Brenda K Hutson

I have an important question that I need responses to ASAP (due to a battle with our Nursing Dept.). My predecessor instituted having Transfusion Orders from the Hospital computer system, print out in the Blood Bank. She did it because 1 time a Nurse transfused when there was no Order on the chart to transfuse.....so decided we would become the "check" for them. I have never done this anywhere else I have worked (5 places); and certainly don't think it is the responsibility of the Blood Bank to police whether or not Nursing follows their protocol (because when/where does it end....should I take each unit to the floor to make sure they do all of their checks and hang the blood appropriately and document everything?). I had made it clear to Nursing here when I came a couple of years ago, that when time allowed, I was going to discontinue that printing out. Then a couple of weeks ago, another Nurse transfused without an order to transfuse (actually, she said the doctor verbally told her to transfuse; and the order was "later" entered in the computer). So now Nursing wants us to continue to receive this Form so we don't hand out any blood unless we have an Order to transfuse. Would love to hear what the rest of you do (hoping to back my position....because unfortunately, in the state I moved to, many of the Hospitals "do" look at the Transfusion Order for exactly that reason). Thanks so much! Brenda Hutson, CLS(ASCP)SBB

I have tried that many times in various places...but oddly, just as with many other aspects of Blood Banking, they don't seem to see the issue as being as critical as we do in the Blood Bank (don't understand possible patient ramifications). Like where I work now; that they must have 3 identifiers that match "exactly" in order to link a patient. I am sure that in their mind, that is their way of being extra diligent. However, if no one ever made clerical errors, this wouldn't be an issue in the first place. Brenda

We receive a Report of Expired Patients from our IT Department. But unfortunately, I think it is a fairly current list (in other words, they do not know if some patient that was in our Hospital 3 years ago, has expired). Brenda Hutson

First, that is not the Blood Bank's responsibility; it is Nursing's responsibility. Where I am at currently, my predecessor set it up so that a Transfusion Order prints out in the Blood Bank. I am planning to "cease and dissist" with that practice. What you do need is the Name of the Physician who ordered the Transfusion/Infusion (vs. Crossmatch; and it may be the same MD, or it may be a different one). One way to accomplish that (and what I am going to change us to here) is to have a place on your Blood Bank Pick-Up Slip for "Physician ordering Infusion." That then will also serve as a reminder to Nursing that they need this. Brenda Hutson

If the Last Name has changed, you are at the mercy of Registration. You can only hope that in their discussion with the patient, the patient told them that they had been there before, but under a diferent name; so that they find the "correct" previous MR#. Brenda Hutson

Checking your computer by entering the MR# only, will not catch these registration errors. If there "was" no error and that is the only MR# for that patient, then fine; you can look at their historical blood type and antibodies. But that would negate the reason for this post.... Brenda Hutson

Ah, one of my favorite topics (and a process I have had to change at various Institutions I have worked at; also something I cited a Hospital on that we inspected this year because their idea of fulfilling the requirement to search for a historical blood type and antibodies was to enter the MR# and see if the patient came up......and in my mind, that is an accident just waiting to happen). First, I can tell you that having worked at a number of Institutions in my career, this is (unfortunately), a common problem with Registration. I think it has to do with how they look up patient histories. For example, where I currently work, they must find 3 unique identifiers that ALL match in order to link a patient to that name/number in the computer. Another issue might be the kind of identification the Registration Dept. in any Hospital, requires to register a patient. Here is "what" I do and "why:" First, Search by LAST NAME only. If you put in even a First Initial, you have already limited your Search and may miss what you can find by Step 2 below. Depending on how common the Last Name is, it may take awhile to bring up all of the patients; but "patience" is the key. Then scroll down until you find the patient(s) with the First Name you are looking for. Look to see if there are 2 or more patients with the same First and Last Name and maybe a Date-of-Birth is just off by 1 number (could have been a clerical error at entry). Or maybe a patient where 1 letter of the First Name is different. If I find that, I go into the Hospital system and look at things like SS# or Address to see if it looks like it "might" be the same patient. Then I notify Registration that there may be a patient with a Duplicate MR#. You can also see if you have the "other" patient in your Blood Bank computer system (maybe you have blood types or antibodies on both of these patients and can either determine immediately that they are in fact 2 different patients, or, that they may be the same). Going back to the beginning of Step 1 above where you typed in LAST NAME only....after you look at the name just before and after the First Name of your patient, I then sort the Date-of-Birth field. That will catch patients with interchangeable names (i.e. Robert and Bob; Rebecca and Becky; etc.; there are plenty of them). So you see that if you used even the First Letter of the patient's First Name in step 1 above, you would not catch this problem (and it does occur; 1 time the patient comes in and says their name is Robert and the next time they say their name is Bob; and again, just depends on how your Registration Dept. looks up patients). So when you sort the DOB; if you find >1 patient with the same DOB, see if the names might fit this category. Another thing to look for here would be a middle initial; so maybe they came in as John F. Smith 1 time; then Frank (middle name) Smith the next.Just some thoughts based on problems that I have seen at other Institutions. Brenda Hutson, CLS(ASCP)SBB

And again, my apologies for not spending more time on this website (would really love to). Just the challenges of getting ready to move into a new Hospital, plus some family illness has kept me busy. But I am very grateful for all of your input. I know the day will come when I can spend more time on the site.... Brenda Hutson

I have tried making new Wash Solution; and have also changed the centrifuge used for the final centrifugation step to one that spins harder and longer (but only do it once; maybe we will spin X2 as goodchild suggested). Can also try a different water source for Wash Solution. Rravkin...reactions often have a mixed-field appearance but sometimes have some cells dispersed throughout cell; and sometimes hemolysis at top). We only wash X1 with Saline (as per Manufacturer's Instructions; though can't see how it would hurt to wash more). What is odd is the inconsistency. Sometimes we get perfect results; other times we have this problem. And I have been doing Direct Observations on staff preparing and testing the eluate and see no differences. So our current approach is to first have them Test the Eluate with just a GEL Antibody Screen; then if they get this type of reactivity, I have them repeat it in Tube. It is just a mystery to me! Thanks for all of your suggestions and replies! Brenda

For those of you who may be working in a Reference Lab and have access to a frozen Anti-Vel sample..... We performed a Type and Screen 2 days ago on a patient who has a historical Anti-Vel. We used Ortho Panel A (GEL) Lot# VRA184 to perform the work-up. All cells were reactive except cell 8 (X2). There were no transfusion orders so we did not send it out to see if it was the Anti-Vel reacting, or, possibly multiple antibodies (though we do have a complete phenotype on the patient and could have tested a phenotypically matched cell to see if it was reactive or not). Anyway, I contacted Ortho to let them know they may want to test that cell so that donor does not continue to be wasted as a panel cell (if in fact it is Vel Negative). But just out of curiousity, if any of you do have frozen Anti-Vel; and do carry that panel; and do choose to test this "just because," I would love to know the answer! Thanks, Brenda Hutson, CLS(ASCP)SBB

I have previously used Cesium Irradiators; but in large Medical Centers with complex patients such that we utilized a lot of Irradiated Products (so we could justify the cost). Also, if you do decide to purchase an Irradiator, I am told that the Cesium Irradiators have less downtime than X-Ray. That being said, I am currently in the process of moving to a new Hospital where I am at, and we have purchased the Raycell Irradiator because you don't have to have all of the safety bells and whistles. When I started here (and still in place, though we have been trying to transition for 8 months; just still trying to get correct Orders on patients), they had been giving 100% Irradiated. That would certainly justify an Irradiator. Per my calculations, once we only give Irradiated to patients who require it by diagnosis, that will be approx. 40-45% of our patient population (as we have a Cancer Center). We currently pay an additional $30/unit for the Donor Center to Irradiate. While we will eventually have paid off the cost of the purchase of the Irradiator in the savings, the monthly energy costs and Rad-Sure Labels may not result in a cost savings at all.....we will see. So all things to consider. Brenda Hutson

That Nurse is thinking of the time-frame a lot of Hospitals giving Nursing as to when they can "return" a unit to the Blood Bank if not used. But even that is controversial (still referenced in Technical Manual as 30 mins., but FDA wants temps. taken). So whatever your Policy for units being "returned" to the Blood Bank (whether 30 mins.; whether you take the temp. upon return to determine if still in range; etc.), I have always told Nursing (i.e. if there has been a delay in starting the transfusion for some reason) that if it is no longer acceptable back "by us," they should keep the unit because they have 4 hours from the time it left the Blood Bank, in which to transfuse. Because the reality is (and what does not make rational sense in this Nurse's response) is that the unit is out at Room Temp. for 4 hours even if the transfusion is started right away. So the fact that she did not start it within 30 mins., may only mean it cannot be returned to the Blood Bank; it does not mean it cannot still be transfused (it just means she has lost part of her 4 hour transfusion window). And I know I have seen controversial posts here also with regard to "when" the 4 hour clock starts. But in my mind, it starts once the blood product is no longer being stored in the acceptable temperature range (so if not Issued in a Cooler, it starts when Issued from Blood Bank....in my opinion). Brenda Hutson

First, I would point out that Nursing accepts verbal orders from Physicians all the time. I too have worked places where we accepted Verbal Orders "for emergencies only;" but we had a Manual Form where we wrote down everything the caller was saying to us (including their name and the name of the ordering Physician). We kept those documents. At 1 Trauma Center I worked at, we just had an alarm go off in the dept. as an indication that the ER wanted us to bring over a Trauma Cooler (6 units of uncrossmatched RBCs). That is even less than a verbal order....so sometimes, you just have to "do what you have to do" in an urgent situation. Also worked at a place where a post-partum woman hemorrhaged to death on the Night Shift. Labor and Delivery was sending erroneous orders in their urgency (i.e. Fresh Frozen Platelets....). Perhaps talking with them on the phone and getting immediate clarificaiton, might have resulted in a different outcome; don't know....... You have to follow regulations and you have to be safe....but you also have to be realistic and do everything possible to ensure a patient does not bleed to death, just because you do not have a writen order in hand. Just my thoughts/experience.... Brenda Hutson

Just one additional thought.....if you have the typing results in the computer; and if your computer system will not allow you to Test and/or Issue Products unless that confirmation testing has been done, you do not need to place stickers on the units indicating that they have been confirm typed (it is just an extra step....extra label supply...and more time). And to eliminate finding out "later" in the process that a unit was not confirmed, would recommend you have a shelf where you place "Units in Progress" (or whatever title you want to put on the shelf; just so it is known to all what the status of those units are). Should not be placed on an Available shelf unless they are truly "available." Brenda Hutson

Switched to Credo at my last place for same reason; was unable to get Cell Safe any longer. You can purchase smaller ones and larger ones. They hold temperature really well (for up to 12 hours if you get those bad surgical cases); especially at Storage Temps. of 1-6C (validated with 6C Safe-T-Vue Monitors). They are more cumbersome however in that you have to first put the interior box in the freezer; then it has to be refrigerated for a certain period of time before you can use it; but it can only be refrigerated for a set amount of time before it has to be re-frozen. So also a bit of a pain to validate (though we purchased Val-A-Sure Cooler Validation Kit which is a nice methodology). It is just getting more complex with limited coolers......validation studies.....Storage vs. Transport Temps......various types of Temperature Monitors.....etc.; isn't it? Brenda Hutson, CLS(ASCP)SBB

Yes, we do; and once it starts to turn blue, we check the pH with pH paper after the addition of each subsequent drop of Buffering Solution. Brenda

Sorry, changed Deionized Water to Distilled Water.... I brought this up before, but we continue to have problems that I cannot figure out. We currently test Eluates using GEL (something I had not done until coming here; but I know others do it). In the past several months, we have been having problems. It seems to be intermittent; yet too frequent. What we are seeing is: 1.All cells on Antibody Screen and Panel appearing to be Positive 2.Often a mixed field appearance 3.Often see hemolysis in liquid in top of well 4.Repeat with Tube Eluate Testing is Negative With the mixed field, I thought perhaps we were not performing a hard/long enough last spin of the eluate; so I changed that. But it continues to happen; and the hemolysis is baffling. It makes me think it has to do with the Reagents (maybe the Distilled Water used for the Wash Solution)?? But we have tried to make new Wash Solution.....to open a different Eluate Kit...etc. Plus we are at 2 different Hospitals and it is occurring at both. I don't think it is technique because my 2 Leads have the problems also; plus they have watched staff prepare eluates (for Annual Direct Observations) and know they are doing it correctly (and I have observed my Leads). Would love any ideas/thoughts/hypothesis any of you have to offer. I would just say that we will switch to Tube Eluate Testing but currently, we only stock 2 Ortho GEL Panels so would have to concentrate the cells to perform Tube Testing. Thanks, Brenda Hutson, CLS(ASCP)SBB

I agree that unless the patient has expired, you need a specimen! I'm sure many others have stories like this, but I worked the midnight shift one night at a large Trauma Center. We gave the ER 2 units of uncrossmatched blood; they gave us a specimen. As soon as the Antibody Screen was completed and found to be Positive, i called the ER and spoke to the Physician, suggesting they stop the transfusion. She said they were already on the 2nd unit and the patient needed it. I then asked her to try and get a history. Just as I finished identifying the Anti-E and Anti-c, the doctor called back and said "The patient said something about having an antibody ID card; would that help?" YES, about 1 1/2 hours ago! We kept a lot of Antigen Screened units on a shelf so I could have at least given 2 E-,c- Uncrossmatched RBCs. Oh well, at least we were able to provide compatible units for the remainder of her transfusions; and explain why her hematocrit might be expected to drop, as one of the uncrossmatched units was E+ (as per Murphy's Law). Brenda Hutson, CLS(ASCP)SBB

I recently attended a Seminar where this was one of the topics. The Cleveland Clinic studies were discussed but here is the problem with their studies (and all others done "to date"). They were not comparing "apples to apples." Their first study was on Cardiac Patients (in which they said the age of blood definitely affected morbidity and mortality). The 2nd study was done on Non-Cardiac patients (which they said contradicted their first study). And that is the problem with all of these studies; no 2 patients, even if they have the same admitting diagnosis, are exactly the same. They can vary by age, by "general health," by additional health issues, emotional issues, etc. The speaker also brought up the point that while we have shown that RBCs survive for the amount of time of the anticoagulant, what we still don't know is, "do they still function" well in providing oxygen to the patient. His conclusion was that basically, we still just don't know because there are no conclusive studies. David Saiken....wonder if you were at the same seminar I attended?? Brenda Hutson

I brought this up before, but we continue to have problems that I cannot figure out. We currently test Eluates using GEL (something I had not done until coming here; but I know others do it). In the past several months, we have been having problems. It seems to be intermittent; yet too frequent. What we are seeing is: All cells on Antibody Screen and Panel appearing to be Positive Often a mixed field appearance Often see hemolysis in liquid in top of well Repeat with Tube Eluate Testing is NegativeWith the mixed field, I thought perhaps we were not performing a hard/long enough last spin of the eluate; so I changed that. But it continues to happen; and the hemolysis is baffling. It makes me think it has to do with the Reagents (maybe the Deionized Water used for the Wash Solution)?? But we have tried to make new Wash Solution.....to open a different Eluate Kit...etc. Plus we are at 2 different Hospitals and it is occurring at both. I don't think it is technique because my 2 Leads have the problems also; plus they have watched staff prepare eluates (for Annual Direct Observations) and know they are doing it correctly (and I have observed my Leads). Would love any ideas/thoughts/hypothesis any of you have to offer. I would just say that we will switch to Tube Eluate Testing but currently, we only stock 2 Ortho GEL Panels so would have to concentrate the cells to perform Tube Testing. Thanks, Brenda Hutson, CLS(ASCP)SBB

Having used both, I am definitely pro-GEL! Reasons: 1. In my experience, more downtime on solid phase instruments 2. GEL very user-friendly for the Generalist 3. You don't have to use manual tube if you are using Solid Phase Automation and it is down....you can do manual Solid Phase. But that can be rather tricky to interpret unless you are really experienced in it. Brenda Hutson