maureen320 7 Posted November 4, 2015 Share Posted November 4, 2015 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 If the 30 minute rule is indeed outdated, I would like to suggest new verbiage but wanted to get a feel for what others have in their policies.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! Malcolm Needs 1 Link to post Share on other sites
Malcolm Needs ★ 4,921 Posted November 4, 2015 Share Posted November 4, 2015 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). AuntiS and John C. Staley 2 Link to post Share on other sites
David Saikin 1,439 Posted November 4, 2015 Share Posted November 4, 2015 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. John C. Staley 1 Link to post Share on other sites
tbostock 1,063 Posted November 4, 2015 Share Posted November 4, 2015 Ours says that the unit must be started as soon as possible after issue, and it must be complete w/in 4 hours of issue. John C. Staley, Dr. Pepper, David Saikin and 1 other 4 Link to post Share on other sites
goodchild 529 Posted November 5, 2015 Share Posted November 5, 2015 (edited) 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 November 5, 2015 by goodchild Link to post Share on other sites
AuntiS 82 Posted November 5, 2015 Share Posted November 5, 2015 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 Link to post Share on other sites
BankerGirl 214 Posted November 5, 2015 Share Posted November 5, 2015 Ours is the same as Terri's. Link to post Share on other sites
L106 271 Posted November 5, 2015 Share Posted November 5, 2015 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. Link to post Share on other sites
LaurelMae 2 Posted November 5, 2015 Share Posted November 5, 2015 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). Link to post Share on other sites
goodchild 529 Posted November 5, 2015 Share Posted November 5, 2015 Can someone point me towards the regulation that says it must be transfused within four hours from leaving the blood bank? The circular of information only indicates "transfusion must complete within 4 hours." Link to post Share on other sites
LaurelMae 2 Posted November 5, 2015 Share Posted November 5, 2015 The Circular states "It is undesirable for components that contain red cells to remain at room temperature longer than 4 hours". If you are using a validated cooler to transport the blood then it would be from the time it is spiked. www.aabb.org/tm/coi/documents/coi113.pdf David Saikin 1 Link to post Share on other sites
LaurelMae 2 Posted November 5, 2015 Share Posted November 5, 2015 Sorry about the bad link. I am having difficulty pasting here. It is on page 9 in the circular. Link to post Share on other sites
mollyredone 318 Posted November 7, 2015 Share Posted November 7, 2015 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? Link to post Share on other sites
Dr. Pepper 912 Posted November 9, 2015 Share Posted November 9, 2015 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. Sandy L 1 Link to post Share on other sites
LaurelMae 2 Posted November 9, 2015 Share Posted November 9, 2015 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. Link to post Share on other sites
David Saikin 1,439 Posted November 9, 2015 Share Posted November 9, 2015 (edited) 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 November 9, 2015 by David Saikin tbostock, LaurelMae, Malcolm Needs and 4 others 7 Link to post Share on other sites
tbostock 1,063 Posted November 10, 2015 Share Posted November 10, 2015 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. David Saikin and Malcolm Needs 2 Link to post Share on other sites
amym1586 118 Posted December 15, 2015 Share Posted December 15, 2015 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? Link to post Share on other sites
seraph44 20 Posted December 15, 2015 Share Posted December 15, 2015 We practice the 4 hour rule from the time of issue, but my previous experience and the circular of information state it should be 4 hours from the time the unit is spiked. amym1586 1 Link to post Share on other sites
amym1586 118 Posted December 15, 2015 Share Posted December 15, 2015 Is there a reasonable time limit with plasma as well ? I'm constantly getting asked if they can issue more than one unit of plasma at a time. I always went by well if you get it started in the 30 minute rule I don't care how many you get. Link to post Share on other sites
tbostock 1,063 Posted December 18, 2015 Share Posted December 18, 2015 We only allow 2 units of anything at once if: Massive bleed and using a rapid infuser. Actively bleeding with two IV sites to give units simultaneously. Otherwise, give one and let us know when you need the second. AMcCord, amym1586 and seraph44 3 Link to post Share on other sites
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