caj1018

I am really needing assistance from experienced blood bankers. I recently was assigned to perform a minimum of 10 transfusion audits per month. I made a comprehensive checklist from our BB and Nursing procedures and have started observing transfusions from issue in the lab to transfusion on the nursing floor. I have noticed several discrepancies from our written procedure: 1. 15 minute vitals taken 15 minutes after first set - yet the patient hasn't actually received any red cells yet - the first set was taken when the nurse arrived in the room, then there was a delay in getting everyone and everything started so the patient received saline only.... 2. Nurse started unit then promptly left. Her instructions to the patient were to use the call light if the patient felt funny. After about 20 minutes the Nurse tech entered room and wrote something on the door in the patient's room. Nurse eventually returned after 25 minutes and wrote on the transfusion card. When questioned she said she was writing the vitals taken at 15 minutes by the nurse tech. She said the Dynamap took the vitals - when I know that actually no one took any vitals since I was observing in the room the whole time. Our policy says that the transfusionist is to remain "close" during the first 15 minutes. During those 25 minutes the nurse was chatting on her phone and visiting with other nurses and did not return to the room at all during this time. My dilemma - and I really need help with this - I reported my findings to transfusion committee and was told that I needed to report these issues to the nurse manager. I did so and the nurse manager complained to the DON. I've been told by the DON that nurses do not need to stay in the room with the patient during the first 15 minutes and that it is just not feasible. I also conducted an audit in the ED and the nurse was somewhat inexperienced at starting transfusions. The nurses asked each other what rate to start with and decided on 150. Our policy states that units should be initiated at a rate of 60 for 15 minutes. I told the nurse (politely) that I believed that the policy said 60-80. The nurse asked the charge nurse and the charge nurse said 120. The charge nurse then looked up the policy and discovered that it said 60 and said that he'd never initiated a transfusion at less than 100 in all the years he'd worked at the institution. He did not seem to be angry or upset, but later he complained to the DON. I received an email from the DON saying that nurses do not need to stay in the room with the patient during the first 15 minutes and that it is just not feasible. She also said that she received a call from the ER and they were VERY upset that I was conducting audits in the ER without any notice. I sent an email to the COO and risk manager and Quality Director about my concerns - that the DON is reporting that nursing does not need to stay in the room to observe the patient for 15 minutes and that the ER staff had seemed to welcome the information I was sharing with them. The COO is backing up the DON and as long as patients have call lights and nurses are close by we are following the policy and yet is the one mandating that I the perform the audits. What is the point of doing an audit if I am not permitted to report my findings and am getting the staff all upset? I have been a Blood Bank Supervisor for 20+ years and currently the Lab Manager for 4 years. So, why you ask are we doing these audits now? A Nurse with one of our contracted services gave an A pos unit of blood to an O Pos patient. Our blood bank has passed FDA and CAP investigation - yet we are being held accountable for the error by nursing staff. The audits are being done as part of an action plan for CMS. So, I am asking for your help on what your institution's policy is during that 15 minutes and how you define "close". I want to make sure that I continue to push for patient safety and YES I've started a job search.:cries:

I've taught blood bank to MT and MLT students. The MT program had 5 weeks of BB clinical training preceeded by 3 weeks of Immunology/Serology which also included significant BB training. The MLT school consisted of 2 weeks of BB training. When I asked for more time the school informed me that the graduates weren't expected to be able to perform BB testing "in the real world". Yet I have a graduate from this school that does work in BB on a regular basis and does a good job. We spent a significant time "in orientation" training her to work in the dept and she is able to work independently. I cannot imagine someone with this training as the Supervisor of the department.

It seems to me that your docs have used flawed logic: "If the patient's have never been transfused with platelets before, then lets give them some even though they currently don't need them so that they can be sensitized to platelet antigens thereby decreasing the odds that platelet transfusions will be beneficial in the future." Sounds like you work at a teaching hospital. I thnk our patients have a right NOT to be experimented on!

We have been using FFP and FP interchangable for several years. The computer gives the product an expiration date of 5 days as soon as we change the product status as thawed. The product is labeled with the 5 day expiration date and time with a purchased sticker. If the product(s) are not transfused that day and are kept refrigerated, the following morning the day shift techs will put a yellow "plasma" sticker over the fresh frozen or frozen words on the product label. This is our fix until ISBT 128 labels are ready. We use AB FFP pedipaks for neonates and always within 24 hours. We have a busy NICU, but rarely have pediatric patients. Any patient treated in our peds would be handled the same as a NICU patient. We would rethink this if we had a busy peds department.

I would like to know what red cell product you use for your NICU babies: What anticoagulant, irradiation, CMV, as well as dating. Do you use only fresh less than 10 day old blood or do you use one unit/baby until it expires? I would also like to know what sample you use from the baby - Do you use the cord blood sample only? And do you perform an antibody screen on it or do you ue the mom's results for the antibody screen? Do you get a new sample from baby and do a type&screen? We are currently restarting a NICU practice at our hospital with new physicians and there is current debate about best practices. Thank you for your help

I believe that the new CAP requirement is trying to address a patient identification issue - and is a separate issue from electronic crossmatches. We use Meditech and do not do electronic crossmatches cuz meditech just seems to have trouble with this. One way to meet the new requirement - and what I believe is strongly recommended by CAP is to require that TWO different types be performed on TWO different samples drawn at TWO different times. The good news is that this for those patients that do not already have a blood type hsitory in the computer or manual records and are blood groups other than group O. The same tech can do both types. One way to do this is to find a CBC sample drawn at a different time on that patient and use that sample for your confirmatiory type. We are currently trying to set this up - but having trouble setting this up in the Meditech computer so that we are 100% in compliance. We just finished our CAP self inspection and need to get this done ASAP. If anyone has ideas on how we can get this to work in Meditech, I'd sure love to here from you. pss - i missed reading pages 2-4 before posting. So sorry for beating a dead horse. Would still like meditech suggestions however!

It seems that ideas and suggestions just don't have the same impact unless you can get physicians to attend. Our nursing staff and QA people show up religiously, but the decision makers that we need to really impact the changes in our institution are often absent. (ie trying to get our docs to stop transfusing to patients with Hgb greater than 10!) One thing that has helped us is to invite the Medical Director of our blood supplier to these meetings. It has been wonderful to have someone support what I've been trying to do - and usually when recommendations comes from a physician rather than some tech in the lab - it is much better received. And now I don't dread that trip to the soap box every quarter as much as I used to.

Since my last visit I've been made lab manager - but I am also still BB Supervisor. The good part about this - sort of- is that I currently am updating the hospital transfusion policy (at home this wekend:( ). Once I've made the appropriate changes it will take some time to educate our nursing staff. If you have a powerpoint I would very much like to see it. I can use all the help I can get! The double hat role is a bit too big for my puny head. caj1018@sbcglobal.net

Thank you all for your help. We currently do workups only if ordered by a physician. We haven't done a workup in months. Yet when I review transfusion cards later (days or weeks later when they finally are returned) I notice anywhere from 2 to 10 cards with documented signs of a possible reaction. Most are mild febrile - but some as much as 4 degree temp rise! I appreciate that our docs trust us so much, but I fear that with staffing shortage and such that we need to be a bit more proactive in the interests of our patients. I plan to share your answers with my Lab Director today. I have addressed this issue repeatedly with our Medical Director and he does not agree with me. He feels that our current policy is just fine.

At your institution do the physicians have to order a transfusion reaction before you do a workup or is the workup generated when nursing recognizes certain criteria and notifies your blood bank department?

Maybe it's just me, but when I navigate through the pages or try to post a reply I have to relog in. Happened just now when trying to post this. I always get the following : The following errors occurred when this message was submitted You do not have permission to perform this action. Please refresh the page and login before trying again. Usually I give up and log out.

We use purchased QC reagents and test each reagent daily following the manufacturer's directions. In addition, we perform a negative control of our MTS Gel cards using the MTS diluent. Having been burned once many years ago this simple step prevents a major headache.

We prefer MTs but use both interchangably. Even though both do the same work, we DO pay more based on education. This has proved to be a good incentive for our MLTs to continue their education and go for the MT degree. Because of the tech shortage our hospital is encouraging our most capable phlebotomists to go to junior college and get their MLT degrees - and paying for it.

We would perform AHG crossmatch using MTS Gel. It is possible that the previous reactivity was to to antibody to low incidence antigen.

I think that there is strong evidence that TRALI has been associated with antibodies in plasma. Is it wise to ignore this and not try to switch to predominantly male plasma? The plasma from female donors would be used for manufacturing. It is true that there are not enough donors to switch to 100% male plasma plasma at this time, but maybe down the road males can be recruited to donate plasma via pheresis as they are for platelet products. I attended a presentation on Hemovigilance by Dr. Benjamin and feel that his arguments to go in this direction are compelling.

Identity theft can be a headache for the blood banker. A coworker of mine used to work at a VA hospital near the Mexican border. He reported that it was common for family members to share identity cards and information so they could get free medical care. It was common for a patient's blood type to not match their history.

I liked your idea of using a "blue book" so much that I passed the idea on to our Lab Director and Transfusion Committee. They absolutely loved the idea. We have such a problem with physican education. Our transfusion committee is poorly attended by physicians and we are a teaching facility. The associated med school provides a whole TWO hours on transfusion medicine - which consists of transfusion reactions and atypical crossmatch problems. We routinely transfuse blood at 9 and 10 Hgb and just last week a cardiologist ordered transfusion to greater than 13 Hgb because his patient was having knee surgery the following morning. Our docs also continue to transfuse 2 units when 1 (or possibly 0) are needed. Our Pathologist/Medical Director is happy with the status quo and supports all decisions made by our physicians including transfusing to 13. The good news is that he also supports the idea of creating a "blue book" though we will probably change the name to "Orange Book" since we are associated with the OSU Cowboys (Go pokes!). I have one major request! Do you have a copy of your book that we can emulate? Something you can send via email? Thank you again for your wonderful idea.

Patient CB admitted to ICU with hgb 3.5. Type and Screen result - O Neg with negative antibody screen. Patient is given 2 O Neg immediate spin units and post transfusion Hgb is 4.5. Dr orders DAT and result is negative. Pathologist review indicates moderate spherocytes. Bilirubin is 6 and plasma is bright yellow. Pt is a 41 F and had hysterectomy and 2 unit transfusion on 1/15/07. Previous transfusions in 2006 and 2005. No history of allo or autoantibodies. I repeated the DAT using crossmatch sample and obtained microscopic positive with poly and negative with IgG at immediate spin and 1+ positive with poly and still negative with IgG using tube method. i performed a tube panel using poly AHG and received negative results. A post transfusion specimen was sent to ARC reference lab and a negative DAT was resulted. Patient's Hgb dropped to 2.9 and 2 more O neg units were given. Medication history was reviewed and Pharmacy could not find any evidence that Cefotetan was ever used, however, the patient has received Keflex which is also a cephalosporin and has been associated with positive DAT. A small amount of red cells from the crossmatch sample was sent to ARC reference lab for phenotyping. This sample yielded a 4+ DAT using IgG Gel. The patient's LDH is approx 300 and Haptoglobin is also Elevated. This patient was referred to a Hematologist who suspects an autoimmune IgM process. He orders a cold agglutinin titer and a wonder drug was ordered but takes 24 hours to arrive. The cold agglutinin titer is negative. This is where we are at and this is a real live case. I have a VERY small amount of pretransfusion cells left to send to ARC on Monday 2/5. The varying DAT results and elevated Haptoglobin are not consistent with a delayed transfusion reaction - so what am I missing here? Do you have any words of wisdom or suggestions?

I think having a benchmark for platelet usage would have helped the problem I had about 2 weeks ago. We are not a trauma hospital though we are a teaching facility. For some reason unknown to me, we received a ruptured AAA via helicoptor on a weekend that I was working. The patient was whisked to surgery and they wanted 8 uncrossmatched O Negs to start with. Once the surgery started they requested 6 platelet pheresis units. Knowing this is a massive transfusion patient I had thawed 2 AB FFP and issued them along with RBCs when they came to pickup blood. They had a hissy fit and refused the FFP and wanted those 6 platelet pheresis products NOW. We only stock 1 plt pheresis. I ordered 5 more from the blood supplier and issued them 1 at a time with other blood products. The patient received 14 RBCs including the 8 uncrossmatched O negs and all 6 Plt pheresis units during surgery as well as 20 units of cryo. Once in the ICU and the coag was WAY out of whack the docs ordered and FINALLY gave the first 2 FFP and eventually 4 more. No coag testing was done before or during surgery. At our facility, during CABG they perform ACTs to determine platelet need! At our teaching facility the doctors get a total of TWO hours of transfusion lecture. I think the problem I was encountering is that the doctors do not know what and how platelets are used - that we have not had random platelets available for years. They would not listen to me during the situation. Part of the problem was that the nurse I was working with ALSO would not listen to me and insisted that YES the patient does need all 6pheresis. Fortunately, our patient is doing well and recovering in LTAC. My solution for now is to create a Massive Transfusion Policy that we can have the medical directors approve. Then I or other Bloodbankers can refer the docs to this policy - ie usually we give 1 or 2 platelet products for every x number of red cells....we should be performing coag testing every x minutes during a massive transfusion so we can determine when cryo and ffp are needed....... Do you have any suggestions or comments that I can use? I hope to complete this policy by January 30th to present to our transfusion committee.

I would suggest that you request AB Rh Neg random platelets or AB Rh Neg Apheresis Platelets for your stock. These products may not always be available, but your supplier may be willing to accommodate this request as much as possible - especially when made during contract negotiation time. Carolyn

I found out today that we may be moving our Blood Bank Department to another area of the main lab. The primary reason is because we have lost several techs recently and we need to make our work area as efficient as possible for our reduced staff. I am not going to have very much time and very little money to redesign the area. I know that many of you are very talented and experienced and have probably been through this yourself. Are there any experts that can recommend a source for information or advice? We are a 300 bed hospital and will need 1-3 workstations - though we rarely have more than one BB tech scheduled per shift. Also - the Blood Bank Department includes Urinalysis and Serology and this designated area will have to accomodate those areas as well. Thank you in advance for your words of wisdom.

We have a policy that the antibody screen must be performed within 48 hours of collection, though rarely does the antibody screen test get performed greater than 4 hours after collection. I seem to remember reading somewhere - maybe the technical manual- suggesting the 48 hour deadline. We use the sample for 3 days for crossmatching.

We perform Cord Type on all NICU babes, those with Rh neg moms and/or O moms. Also for the immucor fetal screen we use a well mixed EDTA tube. PS - We really really like Meditech. Except for a few months back when we had a scheduled downtime and someone at corporate entered the wrong DATE in the computer in took hours and hours to manually restore all the lost data that occured when they had to erase everything and fix the date problem. So - faithfully print and store your weekly reports. And always always print and keep reports handy before every scheduled downtime.

We recently changed our criteria to less than 7 Hgb for all nonbleeding patients. In theory anyway. Currently we do not have a way to see that this actually happens. Currently most of our docs feel that it is ok to transfuse anyone with a HGB less than 10. This is especially true for our nephrologists that feel that 9 is too low for a patient with ESRD. I cannot find any literature to support their claims that these patients should be kept above 9 or 10. Our Pathology dept supports whatever the nephrologist wants to do. How do we educate or physicians?

We have an OB doc in our community that read that 1.7 % of Rh neg OB patients make Anti-D even when they get antenatal RhIg so he wants an automatic Anti-D titer on all patients that have an Anti-D detected when the patient is admitted for labor - even though they know the patient received RhIg and the screen was negative prior to the dose. This doc practices at a "sister" hospital and the Pathologist there have asked for info on how to handle this situation. All OB patients have a TS ordered when admitted for labor. This hospital uses gel technique. I suggested that if they identify an Anti-D they repeat the antibody screen using tube technique and if negative then not perform the titer. What do other labs do? Is this a situation that has arisen elsewhere? Any words of wisdom would be greatly appreciated. Thank you.