Brenda K Hutson

My apologies ahead of time for the length of this e-mail...... So we just had our first meeting to discuss the implementation. I think we came up with more issues (mostly created by ourselves) than we did solutions at this point (you know that saying; too many cooks in the kitchen; and some of them really belong in the bathroom....ok, I digress). First, let me add a comment based on what I have read in this Thread. There is mention of barcoded armbands. Currently, the Inpatients do have a Hospital armband on with a barcode reader (I am told it is the financial #; but other identifiers still visible on armband also). That is used by phlebotomy. Then the phlebotomy Manager decided to throw a 2nd wrench in the works; another barcode system that is used both in the BB, and on the Nursing Unit. I guess the most important purpose of this is making sure the unit belongs to that patient. Unfortunately though, it is not interfaced with our BB system! So we have to Issue in 2 systems! He chose this 2nd system because it is what the phlebotomists are using to identify patients against specimens. So now it is being extrapolated to identify units against patients. But that also means Nursing has to use 2 systems to process the unit they receive (but this barcode system eliminates the requirement for a 2nd Nurse to check). Problem is, Outpatients don't have that armband; so they get the red typenex armbands. So part of moving to a 2nd blood draw is to eliminate that red armband (and note, the Hospital will not give the Hospital armband to outpatients). So, we have our internal BB computer system doing checks; we have started this barcode reader system to double-issue; and now we are going to a 2nd blood draw. I say just bring the patient down to the BB, we will draw their blood, test it, then transfuse them right then and there!! THAT would be easier than all of this. I am totally onboard with added patient safety; but it seems to me we are going way overboard and perhaps doing some processes we don't need to (i.e. duplicating work). Thanks for listening; whining completed. Now on to my questions..... 1. Easy question 1st: does anyone charge for this 2nd blood type? Currently we perform 2 types on the same specimen and the 2nd type is a no-charge confirmation type. However, given that the regulatory agencies are moving towards this 2nd blood draw, just wondering if we can charge for it? 2. A couple of Institutions actually provide the tube to be used by phlebotomy or the Nurse; ensuring they are not "cheating" and sending another specimen that was drawn at the same time as the first; maybe just changing the time. I like that but the phlebotomy manager doesn't. He said that it would be his staff drawing most of those; that sending tubes to Nursing Units would just confuse things and possibly delay that 2nd draw; and that we should be "trusting" whoever draws the 2nd specimen to not play any games like that (well....maybe in a perfect world; but that is not the world I have worked in for 28 years and 6 Institutions). 3. Currently, the Test Results the BB enters go back through the Hospital I.S. and can be viewed by Nurses. 3 years ago after attending Nursing Management Meetings, I convinced them that the Nurses needed to look at blood availability in the Hospital I.S. system; not call us all day asking if blood is ready (is that not what interfacing is for??). And it worked! It will show the Unit #; the Product Type; Status of Ready, Issued or Transfused. So some in the meeting were saying that Nurses would have to look and see if the 2nd type was completed yet; before they sent for blood that said READY (so now READY will not necessarily mean READY). I DON'T THINK SO!! That is just asking for the calls to come in again. I say we need to have a mechanism that alerts the Nurses that we require a 2nd specimen on their patient, even though they may not be drawing it themselves. But then that brings up; how will they know when it has been completed and the blood is in the BB; so they don't call?? 4. So, need a simple system (if there is such a thing for this) that does not result in Nurse calls to the BB; or BB calls to the Nursing Units. Brenda Hutson, CLS(ASCP)SBB

But where I was coming from (in that Liz's remark was in response to mine) is a place that I have not seen too infrequently in my 28 years; errors in testing at reference labs (which are often used for prenatal testing). You could always ask the Physician about any unusual history the patient might have had; but barring that, you may very well be looking at either a mislabeled specimen, and/or erroneous testing. And when/if I say this to a Physician, it is not an emphatic statement; but rather 1 possibility based on my experience. Brenda Hutson

I guess we will have to "agree to disagree" on this one. Of course the first thing I would do in a situation like this (where a patient was told a different blood group elsewhere than what I was getting), is to ask for another specimen. If that one concurred with my results, I would be honest with the Physician; that sometimes erroneous test results are obtained (whether or not you mention "reference labs" or not is up to you). To err instead on the side of agreeing that blood types can change (which is certainly much less likely than the former and only under certain circumstances), to me, would only serve to confuse the Physician and/or patient. Your feedback just might make the Physician re-think where they send their prenatal work (though it could have been a specimen labeling error). Just my opinion... Brenda

I did not literally mean a regulation stating 30 mins. Even the Technical Manual references 30 mins (as an example). See 16th Edition, pg. 617. Specifically, it states (usually 30 minutes). I am not saying it should or should not be 30 mins.; rather just stating where I think a lof of us came up with that number in the first place. Brenda Hutson

Depends on "why" it was positive in GEL. Once you use it for awhile, you get a "feel" for what may appear to be due to rouleaux or a cold agglutinin. You can then confirm (or rule out) those with further tube testing. If those are interfering, you could use tube for that patient. Same for warm autos (if upon further testing for example, you clearly identify it is a warm auto; and it is weak enough to be negative in LISS; then you can use LISS for that patient). Sometimes we get scratchy reactions in the GEL Antibody Screen; then obtain a Negative GEL Panel. Just have to be careful when deciding whether it was just junk in the screen, vs. a Low Incidence. So it will become a combination of learning what reactions to be suspicious of in GEL, and having your own Institutional SOPs as far as approach to work-up and changes in potentiating media used. And that will result in > 1 possible approach. Not sure that all came out as intended....sorry. Brenda Hutson

We use tube testing for our blood types; just use GEL for the Antibody Screen and Antibody Identification (though have LISS and PeG available for Antibody ID when/if needed). I don't think it takes that long to set up an antibody screen in GEL; and it is certainly much easier to read and grade the reactions. Brenda

LOVE IT!! And I have pretty much used every method at this point. I worked in 1 large Medical Center that used automated Immucor Instrumentation (ABS 2000 at that time). They were looking then at just moving on to the Galileo. I had used GEL previous to that and felt this Institution was one that would really benefit from GEL. Just one of the really nice things about GEL is that it takes away that subjectivity of grading reactions among staff (well, not entirely; but almost). That was a problem in that Institution. I was surprised how far off the grading of reactions was (when they performed Tube Testing; which they did for STATs and Antibody ID). The Manager had already decided that they were going to get the Galileo (though she took several of us on trips to view both the Galileo and the ProVue). To make a long story short, they ended up getting the Provue. I actually transferred to another Hospital before that occurred but the Manager called me more than once to say how much everyone loved GEL and that she was glad I pushed for that. Truthfully, I have never known of anyone who used GEL, that did not love it. Brenda

You raise a lot of good point/ideas. Since I want to move towards taking temps. on returned unit using an Infrared Thermometer, I have no doubt I will also be wasting more units that I am currently with the 30 min. rule. So putting Antigen Negative Units in a cooler is not such a bad idea. But I also, like you (and I suspect most others) are frustrated when Nursing sends for a unit when they are not in fact, ready to begin the transfusion. Then after they have spent 35 mins. trying to start the IV, etc., they send the unit back. It is in their SOP to send for blood when they are prepared (pre-vitals; IV; patient consent form; infusion order from MD; etc) yet it continues to occur. In fact, we had a big meeting last week (Lab Management will Hospital Accounting/ Billing) regarding wasted units, and who should pay for them. Wish there was a way to charge the Nursing Units or Anesthesiologists! Maybe we could make a rule that if someone wastes a unit, they have to donate to replace it (Ha Ha; like that would fly). Brenda Hutson

I need to re-visit this issue of specimen labeling; specifically, what do you do if a complete name is a mandatory requirement for your specimens but the last name is so long, that all that prints out on the label is the last name! We had a patient recently who had 21 letters in the last name (long, hyphenated Indian name; had seen patient before with only part of that last name); and 6 letters to the first name. Though the entire name was captured in our Transfusion Service computer; and the Hospital LIS; the Lab System through which the phlebotomy orders are processed (and labels print out) had cut off part of the last name and part of the first name. When this came up previously, I stood my ground and stated that the phlebotomist could hand-write the missing part of the name (and note: the patient's armband had the complete name because that comes from the Hospital LIS system). There was also some discussion with the phlebotomy manager about having the text wrap around on long names so that it is all captured on the labels (but apparently that was never initiated). So can I just get some more feedback about what others do with these really long names when the Name is one of your 2 identifiers (and your SOP states you will only accept a complete Last,First Name)? Thanks, Brenda Hutson

You make a good point for Medical Director involvement in Nursing SOPs around transfusion. While I have seen the Nursing SOPs, and while I have written the Lab Transfusion Reaction SOP (with types of reactions; signs indicating them; etc), the truth of the matter is that unless we are told of a reaction, we have no way of knowing something occurred! And I have to say that in every Facility I have worked, there have been occassions where we have found out "after the fact" that a patient had a reaction that the Doctor decided was probably not due to the transfusion; and they therefore directed Nursing to NOT call a reaction. I appreciate your JCAHO reference. As we know, Nursing do not have to answer to the AABB, CAP, FDA (and that in fact, the Blood Banks often get cited for Nursing issues; but as an Institution, that usually assists the Lab in obtaining compliance from Nursing on the given issue); but they do have to answer to JCAHO. Brenda Hutson

Thank you; well said. Unfortunately, my current Hospital does not have a Transfusion Committee! That in itself is problematic to me. But I do have certain Reports I write that are seen by various depts. in the Hospital so that is my way of bringing up issues. But as with so many things, you really need a supportive Medical Director backing you up to accomplish much outside of the Lab. It sounds like you are very fortunate with the Team you have there. Brenda Hutson

Thank you for taking the time to provide all of that information; I will look at it. And I agree that the Lab cannot totally mandate the transfusion process used by Nursing. But that being said, the current process where I am at (check patient at 15 mins only) just seems way too out-of-line with patient safety for my comfort. And given that it has been my experience that Medical Directors are to be involved in transfusion policies, I do think it valid to be familiar with what your Institution does, and speak up if you have concerns. Brenda

If it were not for the fact that you lived in Ohio, I would think perhaps you worked at one of the places I worked previously in that your process sounds just like theirs. Thanks, that is what I am asking for; what intervals of documenting vitals are in-place at various Institutions. Brenda

I can post it on this website when I get time, but if you want to give me your e-mail, I can at least get it to you sooner! Thanks, Brenda

Thanks for sending that! I will definately use that in training. It also highlights the fact that while there are many places where something could go wrong (be missed; overlooked; presumed), we also have many opportunities prior to the time the blood is actually flowing through the IV and into the patient, to catch errors. But it means each person (representing each step above) must do their part and make NO assumptions about those that have gone before them. Brenda Hutson

I totally understand your point regarding "2 people checking the same info is not usually safer because each tends to assume the other was really paying attention." I have been training Techs and Lab Assistants for most of my career (a number of Facilities) and I always discuss with them what I call "Biased Blood Banking." That can take on many forms. I have taught that in my experience, the further down the road of a given process 1 is, the more they "assume" that surely any error would have been caught by now; so they are not as careful. I try to teach that every person; for whatever their part is in a process, should view it as if no one before them looked closely enough; that they must take the time to look carefully at everything. I also teach that in Antibody ID. For example, seeing a Positive Antibody Screen and upon looking at the antigram, deciding what they think it is. Or making an assumption that a positive screen is just due to the known historical antibody. Sometimes, unbelievable though it is, Techs will actually identify the antibody they expect to see; overlooking reactions they should not have. I teach that when I am performing antibody ID, I look at my reactions (GEL or Tube), decide what to grade them, then look at which cell it is and write the result on the panel. Then go back and do the same with every cell tested; not looking for a pattern while reading; not even looking at what cell # you are looking at until you decide what you will call it (just in case you decided ahead of time what it was and are expecting certain cells to be positive). So, to make a "short story long," I would also emphasize this in training phlebotomists, Nurses, and anesthesiologists about this 2nd blood draw. Doesn't ensure that your valid concern will not occur; but I can only do what I can do. Thanks for your input! Brenda Hutson

Are you stating that instead of having a 2nd blood draw (at a different time), you are just requiring that 2 different people be in the room to confirm patient identity for those patients with no history; and you then accept that 1 specimen as being accurate? Because I thought the premise of your post had to do with a 2nd, separate blood draw. I am not sure I would feel that having 2 people in the room at the same time, for 1 blood draw, will add that much more protection. But that is just me.... Brenda Hutson

This brings up an issue that is frustrating to me; not only at my current Hospital, but places I have worked previously. That is the issue of STAT Same-Day-OR orders (even when the patient is on the OR schedule). Rather than give OR an "easy" way to get 2 specimens on patients admitted the day of surgery, I would prefer to "try" to use this to enforce the request that the patient be drawn at least 24 hours prior to surgery (though we will extend specimens for up to 10 days on patients not pregnant and/or transfused in 3 mos). Brenda Hutson

I am reading this post right now in preparation for a meeting this afternoon regarding a 2nd blood draw. But I am also trying to figure out "how many different systems" one should have in place for safety. Currently, this is our armband system (very poor): Patients are given a white Hospital armband upon admission. Since they cannot get it until admission, all patients having blood drawn as an Outpatient (so either Pre-Op, or Outpatient Transfusions) are given a red typenex armband (I know; that is NOT using that band as intended; just one of my battles). But on top of that, we are a beta site for a barcode system in which we print barcode labels that are placed on the paperwork attached to blood products; we then have to Issue the products not only in our BB LIS, but in this 2nd system; then the Nurse uses this 2nd system to barcode the label on the paperwork against the patients's armband). It is crazy! So I am trying to see "how much is enough; and what is critical." The posting I responded to mentions getting rid of the armband once they have this system in place. My first thought was to use the 2nd blood draw and eliminate not only the red typenex armband, but perhaps the barcode system we are trying out (not yet FDA approved). Yet it seems that while the 2nd blood draw will help prevent the wrong patient from being drawn and/or specimens from being labeled with incorrect labels, I am thinking that this does not catch the problem of a unit being transfused to the incorrect patient. So there are 2 different critical issues: obtaining a correct specimen to be more assured that we have typed and screened the right patient, and, using the barcode system to ensure the blood we Issue is not transfused for any other patient. Anyone else out there with "combo" systems? Would be interested in hearing what others do? Thanks, Brenda Hutson

Yep to many of the posts. I used it for many years at one Institution (and hope to implement it here) and as EDibble noted; Once you do it for awhile, you will love it. The staff at my current Hospital know this is in my plans and they are very nervous. I think that is normal. It will just take time for them to see the safety of the system. Just wondering about your comment regarding looking at "past" records for your validation. I think you need to validate the electronic crossmatch function itself; not just look at past records of a system you know worked. For example, if you have an antibody patient and had to perform AHG crossmatches, just because your computer system noticed if you accidentally only performed an I.S. crossmatch instead of AHG, does not mean that if you tried to get away with an electronic crossmatch, that your computer would detect that and appropriately warn and/or forbid certain functions. But there probably are some things you could use from looking at previous records. Having not participated in the validation myself (yet), not sure what all we could obtain from past records vs. current records. Good luck; do not give up because people are nervous. It WILL be ok; and wonderful! Brenda Hutson

And that is part of where I am coming from; experience of the Lab being cited due to Nursing non-compliance for protocols that work very closely with the Lab (i.e. transfusions and transfusion reactions). And in every place I have worked, we performed periodic audits of the transfusion process on a patient to ensure all steps were following protocol (we actually follow a unit to the floor and document results on a checklist we carry with us). And I absolutely understand "picking one's battles." believe me, having worked at a number of Facilities where I have come in and had responsibility for the Transfusion Service, I have always had to pick my battles. And perhaps I should explain where this question even came from as you might be surprised. We are a beta site for a barcode system whereby we will be printing out barcode labels on the paperwork of blood products; then when we Issue them, we will scan that barcode; then on the Nursing unit, the Nurse will scan the barcode on the paperwork of units, against the armband. The Rep. for the company (whose past career is actually in High Tech.), was surprised to see (when up on a Nursing unit going through the process with them), that they only documented the vital signs at 15 mins (because they are documenting them in this hand-held monitor) and "his experience" was that the transfusions are monitored more frequently (i.e. hourly). And that is coming from a non-Blood Banker; or non-Technologist for that matter! To me, that says something. Brenda

I do appreciate where you are coming from John; I do not mean to dispute your experience and/or opinions. I just think our experiences have been different. When we audited those Forms in 1 place I worked, and found problems, the Nurses were absolutely held accountable! In part because our Medical Director had participated in coming up with the Nursing SOPs for monitoring Transfusions and looking for reactions; and in part because the FDA and AABB would actually look at our audits and at the very least, make suggestions regarding non-compliance from Nursing; and at the most, cite us for incomplete documentation by Nursing and/or not following their own protocol. And even though those were Inspections of the Transfusion Service, you better believe the head of Nursing was told to be present at the closing meetings and later held accountable (by the Lab and the Hospital) for following protocol. But that may largely go back to another issue that comes up occassionally in various threads; how involved and supportive is one's Medical Director with Hosptial Policy that involves Lab processes. Brenda

Our Nursing Dept. does have all of that information also. In fact, to meet a CAP requirement of annual review, I had the Nursing Educator here create a powerpoint presentation that is actually used as part of their annual review of Health and Safety processes (which here, is done by a computer program called Healthstream; they read the information, then have to take and pass a quiz). I think it was a really good powerpoint presentation; thorough. Also, I recently revised our Transfusion Reaction Form (big-time) with input from Nursing (and of course, our Hospital Forms Committee; which has Nurses on it). They were given additional information regarding Transfusion Reactions at that time. So I would not say that the "biggest" problem is not knowing what to look for. I would say that my concern at this point is the frequency at which they look for the symptoms. But yes, there is still the occassional Nurse (everywhere I have worked) that will call and ask us if they should initiate a transfusion reaction (even though the symptoms are clearly indicated in the protocol). We always tell them it is up to the Physician to make that call; but that they should use the protocol as a guide to making those decisions. But I can also say, there have been instances everywhere I have worked where a patient has clearly had the symptoms of a reaction, yet they did not call it (or they called us and told us about it a couple of days later; or the patient has a 2nd reaction at 1 point and they tell us that the patient had reacted the other time also, but they did not submit a reaction form; things like that). Thanks, Brenda

Well, not sure I totally agree with your premise that "the actual transfusion is generally not considered part of our world." But that may just be my bias. I say that because: 1. I cannot tell you how many times in my career a Nurse has called and told of vital signs a patient is having, wanting to know if that is a Transfusion Reaction (and asked if they should they call it). 2. One place I worked had the spaces for vital signs (at 15, 30, 1hr, etc) on the Transfusion Form. One copy of the Form always came back to the BB after transfusion. We would audit them to make sure vitals were taken at each interval; to make sure the transfusion took place within 4 hours of Issue; to make sure they noticed vital signs that could be a reaction; et al. We definitely came across problems in each of these areas. Nurses may be the ones who know how to give a patient products through the IV, but when it comes to some of the issues of blood compatibility/incompatibility and reactions for blood, they are not always that knowledgeable. I have given inservices and training to Nurses enough to know that some things they do with blood products are scary! That is also why we audit transfusions. There are any number of things that occur with blood products once they leave our possession, and I for one would like to know what they are. Brenda

It was just brought to my attention that Nursing in my current Hospital, only monitors trasfusions at the initial 15 mins. (and after the transfusion). I know for a fact that at other places I have worked, they "closely" watched the patient for the 1st 15 mins.; then took vitals every hour thereafter. In looking in the Technical Manual, AABB Standards, CAP Checklist, and Circular of Information, I only see a reference as described above. There are "vague" statements about monitoring throughout the tranfusion (such as the recommendation for periodic observations); but I do not find any place where monitoring after the 15 mins. is "mandated;" nor are there any specific time-frames mentioned. It clearly states that the Medical Director needs to be involved in those decisions so I am assuming this practice is acceptable to him. It is really not acceptable to me, but before I talk with him, I just want to see: 1. What are other places doing 2. Is there some regulatory requirement somewhere that I am just missing, regarding a required frequency? As always, THANKS in advance for your input! Brenda Hutson, CLS(ASCP)SBB