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Transfusion Start Time Requirement


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Hello everyone,

 

We have a hospital policy that states transfusions must be started within 30 minutes of receipt from the Blood Bank. 

 

I've read the posts about the 30 minute rule here but my question to all is this:  what do your nursing/hospital policies say about transfusion start time?  If you have a specific statement like mine, do you monitor compliance?

 

In my opinion, if the transfusion start time is delayed (> 30 minutes in my case) and the entire transfusion event was completed within 4 hours, I do not see an issue other than non-compliance with our SOP (non compliance with SOP is something I would monitor).  If the 30 minute rule is indeed outdated, I would like to suggest new verbiage but wanted to get a feel for what others have in their policies.

 

Thanks!

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I agree.  In the UK the 30 minute rule applies to the return of the unit to the laboratory, but not to the time before hanging, as long as the transfusion is completed within four hours of the unit leaving the laboratory (or other controlled environment, such as the blood fridge in the operating theatre, if your hospital happens to have such a thing).

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I get the impression we're an outlier on this detail. We start our 4 hour timer from the time the bag is spiked, not from time of issue. Oh but yeah our policy says it should be started as soon as possible and to coordinate return to the blood bank if it will be a >20 minute delay.

Edited by goodchild
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Ours says something similar - to start transfusion within 30 minutes of pickup from TM.  And complete within 4 hours.  If they call and say there was a problem with the IV and they haven't started it yet, we always tell them they can keep the blood as long as it is complete within the 4 hours from the pickup.

 

That being said... it specifically states that everything should be in place and ready to go BEFORE they pick up the blood, so there shouldn't be a delay :)

s

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I agree also - a start time should be a guideline.  If you do have one it would be an interesting monitor just to see what you get.  The more important thing is that the transfusion is not more than 4 hrs. from release.

 

Same here.

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We were just cited by CAP for this very thing.  Our Hospital administration policy states that the blood is to be hung 30 minutes after leaving the BB and transfused within 4 hours from leaving the blood bank.  We are now revising the policy to state the blood must be hung as soon as possible and transfused within four hours from leaving the Blood Bank (we do not use coolers).

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We were just cited by CAP for this very thing.  Our Hospital administration policy states that the blood is to be hung 30 minutes after leaving the BB and transfused within 4 hours from leaving the blood bank.  We are now revising the policy to state the blood must be hung as soon as possible and transfused within four hours from leaving the Blood Bank (we do not use coolers).

What was the checklist item for this citation?

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For what it's worth I was told by an AABB assessor that there is not any experimental data that shows the blood turns poisonous after 4 hours, but that it it was just a "sounds reasonable" thing, that you should be able to get a unit into a patient in 4 hours and that there's an increasing chance of bad things happening to the blood as time drags on after that.

 

I would guess the CAP citation is the one about staff being knowlegable (i.e. following) about procedures. If your P&P says everyone should be wearing red clown noses, you'd better be doing it when they come.

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The citation was exactly what Dr Pepper says.  The checklist item was TRM.41000  Transfusion Protocol.  And just to keep you updated we will not be changing our policy, it was shot down by the Nursing Quality Director because Lippincott Nursing standards state the Blood must be hung within 30 minutes.  This makes no sense to me.  If you have up to four hours to infuse then what is the difference in what time it starts.  Of course Nursing trumps Lab again.  No disrespect to Nurses.

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The citation was exactly what Dr Pepper says.  The checklist item was TRM.41000  Transfusion Protocol.  And just to keep you updated we will not be changing our policy, it was shot down by the Nursing Quality Director because Lippincott Nursing standards state the Blood must be hung within 30 minutes.  This makes no sense to me.  If you have up to four hours to infuse then what is the difference in what time it starts.  Of course Nursing trumps Lab again.  No disrespect to Nurses.

We dealt with the Lippincott premade policies by having the BB Medical Director state succinctly what he wanted in the transfusion protocol. THERE CAN BE NO ARGUING when that happens. The Medical Director's final decisions in the Blood Bank (and the Lab in general) are sacrosanct/CLIA. I had a new MD and had to convince him that his word was the law. He finally saw the light. Granted, there has to be good reasoning behind decisions but there can be no ifs, ands, or buts when the Director sets policy.

Just hope you don't have a "good ol' boy" as a director - I've been there. Been chewed out for not trusting the hematologist's lab results for plt cts. Fortunately we always drew our own before transfusing. Hematologist got 25k, we got 225k, even on repeat. Turns out the Hemo's lab set up their coulter and ran it - no calibration, no controls . . . gotta love it.

Edited by David Saikin
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We dealt with the Lippincott premade policies by having the BB Medical Director state succinctly what he wanted in the transfusion protocol. THERE CAN BE NO ARGUING when that happens. The Medical Director's final decisions in the Blood Bank (and the Lab in general) are sacrosanct/CLIA. I had a new MD and had to convince him that his word was the law. He finally saw the light. Granted, there has to be good reasoning behind decisions but there can be no ifs, ands, or buts when the Director sets policy.

Just hope you don't have a "good ol' boy" as a director - I've been there. Been chewed out for not trusting the hematologist's lab results for plt cts. Fortunately we always drew our own before transfusing. Hematologist got 25k, we got 225k, even on repeat. Turns out the Hemo's lab set up their coulter and ran it - no calibration, no controls . . . gotta love it.

Yes, we always draw our own before transfusing.  Office lab said they had a 7 Hgb, ours was 11.5.  So we didn't transfuse him; I spoke to the office and asked if their QC was in and they said "what's that?".  Needless to say we got a call later that day saying that their machine was "down" until it could be fixed and could they send us their CBCs.

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  • 1 month later...

I've just noticed we don't write an issue time on the blood tag at my new hospital.   I don't know how they are monitoring that the transfusion is started in a timely manner or if it's finished in 4 hours.     I am not in charge of monitoring this info here.

 

Also, If you are issuing products in a cooler/refrigerator are they supposed to write in a time removed and then a time started?  

 

 

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