What Would You Do?

[Brenda K Hutson]

So we know that a specimen (and therefore a crossmatch) is good until 2359 of the 3rd day (with the day of draw being day zero). The Nurse comes to pick up blood at 0015 (15 mins. after given specimen/unit expired) and while issuing it, you get a warning due to the outdated specimen. Do you override the warning with a logical reason (i.e. will complete transfusion in < 3 hrs, 45 mins.), or do you tell them you need a new specimen?

Could be resolved of course depending on when you release your expired crossmatches; we do it in the morning but we know we will get a warning beginning at midnight.

ASIDE: Have not had time to be online for some time now, but noticed that Thread I began on "Just for Fun" has had over 12,000 readers!! WOW; like I said, it can go on forever because everyday we are given new amunition.

Brenda Hutson, CLS(ASCP)SBB

[Bill]

If patient is pregnant or been transfused within last 3 months, I would get new specimen and repeat antibody screen prior to issue. Otherwise, would do override with logical reason.

[mobea]

I would issue the unit and get the new specimen later - nothing good happens after midnight, especially collecting a properly labeled sample!

I'd also have a policy that addresses this, and the circumstances under which such an override is allowed.

[Brenda K Hutson]

If patient is pregnant or been transfused within last 3 months, I would get new specimen and repeat antibody screen prior to issue. Otherwise, would do override with logical reason.

Ok, so let's take out the variable of previous transfusions. For subsequent responses, let's assume the patient has been pregnant and/or transfused in the past 3 months.

I am trying to assess if this could be considered a "gray area" in that technically, you could Issue the blood at 2330 and the transfusion would still be occurring after 2359. So, can you Issue the blood at 0015 provided the Nurse is told the transfusion must be complete by 0400......

Thanks,

Brenda

[SMW]

if the sample has expired I would obtained a new sample and restart the process/clock. What would you do if they came at 1:00 AM, or 1:15 AM, or 3:00 AM or 3:45 AM?......If it is an urgent situation, then there is always the uncrossmatch/urgent release process which could be followed according to your local policies/procedures (which typically require a phyisician authorization).

To Bill and Mobea:

Are you documenting this (and obtaining appropirate prior approvals) through your process of deviaiton from SOPs/Standards? Otherwise I believe (in the US) it would be a reportable event due to deviation from Standards/your SOPs. [i don't believe a computer overide which most users can perform generally meets the intent of prior authorization........]

[Brenda K Hutson]

if the sample has expired I would obtained a new sample and restart the process/clock. What would you do if they came at 1:00 AM, or 1:15 AM, or 3:00 AM or 3:45 AM?......If it is an urgent situation, then there is always the uncrossmatch/urgent release process which could be followed according to your local policies/procedures (which typically require a phyisician authorization).

To Bill and Mobea:

Are you documenting this (and obtaining appropirate prior approvals) through your process of deviaiton from SOPs/Standards? Otherwise I believe (in the US) it would be a reportable event due to deviation from Standards/your SOPs. [i don't believe a computer overide which most users can perform generally meets the intent of prior authorization........]

Well I don't think Bill would need authorization; you can extend a specimen on patients who have not been pregnant and/or transfused. He did distinguish that group, but perhaps did not emphasize the fact that he would have determined that in writing prior to overriding and allowing Issue after Day 3.

Just my thoughts...

Brenda

[L106]

I would routinely make the nursing unit place new crossmatch orders, have a new specimen collected, and do all the necessary testing on the new pt sample. If there was some unusual circumstance that made this unfeasible (ie: patient massively hemorrhaging in surgery) the blood could be issued with the pathologist's or my (ie: the supervisor) approval (and I would document the situation. (Or, as SMW suggested, I might made the physician sign for Uncrossmatched blood.)

[Nancy L.]

I would do the same as L106. In addition, if units were issued after expiration of the crossmatch, this would constitute a deviation from SOP and an incident report would be filled out and reviewed by the pathologist/medical director.

[Malcolm Needs ☆]

I would also require medical input; probably from my own Haematology Consultant, rather than the physician looking after the patient. If the cross-matched blood is outside the strict criteria laid down, then there needs to be discussion between the Haematologist and the other physician as to the dangers that may be involved in giving, or not giving the blood to the patient at that time.

There may be a very good reason why the blood should be given, but if it then causes a transfusion reaction, I would rather the litigation was against my Consultant (who has the medical know-how to give a clinical defence and the medical authority to override the strict criteria), than against me (who does not - and who has not the medical authority to override the strict criteria).

:redface:

[LaraT23]

We ask that our nurses send us a message on our printer wheneve they have a transfuse order on a patient. We then check the time on that person's units and call with the you better get up here time. If they cannot get all units in or even picked up, we just get a new specimen right off the bat.

I have extended an expiration before. My system right now will not allow us to issue, at all. The only exception is myself as I am also the Blood Bank module computer coordinator. So, in summary, most cases it would not be possible unless I am here. I am most certainly not at work usually at that time.. although it is not impossible unfortunately.

[Brenda K Hutson]

We ask that our nurses send us a message on our printer wheneve they have a transfuse order on a patient. We then check the time on that person's units and call with the you better get up here time. If they cannot get all units in or even picked up, we just get a new specimen right off the bat.

I have extended an expiration before. My system right now will not allow us to issue, at all. The only exception is myself as I am also the Blood Bank module computer coordinator. So, in summary, most cases it would not be possible unless I am here. I am most certainly not at work usually at that time.. although it is not impossible unfortunately.

Well, even if our computer system didn't allow us to Issue if a specimen/XM was expired, it does allow us to change the expiration date of a specimen. For patients who have not been pregnant and/or transfused in the past 3 months, we will extend pre-op orders to 3 days past Intended-Use-Date, not to exceed 10 days; and while we do have an Instruction we add when doing that, stating we received a sign form stating this, obviously the computer would not know the difference.

Anyway, thanks everyone, we are on the same page....

Brenda

[Malcolm Needs ☆]

I would also require medical input; probably from my own Haematology Consultant, rather than the physician looking after the patient. If the cross-matched blood is outside the strict criteria laid down, then there needs to be discussion between the Haematologist and the other physician as to the dangers that may be involved in giving, or not giving the blood to the patient at that time.

There may be a very good reason why the blood should be given, but if it then causes a transfusion reaction, I would rather the litigation was against my Consultant (who has the medical know-how to give a clinical defence and the medical authority to override the strict criteria), than against me (who does not - and who has not the medical authority to override the strict criteria).

:redface:

Having rattled on as above, what I should have said is that, in the UK, the SHOT (Severe Hazards of Transfusion) Haemovigilance Scheme is strongly against transfusion at night, unless there is a compelling clinical reason; so it shouldn't happen (and pigs might fly)!!!!!!!!!!

:D:D

[Malcolm Needs ☆]

Anyway, thanks everyone, we are on the same page....

Brenda

No, we're on two pages now!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

:haha::haha:

Edited November 19, 2009 by Malcolm Needs

[RR1]

So if you are saying that the specimen is valid from Day 0 = 00:01hrs to Day 3 = 24:00hrs, and you released blood on day 3 at 22;00hrs, these units will probably still be valid for transfusion until day 5, if you hold for 2 days, which sort of messes up the logic of the 3 day rule anyway.

[Brenda K Hutson]

So if you are saying that the specimen is valid from Day 0 = 00:01hrs to Day 3 = 24:00hrs, and you released blood on day 3 at 22;00hrs, these units will probably still be valid for transfusion until day 5, if you hold for 2 days, which sort of messes up the logic of the 3 day rule anyway.

You lost me with "these units will probably still be valid for transfusion until day 5, if you hold for 2 days, which sort of messes up the logic of the 3 day rule anyway. " ???

Brenda

[RR1]

Brenda, it's not impossible I could be confusing myself and the rest of the world!

If you issue blood on day 3 of the sample, when will you return this to stock if not used?

[Brenda K Hutson]

Brenda, it's not impossible I could be confusing myself and the rest of the world!

If you issue blood on day 3 of the sample, when will you return this to stock if not used?

So are you saying if the floor returns the Unit for some reason, that you might put it back on the XM and not know it should have been released (because at that point, the specimen/XM is expired)?

If that is what you are saying, I am thinking that our computer system would probably say something when we are Returning it in the computer; but even if it wouldn't, while it might sit on the shelf, it would give the same warning (specimen/XM expired) whenever you go to Issue it.

Brenda

[RR1]

I think so ! Do your clinical staff have to log the units in and out of your blood issue fridge or do you just have a paper based register?

[Brenda K Hutson]

I think so ! Do your clinical staff have to log the units in and out of your blood issue fridge or do you just have a paper based register?

Ok sorry, confused again. What do you mean by "Do your clinical staff have to log the units in and out of your blood issue fridge or do you just have a paper based register?"

Sorry if I am dense.....

Brenda

[RR1]

It's OK Brenda, I could just be confusing things...Oh for the days we could discuss these issues over a drink after work, rather than the internet!!

The following are the current UK BCSH Guidelines for sample requirements: Is this any different to how you handle your samples?

Patient transfused within ....Sample to be taken

3–14 days................................ 24 h before transfusion

15–28 days ............................. 72 h before transfusion

29 days to 3 months................. 1 week before transfusion

Regarding 'logging' units in and out of the blood fridge, once you have issued the blood, do these go into a designated fridge for nurses to collect, or are these directly issued by your lab staff? Either way, I presume you have to register these as being collected on your computer system or by signing out in a 'collection register'? .....am I on the right track yet??

[Brenda K Hutson]

It's OK Brenda, I could just be confusing things...Oh for the days we could discuss these issues over a drink after work, rather than the internet!!

The following are the current UK BCSH Guidelines for sample requirements: Is this any different to how you handle your samples?

Patient transfused within ....Sample to be taken

3–14 days................................ 24 h before transfusion

15–28 days ............................. 72 h before transfusion

29 days to 3 months................. 1 week before transfusion

Regarding 'logging' units in and out of the blood fridge, once you have issued the blood, do these go into a designated fridge for nurses to collect, or are these directly issued by your lab staff? Either way, I presume you have to register these as being collected on your computer system or by signing out in a 'collection register'? .....am I on the right track yet??

Wow, that is a rather complicated system you have. No, we do not have guidelines like that.

If a patient has been pregnant and/or transfused in past 3 months, we need a specimen every 3 days. For patients who have not been pregnant and/or transfused in the past 3 months, it is an Institutional decision as to how long they are willing to extend the specimen, if at all (10 days at my current place; 30 at another I worked at). But while we will extend it "up to" that number of days, we actually extend it to 3 days past the date-of-use, not to exceed X# days.

I am still kind of confused about the word "logging," but our process is to log the blood into our computer system when we receive it form the donor center (and perform confirmation testing), then XM the blood, then Issue the blood to a transporter who comes for it (will soon change to using the pneumatic tube for that).

So, I have no idea what a "collection register" is or a "designated fridge" for Nursing, etc.

But I think we are getting closer.....

Brenda

[RR1]

Thanks Brenda, when your transporter collects the issued blood how is this recorded as being collected?

We place our issued blood into an issue fridge, where a nurse will collect one unit ( if two have been allocated for a patient), for transfusion. The nurse will be responsible for recording the collection date and time and her details on a paper register. In some places this process may be computerised. The second unit will then be collected after transfusion of the first one in same way. Our units are kept issued for the named patient for two calendar days from the date of issue.

[Marilyn Plett]

It sounds as if in the UK you have an interim storage area for units after they are "issued" by the blood bank and before they are actually "picked up" by nursing staff. In the US most blood banks would consider that "issue" and "pick up" are simultaneous events.

[RR1]

Thanks Marilyn, it does sound like that. What do you do with blood reserved for operations, is this not placed into interim storage (a day or so before) a planned surgical procedure?

[Marilyn Plett]

I think all hospital blood banks would "issue" on the day of surgery. Many "issue" in a cooler validated to maintain the temperature for 4-6 hours so that the blood can remain in the same room as the patient. The actual transfusion would be documented in the patient's chart. Untransfused units would be returned to the blood bank, inspected and logged back in. Hospitals with active trauma centers frequently keep a prepared cooler with O negative RBCs ready to go. Nearly everyone has heard of a horror story where nurses remove a unit from remote storage and give it to the wrong patient, so my sense is that most hospitals are moving away from remote storage.