4 hour rule

[Mabel Adams]

But various inspectors say that a transfusion starts when the blood reaches the patient's vein (for timing of vitals anyway). So we have a start time for the sake of the filter that would start when the red stuff reaches the filter, another start time for the blood reaching the patient's vein, plus the time since issue. Whew. At least the first two should be within a minute or two of each other.

[janet]

What about a unit that is started but IV site lost just before it reaches patient .... so filter and tubing are full of blood - still okay if given within 4 hours or would you worry that the stagnant blood in the tubing and filter might have bacteria proliferate??

[Mabel Adams]

I don't think the blood sitting there stagnant would change its ability to grow bacteria significantly and we allow a transfusion (with blood flowing) to take 4 hours. The tubing is sterile so shouldn't be much different than the spiked bag sitting there waiting for them to get a good IV going. I assume they cover the end of the tubing with a sterile cap while they mess with the IV?

[James Smith]

Hi

The options are to return it to blood bank and store until good iv gained, then re-issue or give blood with a delay but stick to stopping transfusion at 4 hours since issue from lab even if not all given...Jamie

[L106]

Hi

The options are to return it to blood bank and store until good iv gained, then re-issue or give blood with a delay but stick to stopping transfusion at 4 hours since issue from lab even if not all given...Jamie

I think this was recently discussed on this site. Many of us have a policy that if the donor unit has been spiked, we will not accept it back into the Blood Bank (for further storage or reissue.) If the unit has been spiked we allow the nursing unit to keep the donor unit while they try to regain a good IV site.

If they cannot regain a good IV site, they should return the donor unit to the Blood Bank to be destroyed (and we document the proper disposition in the computer.) If the can get the IV restarted, it is our policy that they may restart the transfusion, but it must be completed within 4 hours from the time the donor unit was issued from the Blood Bank.

Donna

[tbostock]

So in other words, once it leaves your dept., they have "bought it." No Returns, if I read you correctly? Brenda

Correct, we only allow returns now if the physician has cancelled the transfuse order, or if the patient expires. Otherwise they keep the unit up there and have the 4 hours to get it in.

[kirkaw]

Here is a situation that we had last week:

A nurse came to get a unit of blood. 40 min. later, she brought the unit back saying they had a problem with the IV. I was prepared to discard the unit since it had been out >30 minutes but my coworker told the nurse that if they could get the IV started correctly AND could get the unit infused within 4 hours of the original time of issue, that they could take it back. I would've thrown the unit away.

Based on your policy, what would you have done?

[SMILLER]

Like some others have said on this thread, we require that all transfusions begin within 30 minutes from issue, so we would discard a unit returned after 40 minutes if we knew it was at room temp for that amount of time.

Scott

[Malcolm Needs ☆]

Agreed Scott. The other thing is, if you are prepared to break one rule, how many others are you prepared to break? One day you may break a rule that should NEVER be broken, and the patient may die.

[AMcCord]

Our policy says ... If a unit was returned after 40 minutes because of an IV problem, we would ask if they thought they could get the IV restarted. If the answer is "Yes", then we send them back upstairs with the blood and tell them they have 4 hours from the time of checkout to infuse the unit. If it is not completely infused at the end of 4 hours, then they stop it, not matter how much blood remains in the bag. If they don't think they can get the IV started or if they have some other reason to think that they can't start the infusion and want to return the blood, then we discard it. After 40 minutes, the temp of the unit would certainly be above 10 C (we check temps on returns), so it would not be suitable for restock. (If the bag had been spiked, same story - infuse in 4 hours or we discard.) 40 minutes at RT trying to start the IV does not make the unit unsafe/unsuitable to transfuse as long as the 4 hour rule is followed, but it does make it unacceptable for return.

We require that all infusions start within 15 minutes of checkout. This timing was put into nursing SOP at my request to 'encourage' them to be ready to go - IV in good shape, recent vitals, consent, Dr. order checked, etc - before they come down to check out the product. We waste almost no product (outside of ER, Surg) as a result. We don't make discard decisions based solely on time, the temp when the unit is returned is the most important. This situation would be a deviation from SOP, with the appropriate report completed.

Honestly, if the unit has been out 15 minutes, it's hard to get them back with a temp < 10 C. I recently reviewed 300+ infusions and only a handful were started more than 1 or 2 minutes over 15. I credit nursing education with doing an excellent job impressing upon staff the importance of the policy.

[Eagle Eye]

Same here. We take temperature of each returned unit so the temp. would be >10 C and we discard it and then send a report for wasted unit.

[EDibble]

I agree with AMcCord. Just how we do it here.

[James Smith]

Yes that is interesting. I would have done the same as your colleague. The patient must be given the transfusion within the 4 hours and of course the unit would be at RT the whole transfusion so this works assuming the unit can be given in the remaining time. So spend an hour fixing the iv leaves 3 hours to get the unit in. Re-stocking a unit must be for the safety of all recipients. If putting blood back in the fridge puts another patient at risk later on then re-stocking the unit should not be done. Do you measure the temperature of the unit before re-stocking? This to me is a better indicator of safety and we discard units if temp is >10C degrees regardless of time out...Jamie

[Deny Morlino]

As long as the transfusion is completed, or the remainder of the unit discarded within the 4 hour mark the unit may be used according to our processes.

When a unit is returned the temperature of the unit is determined to decide if a unit is acceptable for restock. The time out of lab has no bearing on this process.

[aafrin]

Agreed Scott. The other thing is, if you are prepared to break one rule, how many others are you prepared to break? One day you may break a rule that should NEVER be broken, and the patient may die.

Couldn't agree more, Malcolm. Never test waters when life is at stake.

[Mabel Adams]

What if you have a policy that blood shouldn't be taken from OR to the floor with the patient after surgery. Then they want to bring back a unit that was issued to OR that is above 10 C. If not for the movement of the patient from OR, we would tell them to keep it and get it in within 4 hrs. I guess I have answered my own question using Malcolm's logic. If we have to break one rule to give the unit, then it should be discarded.

[SMILLER]

Once more on the ethical strand of this thread:

Sometimes rules are really bad. By that I mean they may be intended to save time and money, but put the patient at risk. In these cases, rules MUST be broken. Of course, the responsable person would do everything they can to have the rules reviewed and changed appropriately, but once in a while the stupidity of a particular policy becomes apparent unexpectedly, and one must act.

Thankfully, in healthcare, these instances are extremely rare. Part of the reason I like doing what I am doing.

Scott

[Brenda K Hutson]

Unless it is sent to OR in a monitored cooler with temperature indicators on the unit. Then we would say it needs to come back within the cooloer validated time-frame, and, the temperature monitor must still be acceptable. I have seen people send blood in a cooler without temp. monitors; then when it is returned, they take it out of the cooler and say "yep, it is cool; we can take it back." Well, that says nothing about what conditions the unit may have been in for the 3 hours the OR had the cooler (could have sat out for 2 hours, then been placed back in cooler).

Brenda Hutson

What if you have a policy that blood shouldn't be taken from OR to the floor with the patient after surgery. Then they want to bring back a unit that was issued to OR that is above 10 C. If not for the movement of the patient from OR, we would tell them to keep it and get it in within 4 hrs. I guess I have answered my own question using Malcolm's logic. If we have to break one rule to give the unit, then it should be discarded.

[pdameron]

Normal practice is to shorten an outdate for a product that was entered in an open system to:

          4 hours if it is to be stored at room temp (ex. reduced volume platelets, pooled platelets)

          24 hours if it is to be stored at refrigerated temps (ex. RBC aliquots)

 

It's been this way since I began my career 28 years ago.