I would like your opinion..

[PAWHITTECAR]

Ok as most of you know I just took over as technical supervisor in a small hospital. I am the only dedicated blood banker all others are generalists that float through. We do not do a lot of blood bank/transfusions ~ 200 units a months.

After reviewing the records for the last year I posted some criteria for times I would like called.

-Anytime you get a FFP order (There have been several instances where A units were already liquid when an order came in on an O patient and O units were thawed, wasting the A units) (also several with normal coag and <20plt where the order was actually suposed to be platelets again wasted units)

-Any platelet order in plt count >20 (pretty much same as above plts ordered when count is 450 but INR is 15)

-Any positive antibody screen. (we only get a total of about 10 a month so we're only talking maybe 5 calls a month) I would like to hold some like the clearly RhIG anti-D and the Anti-E guy that has 45 hct and send them out in the morning saving the $100+ stat fee. Also if the order is just a TS on a pt with a positive screen I would like to make a decision about ordering in units(we do not antigen type).

Do you think I am being unreasonable? Some of the stuff I have seen on review has really scared me and let me know that the off shift techs do not have a firm enough grasp of blood bank to make these decisions.

FYI no pathology on site - on call for issues but he normally just tells people to call me.

Thanks

Trish

[Eagle Eye]

See my answer with each question.

Ok as most of you know I just took over as technical supervisor in a small hospital. I am the only dedicated blood banker all others are generalists that float through. We do not do a lot of blood bank/transfusions ~ 200 units a months.

After reviewing the records for the last year I posted some criteria for times I would like called.

-Anytime you get a FFP order (There have been several instances where A units were already liquid when an order came in on an O patient and O units were thawed, wasting the A units) (also several with normal coag and <20plt where the order was actually suposed to be platelets again wasted units)------I would tackle this at three level. 1) If A unit is already thawed and O patient needs plasma, no need to thaw O---keep a table posted for compatible group and type. Educate your staff. In the beginning ask them to give you a call if they have question. Once they have understanding and knows your expection--it will be easy 2) have transfusion triggers set (ofcourse with input from pathologist and have it approved by your transfusion comm). Techs should check every order with your transfusion triggers and if not appropriate, you definetly need them to give you a call. 3) investigate this case a) order error by clinician wrong order by RN calling blood bank c) wrong product issued by BB staff----If investigation shows that the order was incorrectly placed, I would report it to appropriate department.

-Any platelet order in plt count >20 (pretty much same as above plts ordered when count is 450 but INR is 15)

----again here you need a call...

-Any positive antibody screen. (we only get a total of about 10 a month so we're only talking maybe 5 calls a month) I would like to hold some like the clearly RhIG anti-D and the Anti-E guy that has 45 hct and send them out in the morning saving the $100+ stat fee. Also if the order is just a TS on a pt with a positive screen I would like to make a decision about ordering in units(we do not antigen type).

------You do not get that many positive...I would ask them to give you a call. We do nto send any specimen out without supervisor & pathologist review. Same goes for antigen negative units. We have dedicated blood banker, but they are not authorized to order units without approval.

Do you think I am being unreasonable? Some of the stuff I have seen on review has really scared me and let me know that the off shift techs do not have a firm enough grasp of blood bank to make these decisions.

I do not think you are being unreasonable. I think you want to do a good job and you are on right track. Before you take this to your staff, do some home work and present them the reason you are making the change. eg. A unit wasted, on three occasion you could have saved stat fee for sending out the specimen etc.

Remember, no one likes the change. In the beginning it will be tough. Most of my staff really like the idea of having me only phone call away when they have a question and there are few techs(been there long time!!!and who thinks they know all and know more!!!) who doesn't want to give a call. So we have it spelled out when they need to give a call. It took a long time to change the culture and workhabit but we made a difference.

FYI no pathology on site - on call for issues but he normally just tells people to call me.

Thanks

Trish

[PAWHITTECAR]

Thanks..The response I got from most was this is great!! I have just had a couple of people complain that I am trying to "babysit" them...Supprisingly these are also some of those that I have found making errors....

I just needed a little reassurance that I was not really totally crazy.(yet)

[Malcolm Needs ☆]

Superb answer aakupaku, and you are dead right in everything you say Trish.

[R1R2]

Hi Trish,

We have solved the thawed plasma problem by posting a note on the freezer that units are already thawed.

[jayinsat]

Unfortunately, I think these are common issues in hospital blood banks of your size. My situation mirrors yours ALMOST EXACTLY! We have the same issues. I'm not in charge but am the one responsible for most of the work and the one who catches all the errors. Communication is a huge problem. Doesn't seem how many notes I post, messages I send or people I talk to, the problems persist. Real continuing education is resisted by my superiors, therefore, training is always wanting.

If I had your authority, I'd handle it the same way, but I would implement a mandatory monthly proficiency exercise that focuses on the prevalent problems.

[Eoin]

Thank God for our Clinical Haematologist who supports us in continuing education and competency testing. We too don't have dedicated BBers, but they must rotate through BB at least once every two years for four months. Also they have enough sense to check if they meet a situation they are unsure of. I sympathise with you PAWHITTECAR and others who do not have the backing of management on this. Makes life very difficult. You are absolutely 100% right in sticking to your principles. They are a bit dumb if they don't realise that you are covering their backsides.

Best of luck with it.

Cheers

Eoin

[LCoronado]

Hi Trish,

I can empathize. We are all generalists and rotate through all areas of the lab. (Even I have to work in other areas at times, though I spend more time in the Blood Bank than anywhere else.) This is a challenge because, not only do some people lack a complete grasp of the department but they are also very fearful of making any decisions on their own, complaining that they are only in the blood bank once every 5 or 6 weeks and they forget things, especially the nuances of the computer system. While I do understand this, I have to hold them to the policies of the department and of course regulatory standards and above all I feel I am ultimately responsible for the safety of the patients. One suggestion I might add to those already posted is a communication log book. We have found this more effective than posting notes which may be lost or overlooked. Everyone knows to go to the communication notebook at the beginning of the shift, to look for messages such as, "there is a thawed FFP in the refrigerator; original order was cancelled so this unit can be used for another patient if compatible." Good luck - you seem to be doing a great job!

[LCoronado]

Also I might add that we keep charts of suggested ABO group selections posted prominantly on the refrigerator and the freezer; they are color coded as a visual aid when a tech needs to make an informed decision on what type product to give.

Edited January 4, 2013 by LCoronado

[JEMarti]

Also I might add that we keep charts of suggested ABO group selections posted prominantly on the refrigerator and the freezer; they are color coded as a visual aid when a tech needs to make an informed decision on what type product to give.

Absolutely! I recall many years ago the night shift generalist getting an plasma order for a baby in the NICU. He thought, "babies in the NICU get O Neg, CMV Neg." Wouldn't you know that we happened to have a unit of FFP in the freezer that was O neg, labeled as CMV neg. The next day the baby had a 4+ DAT. People who are not blood bankers at heart sometimes have a real problem with plasma vs RBC ABO compatibility

Depending on who you see in your ER you may choose to put a caveat on the plt >20,000 requirement to not get called for patients with active bleeding.

[PAWHITTECAR]

The compatibility chart went up on the fridge the first week...they still have issues.

I looked back over 2 years and figure based on the past occurances I will get 8-10 calls a month. To me that is a small price to pay if I am able to "save" 1-2 units of FFP or Platelets from being wasted.

[carolyn swickard]

Just an additional suggestion - we have a dry-erase white board posted in our Blood Bank. All current notes (such as A FFP thawed (OK for O also)) go on this board for all shifts. Communications log good too, especially for pm and mifdnight shifts to leave you complex/ long problems/ notes. Compatible groups for FFP posted both on and IN freezer (on shelves). RBC and FFP compatible groups also backed up by computer program - best way if you have a Blood Bank computer - won't let you issue the wrong type. Good luck.

[goodchild]

Having a prominent white board in the work space is amazingly useful. Incentivize/Force people to look at it by keeping other important things there that they have to check, I.E. the work schedule is posted there with magnets.

[aafrin]

Also I might add that we keep charts of suggested ABO group selections posted prominantly on the refrigerator and the freezer; they are color coded as a visual aid when a tech needs to make an informed decision on what type product to give.

We also did that a few months ago and now I do not get many calls in the middle of the night.

@Trish, I think you are acting responsibly to guard the safety of your patients as well as covering the behinds of your techs. and keeping the hospital away from litigation. Everyone should be really be appreciative.

@ Marti. We had a similar problem. One evening around 9.0 pm we received a STAT order for 4 units of "O' Group FFP for a baby in PICU. They wanted FFP before sending patient's sample and consultant was very insistent with the tech. They were wheeling the baby to OT and wanted these units pronto. The tech on duty feeling pressurized even thawed O group FFP units. Just before issuing he called me to ask about on which group transfusion folder to write (we have group specific color coded transfusion folders on which we can issue 12 units total) and then.....:mad::mad:hell . I stopped the issue, asked him to thaw AB FFP immediately, and connect me to OT. I had to talk to 4 belligerent doctors (Resident Dr., Primary consultant, PICU Intensivist & anaesthetist), who passed me from one to another, explain ABO theory and why AB FFP. Most people and including doctors think O group is universal whether you are asking for red cells, plasma or platelets. :mad: