on this website for input. So, I would appreciate your feedback.

Thanks,

Brenda Hutson, CLS(ASCP)SBB

Hi Brenda....

Check the new edition of the TM (16th ed.) under "delay in starting the transfusion", page 617. It was mentioned there that the 4 hour period starts at the time of issue from the blood bank. Hope this helps

[skopti]

When the unit is issued from the blood bank computer.

[kslaforce]

In every instution I have worked (7 of them) the clock starts when the blood is issued. At my current institution, we stamp the bag tag with the date and time so the nurses know when the clock started - both for the transfusion (4 hours) or to be able to return the unit unused (30 minutes).

[QJULI]

It was my understanding that the FDA believes that a 'hospital' is a monitored environment, and that units should stay within the 1-6 temp range. . .. not the 1-10 that we used to always accept. How then can you allow nursing to return a unit for up to 30 minutes and remain in the 1-6 range?? I did a study and found that in 7 to 10 minutes at room temp, the units were above 6 degrees. I changed SOP to reflect this over 2 years ago and nursing now has only 10 minutes to return a unit. What are others doing???

[AUDREY]

These are nurses you are dealing with. Enough said!

[John C. Staley]

The "30 min return" rule started in the olden days of whole blood and glass bottles. That's how long it took for them to exceed 6oC at RT.

The current plastic bags and packed RBCs will reach RT in less than 15 min. every time.

We dropped the 30 min. rule from our SOP and check the temp of everything returned, 10oC if NOT in a cooler and 6oC if in a cooler.

At least that's how it was in December when I left.

:disbelief

[Malcolm Needs ☆]

Hey John, not so much of the "olden days" please.

I can remember some of our blood components (if not the red cells themselves) in glass bottles.

Makes me feel ancient (well, ancienter actually)!

[John C. Staley]

Just thought the kids would like to know where the "30 minute" rule came from.

[Malcolm Needs ☆]

Fair comment (I still feel all wrinkley though)!

[Cathy]

Though I'm not a kid, I have always wondered where this came from. Thanks!

[Eoin]

The rule (national policy) is four hours from when the bag leaves controlled and monitored temp (Issue Fridge). Definitely not when it gets to the ward. What are we trying to limit here? Bacterial growth. You would need to think about growth dynamics. That is why we only accept a bag back in to bank once (within the thirty minutes). If it comes back a second time, it is scrapped (BloodTrack is set not to allow it back into issue fridge). If there is bacterial growth at RT the first time, the refrig will halt (or slow significantly) growth. The second time out, there will be a higher colony number to start so growth will be exponentially increased.

I too remember glass bottles (in Oz), but I have been in labs fourty years, so don't feel lonesome old-timers.

[Judy hedglin]

Our clock starts 4 hours from the time of issue also!! That is the point where it is taken out of mandated conditions.

[Judy hedglin]

I must also add that I have inspected for AABB and CAP and considerering my sites inspections the 4 hour limit from time of issue is a common sense type of view.

[Tonyd]

The rule (national policy) is four hours from when the bag leaves controlled and monitored temp (Issue Fridge). Definitely not when it gets to the ward. What are we trying to limit here? Bacterial growth. You would need to think about growth dynamics. That is why we only accept a bag back in to bank once (within the thirty minutes). If it comes back a second time, it is scrapped (BloodTrack is set not to allow it back into issue fridge). If there is bacterial growth at RT the first time, the refrig will halt (or slow significantly) growth. The second time out, there will be a higher colony number to start so growth will be exponentially increased.

I too remember glass bottles (in Oz), but I have been in labs fourty years, so don't feel lonesome old-timers.

Spot on Eoin !!

The 30 minute rule may well have originated with glass bottles, but is currently endorsed by JPAC, the professional advisory committee for the 4 UK blood services, and is a recommendation in the UK Department of Health 'Handbook of Transfusion Medicine'.

The likelihood of bacterial proliferation is actually slightly higher now that blood is leucodepleted, and it makes perfect sense to restrict the length of time a unit is out of controlled storage before it can be replaced and used for the same, or another patient at a later date, for the reasons so eloquently given in the previous post..

For this reason, blood that is replaced in controlled storage, and available for use, after 30 minutes has elapsed, is a reportable event to the MHRA (the authority for monitoring the UK Blood Safety and Quality Regulations).

If it is subsequently transfused to a patient it is also reportable to the Serious Hazards Of Transfusion confidential enquiry as a 'handling & storage' error.

Guidelines in the UK recommend starting a transfusion 'as soon as possible' following removal from safe storage, but would in theory allow blood to sit in the clinical area for 3.5 hours following collection from the fridge, then be transfused over 30 minutes !

Edited July 1, 2009 by Tonyd