Brenda K Hutson

Do you ever place FFP in a cooler (i.e. for OR) with temp. monitors? That is our biggest area of wastage; OR asking for the FFP when they are not ready for it (guess they just want it right by the patient "in case"), then sending it back > 30 mins. Wondering if anyone sends them in coolers with temp. monitors. Thanks, Brenda

And that is the beauty of reagents like EGA or Chloroquine. They can pull the antibody off of the cells (unless it is a particularly strong one; then there is nothing you can do), thus allowing Testing with your coombs reactive Antisera. I used to believe in performing the work-ups on the patients, not just giving phenotypically matched. However, I can see why that will vary depending on your Institution. At the large Institutions I worked at, we had a LOT of work-ups; often complicated; and numerous warm autoantibodies. It was just not feasible to support those patients with phenotypically matched products. But where I am not, we have much fewer such patients and giving phenotypically matched is less expensive (not to mention time-consuming) than performing ongoing adsorptions on these patients. Brenda

You are correct; I think everyone likes to feel they are special! Thanks, Brenda

I know there have been numerous Posts discussing what happens when a unit leaves the Transfusion Service; i.e.: 1. How long do we each allow it to be out (not in a cooler) and still take it back? 2. How do we determine when something can come back (i.e. coolers; visual inspection of platelets; temp. monitors; etc). 3. How does the FDA categorize Shipping vs. Storage. So I am ok with my Facilitie's monitoring practices (and some changes I am considering) with relation to RBCs and Platelets. I would like to get a little more feedback though with regard to FFP. What do others do (i.e. do you have a time limit for return; do you use temp. monitors on plasma and put it in coolers for OR; etc). Thanks, Brenda Hutson, CLS(ASCP)SBB

So patient cards are a great idea; IF the patients understand and use them! Case in point. Working the MN shift once in a large Institution. ER took 2 uncrossmatched units. When Antibody Screen completed, it was positive. I immediately called ER and notified the MD. She said they were already transfusing the 2nd unit and the patient needed it. I asked her to try and get a history on the patient (she was a GI Bleed; but was coherent). Just as I finished the work-up (Anti-E and Anti-c) the MD called back. She said, "the patient said something about having an antibody card; would that help?!" Oh well, at least I matched the card! But I also recall at one Institution I worked at that sent cards (with letters attached, explaining what the cards meant and how they should be used), receiving many calls from concerned patients. All they had to do was see the word Antibody in relation to transfusion, and they started wondering if they had Aids! Sometimes it is difficult to help them understand in layman's terms, what the significance of the antibodies are and why we suggest carrying the card with them (which also freaks some of them out in that they think they will die when they are transfused unless they show that card; which could be true, but that would certainly be the exception). Brenda Hutson

I think that is a great idea and would definitely improve patient safety. I am just a little surprised in that I would think HIPAA would have issues with that?? You may not recall this now, but at one point I submitted a Thread regarding the fact that we had purchased a local Hospital previously owned by another group. So this other group had all of the patient histories. Now of course, the patients that went to the Hospital under the other group, were now going to go there under our Hospital affiliation. However, they refused to give us any Blood Bank records on those patients! I thought that was incredibly wrong but I believe they used HIPAA as the reason (which doesn't mean that is a correct interpretation of HIPAA requirements; but sometimes there are gray areas that result in differing opinions with relation to that). Anyway, that experience is what makes it surprising to me that something of that magnitude could ever be pulled off! Brenda Hutson

The usual minimum "practice" that I have always been familiar with is 24 hours. But I also am not aware of a specific regulation. Brenda Hutson

Ok, so here is the "scoop" from a conversation our QA Coordinator had with the FDA today. We were trying to clarify one of the points listed on the INSTRUCTIONS FOR COMPLETING BLOOD REGISTRATION FORM 2830. Specifically, it has a list of tasks that require one to be registered with the FDA. "Item 11; paragraph 2 (in part).PRODUCTS: Similarly, exclude products prepared under emergency conditions. We define an emergency as a situation that demands immediate action that has been suitably documented in writing by a responsible person." So, in my 4+ years at my current Institution, we have had only 1 Exchange Transfusion. According to this FDA Inspector, that would fall into the category of something performed under emergency conditions (keeping in mind not only that we are performing it extremely infrequently, but also that those procedures are almost always ordered as STATS). She said the only thing then we would need to add to our protocol would be to require the Physician to sign an Emergency Release Form. So some of you are probably asking; how infrequently (or vice versa, frequently) does one have to perform something for it to be considered "infrequent" and "emergent?" This FDA Inspector said to the QA Coordinator; "now if you find down the road that the frequency changes and you are performing them maybe every 6 months or once a year, she would recommend becoming registered with the FDA." So, there is some clarity on the subject; but at the same time, it is somewhat vague depending on frequently your Institution performs this task. This is the 6th Hospital of my career. All of the other Institutions where I worked were AABB accredited and FDA Registered. However, I was at one other Institution about the same size as my current one (about 400 beds). We also performed infrequent Exchange Transfusions. We were FDA Registered because we occassionally washed blood. But we did that so infrequently (maybe once a year) that I discontinued that process and we obtained them from our Donor Facility. Even though we still performed the infrequent Exchange Transfusion, we dropped our registration with the FDA w/o issue. All of the above are reasons that for me, I was shocked to hear that performing Exchange Transfusions required FDA Registration (because it was never an issue where I worked). Hope that helps... Brenda Hutson, CLS(ASCP)SBB

One other thing I just remembered. Crazy as it may seem, I find that you have to be very specific when asking the patient's Nurse to obtain the pregnancy and transfusion history on patients. You have to emphasize the words ALL and ANYWHERE! Otherwise, you may get a response from the Nurse that there is no documentation of transfusions on the chart; etc. I once called and asked the Nurse to find out the patient's pregnancy and transfusion history, and she replied, "Of course she isn't pregnant; she is 72 years old!" I wanted to say; Thanks for the news flash; now ask her if she has ever been pregnant!" And with that, if it is a patient that is unable to answer any questions (in coma; dementia; non-English speaking; etc), I can at least get the pregnancy issue answered by asking if the patient has any children. Of course that isn't 100% either; could be 1. Adopted children 2. And w/o being able to ask patient directly, you may not know that they have been pregnant, even though they have no children (and sometimes they are hesitant to say yes if they had an abortion at some point; we had that happen just the other day; you have to be very careful in how you ask about that). And finally, the history is only as good as the knowledge, coherence and honesty of the individual providing the information. But if you get an affirmative, that can definitely be helpful. Brenda

Ah, thanks for the clarification! Brenda

My apologies; I am a little confused on the point of your last paragraph? I understand that you require the patient's Physician to sign a Form for uncrossmatched blood. Just not sure how other testing (bacterial, etc) relates to that? Thanks, Brenda

So a few things come to mind in reading your protocol. 1. Ah yes, the old "sharing of the insurance card!" Don't you just love that?! If they only knew the risks they were taking. Not sure about other places, but every place I have worked, this occurs almost exclusively in Labor and Delivery. 2. When you give your Type Specific, I.S. XM "until screen is completed," I assume you still label that as uncrossmatched? 3. So I guess I see a difference in approach with the various plasma products (FFP, Cryo, Platelets). Every place I have worked, we always give type specific or type compatible FFP. In smaller places where patients don't tend to take a lot of platelets/ day, we can not always give them type specific; or even type compatible. In larger places where we have done things such as liver transplants or a very active Oncology Dept. (i.e. Bone Marrow Transplants), since patients can receive multiple platelets within a day, we actually had a little note on the Platelet Incubator indicating how many cc's of incompatible plasma a patient could receive within 24 hours, based on their age. Since I am currently in a smaller place (about 400 beds), we only stock around 5 platelets at a time; so they get what we have to give them. I have sometimes thought it odd that we will give incompatible plasma from platelets, but not from FFP. But I know that it is much more likely that we give multiple units of FFP, than it is for Platelets. With that in mind, I think I feel more comfortable having a blood type performed "at least" on the current admission. But for Platelets and Cryo, I will use historical types from previous admissions. Anyway, lots to think about. Thanks for sharing your processes! Brenda

Hmmm...so I wonder if I might give all of those choices on just 1 Generic Form; each with a box next to it where we could check exactly what we are providing (so the MD knows more specifically). Something to think about. Thanks, Brenda

I was just thinking about a work-up from this weekend and it brought to mind something I have found myself struggling to impress upon staff when starting a some new positions in my career. I received a call from one of my Techs. this past weekend, asking what else she needed to do. A bleeding patient had come into the ER and had taken 2 uncrossmatched O NEG RBCs. Turned out the patient had a Positive Antibody Screen. The Tech called the ER but both units had already been transfused. The patient ended up having an Anti-E and a positive autocontrol. As Murphys' Law would have it, 1 of the 2 O NEG was actually E POS! The Tech had tried to ask the Physician for a history, but they said he was in no shape to answer questions when he first arrived. I told her to do a DAT (came up positive with IgG). So I told her she needed to keep asking them to try and get a transfusion history; that while we would do an eluate, I was especially concerned about any antibodies that may no longer be demonstrable. She eventually found out that he had been transfused 20+ units at a local Hospital, this past May. So she called that Hospital. The Antibody Screen at that time had been Negative. There have been a few places I have worked where they never bothered to try and get a history on a patient. In fact, they would usually get frustrated with me when I would initiate some type of coversheet for all work-ups. It would include such things as: 1. Any previous Transfusions and/or Pregnancies? 2. Any transfusions/pregnancies in past 3 months? 3. If Transfused ever, where? When? How many? 4. Is patient aware of any antibodies? This happened to me many years ago; similar scenario; patient in ER taking 2 uncrossmatched; positive screen; called ER MD and asked for history; just as I was entering the Anti-E,c in the computer, the MD called back and said "the patient said something about having an antibody card; would that be helpful to you?" Yes, especially an hour ago! 5. Medications 6. et. al. The history of the patient is invaluable. It can tell you how to approach the work-up (i.e. are you possibly looking at a naturally occurring antibody). It can tell you whether you have to do an eluate (even if no history of transfusions and/or pregnancies, if it is a first time patient and appears to possibly be a warm auto, I will still do an elution). Also, if not transfused in 3 months and ends up with Warm Auto, I would try to perform a complete phenotype. And a huge risk for the patient is the possibility that previously identified antibodies elsewhere, have now gone below detectable levels; but it is critical nevertheless that you give Antigen Negative blood. I find that after a few months of seeing the benefits of getting a history (not to mention seeing the negative issues that can occur when you do not get a history and/or are unable to), they start complying. In fact, I would say that obtaining that history is the 2nd thing you should do once your screen comes up positive (the 1st would be to throw in a panel). But if as in this case, you gave uncrossmatched, the first would be to call the MD and let them know. Anyway, just thought I would share that experience in case some of you also have problems convincing staff to get a history. Brenda Hutson, CLS(ASCP)SBB

When you say the transfusion paperwork that accompanies the unit(s), do you mean the slip attached to the unit (that goes on the chart), or are you referring to some other form of paperwork? Brenda

Similar to what I am used to. Thanks, Brenda

Historically, in places I have worked, it has been 1 Form for each "pick-up." So if they initially ask for 2 uncrossmatched units, we send 1 form with that (listing the units). If they ask for additional units after that, a new form is sent with those units. The thought being just to cover ourselves and ensure the MD is taking responsibility for those units. But I am "open" to hearing what others do in that the Techs where I am now have always used the "1 Form fits all" philosophy. I try to not make unnecessary changes so investigate practices different from my own. Thanks, Brenda

Ok, so just want to make sure I hear what you are saying. If they Order uncrossmatched red blood cells, you would give them Type-Specific RBCs based on a historical type from the current admission; regardless of whether that specimen from the current admission is outdated? Not saying right or wrong; just clarifying. Thanks David! Brenda

Though the word crossmatched refers to Red Blood Cells, I actually want to ask a question with regard to all products. 1. For uncrossmatched, Type-Specific RBCs; do you use your same specimen frequency for requesting this product? And if your last specimen was 4 days old, would you give Type-Specific; or give O NEG (or POS) until you received a new, indated specimen? 2. What about FFP? Do you use the historical point? If not, with what frequency do you require a new specimen? And does that frequency depend on it being a continuing current admission vs a new admission? I think this one will be the most controversial. 3. What about Platelets and/or Cryoprecipitate? Will you accept historical types? Even if from a different admission? Thanks Brenda Hutson, CLS(ASCP)SBB

I realize we have discussed Emergency Release of blood products in other Threads; however, I did not see an answer to this question. With regard to the Form you send with the blood, requiring that the MD sign to indicate they are taking responsibility and understand the risks....etc. etc. Do you send one of those Forms each time they come for units; or, it is a "one time fits all?" So maybe they come for 2 units and you send the Form with those units; the Form is subsequently returned with the signature but now they want 2 more uncrossmatched. Do yo require them to sign a new Form; or do you accept the first one for an indefinite # of units? Thanks, Brenda Hutson

Oh, sorry; not so much referring to telling patients that! So I guess I missed that emphasis. I was referring to telling a Physician who is questioning (either because his records show otherwise, and/or because their patient tells them they are a different type) the results. Then it is up to the Physician what they want to tell the patient. If a patient did ask me directly, I would probably list all of the possibilities I can think of, without emphasizing any one. I do not want to mislead anyone; but at the same time, of course you need to be careful of giving a little bit of information to someone who may not know what to do with it. Brenda

I'm sorry, still laughing over one of your sentences; specifically, "can you get your medical director to really push for an interface!" Wouldn't that be special! Enough said... Brenda

That is 1 thing we are considering. However, since we currently perform an Immediate Spin Crossmatch (will eventually move to electronic XM), that is added time they will have to wait. And if we follow some of the protocol used in another place I worked, our 2nd specimen for patients going to surgery, was often when the Transporter came to pick up blood (the 1st specimen being drawn with Pre-Op Lab specimens). So, a lot to consider. Thanks, Brenda

I have heard of other places doing it as you described (and as I mentioned, may be what we change to); that is to give them the Red Cells and FFP separately. Not ideal but it is hardly worth becoming FDA Registered just to perform 1 exchange transfusion every 50 years (so to speak). Brenda

Sorry, we are still trying to clarify something with them. In the FDA Registration Form under Item 11, PRODUCTS: Exclude products prepared under emergency conditions. They define an emergency as a situation that demands immediate action that has been suitably documented in writing by a responsible person. Do not list products that are pooled or divided into pediatric aliquots. We would probably only perform an Exchange Transfusion once every 6 years or so! Babies born with problems at that level are usually transferred to our local Children's Hospital. And if it was known ahead of time (mom with positive antibody screen; antibodies identified; baby being monitored and perhaps even needing intrauterine transfusions), the pregnant woman would certainly have been referred to this local Hospital (which is connected to a large Medical Center where I used to work) for High Risk pregnancies. We are going to see if performing something that infrequently qualifies under this rule. If not, we will meet with NICU and discuss either giving them the 2 products separately (RBCs and FFP), or, letting them know they would have to transfer the baby to the Children's Hospital if they needed an Exchange Transfusion. Our QA Coordinator is trying to reach the FDA for this clarification and I will get back to all of you just as soon as he knows something. Brenda Hutson