Brenda K Hutson

Yes....make your Transfusion Form a single copy Form and let Nursing audit their own process! Here is my experience (and 2 cents worth....as I am currently changing my protocol). I have worked at a number of places, and at most of them, the only Transfusion Slip that went with the unit was the one to be placed on the patient's chart. Also, most of this information is recorded in the computer by Nursing; so I think part of the non-compliance is that they feel they are duplicating their work. In the couple of places I have worked where we got a copy back: 1. We then became responsible for auditing them for completeness; and ultimately, responsible for the degree to which they completed (or did not complete) them 2. There were always problems with Forms being incomplete....and on top of that, constant complaining from Nursing that we were "always returning Forms to them." 3. So, we had a protocol for returning them to be completed....then documenting them on an Occurrence Form....then me trying to work with Managers to get their Nurses to complete them in the first place. While there was always some level of success, it was never a high enough percentage to make the Regulatory Agencies happy. And if we were not successful in getting Nursing to do it correctly, we (the Blood Bank) are the ones that would be held responsible by the regulatory agencies and be cited. If we do not get a Form back, there is no process to audit. Do we "want" to know that Nursing has documented all of the required information; that the transfusion was completed within 4 hours; etc. etc.?? Of course we do; because as Blood Bankers, we want things to be accurate and regulations to be followed. But given my experiences, I think this is another area where we are being asked to babysit Nursing in an effort to get them to do their job (as spelled out in their Policy). We have our Policies to follow in the Blood Bank as far as documentation. The details of a transfusion are the responsibility of the Transfusionist...and I say let "them" make sure they are doing "their" job. So, my current Form (which is a duplicate; and was so when I started here) is currently in the Print Shop and will come back as a single Form; to be compeleted by Nursing and to be placed on the patient's chart by Nursing. Signed, the rebel...... Brenda Hutson

I guess the answer to that would depend on what % of your patient population actually "required" Irradiated Products. For us, it is just not high enough to justify the extra cost (I think about $30/unit if we order them pre-Irradiated....but less for us to do it ourselves). The other problem is that you cannot bill a patient for Irradiated Products if their diagnosis does not warrant it. So what this means for me currently (while we have been giving 100% Irradiated) is that I have to manually reverse charges; either have the units all charge at Issue as non-Irradiated and reverse those patients who I can bill for Irradiation; or vice versa). This is very time-consuming. It was put into practice by my predecessor to make it easier...avoid any risk of giving a non-Irradiated unit to a patient who needed Irradiated. That safety net may be a nice thing to do and require less thinking on the part of the Physician and the Blood Bank staff, but I don't think that is a good enough reason to justify all of the issues; nor do I think it is the standard-of-practice to do so. Just my opinion though.... Brenda Hutson

I agree with Mabel that this is such a critical issue, that it is good for everyone to be involved. For us though, we do not get a printed requisition with a diagnosis; so it takes some sleuthing on the part of the Blood Bank Staff. There is an "admitting diagnosis" in the testing field of the current order....but as mentioned above, that can just be symptomatic (i.e. nausea). So it really involves my staff going into the Hospital computer system and looking at their diagnosis history. This is time-consuming; and they don't feel that responsibility should fall on them (if they can look up the history, why can't the Physician). So, I feel I have only 2 choices at this point: 1. Go back to 100% Irradiated (which I cannot rationalize given that the majority of our patient's do not require it and it is not the standard-of-practice to do so) 2. Continue to work with the Physicians on ordering appropriately. Fortunately, the CMO is very supportive of me so hopefully the process will improve over time (note: we just received our Irradiator so have not yet switched our Policy; but I have been auditing it for over a year to see what the problems would be). Brenda Hutson

We are dealing with this issue right now. My approach on things has always been that we do not take on responsibility that is not ours. That being said.....we are going from giving 100% Irradiated Products; to just giving Irradiated to those who fit the criteria (which are spelled out). This information was sent out to all Physicians over a year ago; and I audited the process. Unfortunately, there have been a number of issues resulting in improper orders. Chief among those are: 1. Hospitalists! In this day where they are using Hospitalists instead of a patient's Primary Care Physician (when Inpatients), they just are not going to know all of that patient's history. 2. As mentioned above...the diagnosis given to a patient upon admission, may just be symptomatic (i.e. anemia; nausea; etc.) and not their primary diagnosis. Because of that...and because of the risk of graft vs. host, I do have my staff looking at diagnosis and location. If the diagnosis is one that is on the list for patient's requiring Irradiated, then we add it to their requirements. I am continuing the audits (> 1 year later) because what I am also working towards, is continuing to educate the Physicians about our Policy change (that we are not giving 100% Irradiated)and to make them take responsibility for ordering appropriately. if we can look back at a patient's diagnosis history, then it seems the Physicians should do that also. Not sure "where this will land" in the end; but feel the need to put the patient first in this issue. Brenda Hutson

You are right Malcolm....a very nice and approachable man; and a huge loss to the Blood Banking community. Brenda Hutson

Had a couple of other thoughts last night.....has the patient received a lot of ABO Incompatible Platelets in a short period of time? One other thought....though may not apply; depending on how many units you tried to crossmatch. Was thinking of a cold reactive antibody that was present on the A1 cells but negative on your group O cells (though the chances of it just happenning to be present on the A1 cells and group A units you crossmatched; but not on the group O units you crossmatched; is probably a stretch). But was thinking of something like Anti-Lea?? That is all "my brain can think of" at this point. Brenda Hutson

We had a case like this recently. Turned out the patient had received IVIgG and there was a passive transfer of Anti-A (which we also eluted). Brenda Hutson

That is an interesting idea....one I had not heard of before. Brenda

I feel like I am always the rebel on this site(Ha Ha).... First of all, if this information is in the interface of your Hospital computer system, you do not "have" to call them. But that would be a battle you would have to fight with them. At my last place, the system they accessed to give them all of the other Lab resuls (i.e. CBC, Chemistry, etc.); also told them Unit#, Type of Product, Status (i.e. Issued, Ready, etc.). Fortunately I received the support of Nursing Management who agreed that just as they looked up other results, they could also look this up (after all.....what is the purpose of an interface?). The alternatives are either the Blood Bank spending a lot ot time calling (and possibly documenting such calls as you describe); or, Nursing calling every 5 minutes to ask if the blood was ready (which is what was happening.....and when we would ask them why they didn't check the computer, they said it was "easier for them to call"). No doubt it is "easier for them," but it was disruptive for us. So Nursing Management enforced that the Nurses had to look in the computer to see when blood was ready. We DID call STATS or actively bleeding patients; ER patients; etc. I think that is the "right" thing to do. Now I am at a Hospital that has the same Hospital computer system. However, my predecessor set it up such that we call everytime we have blood ready; and we have a Log that staff must complete (place for patient Name and MR#; Date/Time Called; What RN we spoke to; and our initials). That is "treating it" like a critical result; but to me, blood availability (with perhaps the exceptions listed above) is not a critical result. So that is now a battle I will need to try and reverse (just currently won the battle to stop having transfusion orders printing out in our dept.; another thing set up by my predecessor....but which Nursing then used to put the owness on us to check for transfusion orders.....so they tried to come after us recently when a Nurse transfused without an Order in the computer). That is also not our responsibility. Did tweak some of the Blood Bank forms they use (i.e. pick-up slip and Transfusion Tag) to add a space where the Nurse has to sign that she verified an Order to transfuse.....that was my assistance to them while giving the responsibility back to them. So I have to wait awhile to address the next battle. Sorry for the long response! Brenda Hutson, CLS(ASCP)SBB

Are you referring to the podcast "Kell Kills?" Did look at that and see that he took a lot of time to point out the correct nomenclature for the Kell Blood Group Antigens/Antibodies (and yes, I do cringe when I hear someone say Anti-Kell....however). And when I am teaching, I do go through this.....but the degree to which I try to get my staff to use the correct nomenclature, depends on the staff. When a Reference Lab Supervisor....yes, I expected them to call them by their correct names. When working at Hospitals where the staff was "Blood Bank" only, I at least "made an effort" to get them to use the correct nomenclature. But when working with Generalists (as I do now)....they are doing well to remember so many things in so many depts.; just to be able to get the work done, that I would seem foolish (and very pedantic) to keep harping on them about something like this. If they tell me they have an Anti-Kell (which they all do); I know what they are referring to and I leave it at that. Also from the podcast.....saw that he discussed the McCleod Phenotype. I was fortunate at 1 large Hospital I worked at, to see one of those. But what really stayed with me was that I was very impressed because it was the Pediatrician who had requested that we type the patient for all Kell System Antigens (the child had CGD). Brenda Hutson

Nope....where is it and/or what does it say? Brenda

I have tried in several Institutions to get the Techs. to say Anti-Big K or Anti-K1. I remember at one place that a Tech. yelled out to me in the Lab....Brenda, the patient just has an Anti-Kell. I said "WHAT" Antibody did you say they had? She then corrected herself and we all got a good laugh out of it. You are correct that Nurse draws are "scary....."fortunately, there aren't many of those here (and most of them have to be witnessed by a phlebotomist who then places the label on the tubes). The phlebotomists may not have the same regard for specimen integrity as a Tech. would....but they do have "scared into them," the repercussions of drawing the wrong patient or mislabeling a specimen when it comes to the Blood Bank.....and where I have worked, they are written up "big time" for that. Questions for you as you talk about your checks and balances: 1. Is the 2nd type you speak of; performed on the same specimen; or on a 2nd blood draw? Because if on the same specimen, that will not detect an error in the blood draw itself (as I am sure you know). It is that way here right now.....but after I finish my "current" project (new Irradiator); electronic crossmatch and a 2nd blood draw will be my next. I know the regulatory agencies have been moving towards that for years and I have worked places that do that. 2. The Blood Bank armband you speak of....is it just one of the typenex (or whichever brand)that is a manual process? Not saying that has "no" benefit; but unfortunately, most places where I have worked that use them (including my current one), do not use them 100% as intended (i.e. must be placed on every patient, at time of draw; while phlebotomist still in the presence of the patient)? Here, the armbands for pre-op patients are placed in a labeled envelope and placed on the patient when they come in for surgery. At another place I worked at, they would not place them on patients being drawn; not only for pre-op, but upcoming outpatient transfusions. Said the patients did not want to wear an armband around outside of the Hospital and they refused. To me, that is a "broken cycle" and is almost useless. Or does the patient have a locking Hospital band with a barcode on it which must be scanned for everything? And cool thing they were just starting to look at where I just came from.....palm scanning (no, not palm reading...that is for another Post). One of my Managers had that done in their ER. Thanks Brenda Nope....we're just being pedantic! Ha Ha Brenda

Have used Meditech, Sunquest, Cerner, HCLL.....of those: 1. Think Meditech may be great for Donor Facilities; but it is probably the most difficult system I have ever used in the Transfusion Service! 2. Love HCLL for the Blood Bank 3. Don't like Sunquest for the Blood Bank.....used in a lot of places because the "whole" Lab is on the same system; and it may be great for other depts.; but not my favorite for the Blood Bank. 4. Have not used Cerner Millineum so don't know about that.....original Cerner was fine. 5. Last place I worked used Softbank for the rest of the Lab and HCLL for Blood Bank. There was talk of switching Blood Bank to Softlab; but since didn't occur when I was there, I cannot comment on it (but would have fought to keep HCLL because I liked it so much). Very user-frienly in the Blood Bank environment; can almost "figure it out" without being taught. Brenda Hutson

I kind of "coined" a couple of bogus techniques when I worked at Stanford many years ago. 1. "Scorch and Vortex" Technique of Antibody ID (gets rid of all of those pesky antibodies) 2. "Increase the Antibody" Method of Antibody ID (i.e. if getting weak, questionable reactions that you think "might" be an Anti-XYZ.....just give blood that is XYZ Positive.....next time, the reactions should be clearer! All just joking....do not try this at home or in your Lab.....LOL And I agree with John Judd on that (except in rare instances....and in the right hands). If the cold is so strong that it is interferring with your crossmatches and you cannot obtain compatible ones....I much prefer the use of RESt absorbed plasma. Brenda Hutson

At least in your case, they noticed their error "before" transfusing. I have worked in places with OR Refrigerators where the patient was transfused with someone else's blood because the blood of "all of the OR patients for that day" was in the refrigerator (in their urgency, they grabbed the wrong unit; and that is the risk). Fortunately, the types were compatible. Brenda

Sorry, Cliff had to delete the articles I had posted in the Library because of the copyright (didn't know you couldn't share articles in that if someone wrote them and presented/shared them.....seems like they are open for public viewing; after all, the reason I had access to them is that they were first sent to me). Guess I don't understand those laws then..... If any of you would like a copy of articles regarding giving Group A Plasma (instead of AB) in emergencies; and/or giving Plasma vs. Vit K.....send me your e-mail address and I will share the information I have. Thanks, Brenda Hutson

Ok, "if" successful, I have posted 2 sections of articles in the Library. 1 (with 2 articles) related to appropriate use of FFP and Vit K. The other (with 5 articles) related to use of "potentially" incompatible (sp. group A) FFP/Plasma in emergency situations (due to decreased availability of AB FFP). Brenda Hutson

Malcolm may say I am being "pedantic" for this (I just love having a new word to use....thanks Malcolm)....but historically, I do not like using specimens from any other dept. Reasons: Possible contamination and the fact that my experience tells me that phlebotomists are much more conscientious when they know they are drawing a specimen for Blood Bank than other Lab Depts. (not to say they are sloppy in other areas....just that there is an increased fear element for the Blood Bank). That being said, I have "on rare occassion" resorted to doing it (i.e. if the Physician only wants a DAT and understands we are using the specimen Hematology used; or, if more specimen needed for ABID and cannot easily obtain it from patient....but would expect reactions to be consistent with work-up already started). Brenda Hutson

We do not perform Weak D testing on Prenatal Samples so not a ProVue issue for us. We only do that testing on Cord Specimens (which we do manually). Brenda Hutson

I do have a couple of articles on use of Vitamin K instead of FFP (which I have to tell you; is a thorn in my side where I work right now). They think the higher the INR, the more FFP they have to Order (but it is not a simple 1:1 ratio; so we waste FFP on these patients). If I can figure out how to add an attachment on this site (right now, I feel like I can barely post on the site); then I will send them out. Also.....I did not attend the last AABB but listened to a synopsis of one of the talks from an ARC Medical Director. Another recommendation being made (and if I recall correctly, this study was performed by Mayo Clinic and is already being done by them; as well as others).....was to use some Group A FFP in trauma situations before switching to group AB (or hopefully by then, you would have a type on the patient). The reasons (as I recall them) that they did not see significant problems were; 1. Most patients are group O or A anyway....so it would "statistically" be compatible with most patients 2. When you think about it, we cannot always give group specific specific platelets (though if you work somewhere that certain patient populations are using a lot of platelets, I have been taught to monitor the amount of incompatible platelets given....may have to pack them at some point). 3. There were no hemolytic reactions in their study (though there were other complications; but not necessarily to the FFP because remember, we are talking about critical patients). Group AB plasma use was decreased by 96.6%. 4. Their conclusion from the study: Use of Group A for emergency release plasma resulted in ABO-incompatible transfusions; however, this had little effect on clinical outcomes. At the talk I heard, they did not give a "magic #" of how many group A to give before you switched them to AB (if you did not yet have a blood type). I also have papers on this study...but again, will have to see if I can put them somewhere on the website..... Coincidentally, I have a meeting tomorrow with ER Physicians and Trauma Surgeons at my Institution to discuss our Uncrossmatched/ Massive Protocol. I briefly mentioned this at a previous ER meeting...but plan to present it again tomorrow when "all parties" are present. I am going to recommend that the first 2 units we give to these bleeding patients coming through the ER (w/o a type) is group A FFP. It just made a lot of sense to me. Brenda Hutson, CLS(ASCP)SBB

S/P Dry Bath/Block Heater Thermometers come in a smaller tube (a microcentrifuge tube) which makes it a little shorter (total is 125mm length). Also, it should be noted that not all heat blocks have digital read-outs so would need to document temps. daily (and I know of 1 occassions where a heat block was accidentally turned off at some point; one of the types that had that flip switch on the front) and the Tech. doing testing did not notice it. She called an Antibody Screen on an ER patient, Negative; but turned out they had an Anti-Fyb.....so not a bad "habit" to get into of looking at your thermometer (or digital reading) when placing something in the heat block. We also have a place on our Temperature Log to document that we move the thermometer 1 space to the right every day so we are making sure each well is working (may be over-kill but is not a difficult process; espeically if on yor Log). Brenda Hutson

Ok, so "now" you are being pedantic! LOL (would put a smiley face but still haven't figured out how to use this website; i.e. for replies). Ugh Brenda

I would perform a Fetal Screen vs. a KB. If the Fetal Screen is Negative....either the baby is Rh Negative (so doesn't really tell you whether their was a large bleed; but then this baby would not have needed the Rhogam anyway); or if the Baby is Weak D Positive, you would be looking for those Rosettes just as you would with an Rh POS baby. And of course if the Fetal Screen is Positive, then you would do the KB. Otherwise, the KB is a very time-consuming test. So I would just do the Fetal Screen and give the 1 vial if it is Negative....and if they really want to know (or it is your Policy to recommend this); then yes, you could ask that the baby be re-typed down the road. Brenda

Ah, but looking back at my post; I wrote "cells" not "Antigens;" so seems like more of a reflection of just interpeting the antigram in reviewing one's work (or me just being pedantic). Brenda