Intra and perioperative blood transfusion

[R1R2]

Hi everyone,

How do you answer the following if this service is contracted out and not part of the hospital or blood bank? Thanks for your replies.

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[TD]TRM.41525

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[TD=width: 481, bgcolor: transparent]Perioperative Blood Program

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[TD=width: 95, bgcolor: transparent]Phase II

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[TD=width: 575, bgcolor: transparent, colspan: 2]The authority, responsibility, and accountability of the perioperative blood recovery and reinfusion program is defined.

Evidence of Compliance:

✓ Memorandum or policy describing the program

REFERENCES

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[TD]1)

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[TD=width: 639, bgcolor: transparent]Stowell CP, et al. Guidelines for blood recovery and reinfusion in Surgery and trauma. Committee on Autologous Transfusion. Bethesda, MD: American Association of Blood Banks, 1997

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[TD]TRM.41550

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[TD=width: 481, bgcolor: transparent]Intraoperative/Perioperative Safety and Efficacy

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[TD=width: 95, bgcolor: transparent]Phase II

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[TD=width: 575, bgcolor: transparent, colspan: 2]The procedures for intraoperative and perioperative blood recovery ensure the safety and efficacy of the recovered blood components.

REFERENCES

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[TD]1)

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[TD=width: 639, bgcolor: transparent]Yawn DH. Ensuring quality during intraoperative blood salvage. Lab Med. 1994;25:626-631

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[TD]TRM.41600

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[TD=width: 481, bgcolor: transparent]Medical Director Involvement

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[TD=width: 95, bgcolor: transparent]Phase II

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[TD=width: 575, bgcolor: transparent, colspan: 2]The transfusion service medical director is involved in establishing policies and procedures related to intra- and perioperative collection and reinfusion procedures.

NOTE: The intra- and perioperative collection and reinfusion procedures are part of the transfusion medicine procedures. The transfusion service medical director must be aware of, and participate in, the development of policies and procedures to help the institution ensure efficacy and patient safety.

Evidence of Compliance:

✓ Written policy defining responsibilities of transfusion service medical director

REFERENCES

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[TD]1)

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[TD=width: 639, bgcolor: transparent]Yawn DH. Ensuring quality during intraoperative blood salvage. Lab Med. 1994;25:626-631

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[Eagle Eye]

Check with CAP. as far as I remember, your MD is not responsible if you outsource it. I would keep a copy of their policy & contract available.

[tbostock]

I was cited for this by CAP years ago, even though we outsourced it. I made a brief SOP explaining who we use, that the Med Director is responsible, etc. Then when the contracted company sent me their updated SOP, I gave it to the Medical Director with a cover page that I made up that he "reviewed" their SOP and approved it.

[cthherbal ☆]

We also require QC records and competency records of "outsourced" cell salvage personnel. We keep the competency records on file and review the QC Quarterly at our Transfusion Committee meeting. My understanding is even though it's contracted out, there should still be a policy defining the process and the Med Dir of the hospital Transfusion Service is involved with that policy development.

[goodchild]

We do the exact same thing as Terri. We actually had a meeting with the blood salvage rep two weeks ago which I found very illuminating.

[Mabel Adams]

Are you including contractors that make plt rich plasma in Surgery also? The AABB Standards for Perioperative Blood .... Transfusion (don't quote me on that title) includes PRP in its list of autologous products that fall under these standards.

[adiescast]

When ours was outsourced (it has come back in house now), the medical director reviewed the SOPs before implementation and annually and all QC performed. We had a company representative report their QA data at the quarterly transfusion committee meetings.