Mabel Adams

This workflow is supposed to work anywhere we have an MTP--ED, ICU, OR and OB. Our regular, routine transfusions in OpTime have dual sign off turned off because they had trouble finding space for the nurse to get to the anesthesiologists' computer to document dual sign-off. Again, they do it, but they don't document it in Epic. We actually still provide them with paper downtime transfusion records just so they can document that the nurse also checked the ID when they gave blood. I hope to get OpTime to create an easy way for them to note that the nurse did it and who it was but it hasn't happened yet and may require an enhancement. Definitely still hitches in the process there. Also, there is an option in OpTime for uncrossmatched blood and they can hang anything they want if they click that button. They used it once to hang blood that was, in the computer's brain, for a different patient and it let it happen. It really was for the same patient, but they were using his real ID in Epic but the original uncrossmatch request had come into the BBIS under a trauma alias which to Epic was a "different patient".

We were the first Epic site in the country to do MTP in BPAM with matching turned on. Be aware that the Epic "foundation" way is to document the transfusions but with the ID checks that are on for routine transfusions turned off. We still use a separate blood bank band because certain patients do not wear hospital bands (e.g. pre-ops drawn in advance of surgery) and I don't trust everyone's workarounds when they aren't playing nice with Epic. I find that SafeTrace Tx and Epic are like two spoiled toddlers--each wants everything exactly its own way and they aren't very good at communicating exactly what that is. We made some significant decisions about using BPAM for MTPs that let the computers do what they are good at (recording numbers accurately) and the humans do what they are better at (thinking) and left out some of the verbal checks of long unit numbers that are still required for routine transfusions. We turned off dual verification in Epic for MTPs. They still do it, but don't have to take the time to document it. Our MTPs require 2 people pretty much dedicated to the process of giving blood. We do about 1 a month but a "real" one who gets more than about 6 RBC units only happens every few months so we are still seeing if this works. We went live in April. We did extensive training on the MTP BPAM process before go-live. We think it is faster than paper, although they still drop back to that if there are any problems. Like others above I had to argue intensely to make them understand that the whole MTP is not universal donor, uncrossmatched blood. Some of the lines I heard from nurses-turned-IT people like, "it's an emergency, you don't check anything" just made my blood run cold. You can contact me directly if you want to see what we came up with and what problems we have faced, although it is still a work in progress--especially at our smaller hospitals that are expected to use the same process once a year.

The Vision prints a barcode of the specimen number on the results page. In our BBIS (SafeTrace) we must scan the specimen number before entering results and if it is not the specimen recorded for the patient it won't take those results. That said, in the year we had our Vision before it was interfaced we always rechecked that the manually entered results had been entered accurately.

We can't justify keeping the monoclonal anti-D that picks up category VI partial D at IS for using it twice per year. We don't want to pick those up on the mom because we want to call category VI Rh negative. We don't test donors so don't need the reagent for that. We wouldn't want anyone to mistakenly use it as a normal anti-D. We usually turn them out as unknown and give RhIG. Sometimes the weak D test does a little heat elution on a weak positive DAT and the control and test are both negative at AHG so you can call it negative. We also have a procedure for doing a heat elution on these so we can then test the cells through AHG.

We are a very popular place to move (Central Oregon) and we are having trouble finding people to hire. To answer the original question, we have one dedicated first shift BBer and everyone else is a generalist. We have capped the number of people trained in BB (about 24) so that they get enough shifts in here to stay competent. They do pretty well. We have evening shift coordinators who are a bit more advanced and staff can always call me.

Can your Haemonetics project manager tell you how to join the STTX user group email list so you can ask there?

My mistake. Keytruda is not the name of the anti-CD47 drug. Does it have any name besides anti-CD47 or HU5F9-G4? Is it still in clinical trials in the US?

I just saw that the FDA approved the use of Keytruda (anti-CD47) for a type of lymphoma so wondered if anyone has newer information for managing these patients if they need transfusion. Does the Immucor AHG work reliably? How are you resolving typing discrepancies?

We turn out a negative DTT-treated screen and do electronic crossmatch. If the screen has gone out as positive our computer won't allow EXM so we would do IS as Malcolm suggests. More complicated if there are alloantibodies but we haven't seen that yet.

Catherine, I am looking for a reference lab that can do this testing for around $300. If you wouldn't mind letting me know who yours is, I would appreciate it (PM, email, or phone call are fine).

I have a note: AABB 2015 (Ask the FDA... question 18) that issued plasma must be stored in a container that maintains proper temperature but that it is acceptable for return regardless of its temperature if properly stored. You are really debating the "properly stored" question but I found the above interesting and useful for those units issued warm and brought back promptly before they cooled down. I will be defining some circumstances in which we will accept them back. This is a more common problem now that the "trauma packs" with plasma go out more routinely.

Thanks all. He seemed so convinced that there was an article and he is a respected practitioner. It could be the article was something he remembered from 1985 and he hasn't had a case in recent years.

I think I read that platelet function lasts longer than we would expect--even longer than the accepted 7-10 day life span. Cold storage slows the platelet metabolism and extends their life??? I'm not sure what you've got on day 21 for platelet function.

What little info I have says they are testing 2 tubes, A & B tested separately. I think IS but I am not sure. If you contact dragonlady on this site, she should know.

Our ARC is starting to offer these products. They are using a titer cut-off of 200. The whole blood units will cost 3 times the price of a RBC. It's good for 21 days. Oregon Health Sciences University will be stocking them for traumas. They are the 4th hospital in the country supplied by ARC to use WB in their trauma program. Our ARC is the Pacific Northwest region in Portland.

We recently had a mom with anti-D deliver and the OB insisted on doing a fetalscreen and giving RhIG. He said he had an article that giving RhIG was recommended to suppress further increase in the titer. He was driving when the pathologist phoned him so we never got the reference. Does anyone know of recent research that recommends this? I feel like I'm back in 1984.

Someone once posted a story of a visitor fainting from the site of a unit of blood being transported so they switched to opaque bags.

March issue of Transfusion has a "How Do I" article on this. How do I implement a whole blood program for massively bleeding patients? Mark H. Yazer,1 Andrew P. Cap,2 Philip C. Spinella,3 Louis Alarcon,4 and Darrell J. Triulzi1 I am working on trying to figure out something for rural hospitals who seldom have massive transfusions but whose patients we would like to save just as much as those who can get to big trauma centers. Any suggestions would be appreciated.

John, it's hard to believe that you have to explain who you are after all these years but I guess there are lots of newbies and you aren't on here as much as you were "back in the day." We've probably been talking online for over 20 years now. Wow! Remember Y2K??? We probably hashed that out together online.

We are a system of 4 hospitals and we collect a new specimen when the patient is transferred to the bigger site. We use a blood bank banding system and the ED is instructed to cut off all bands a patient comes in with so that would make the original sample unusable by us. Also, if serologic crossmatches or a transfusion reaction workup are needed, we need a specimen here, at our site. Besides that, we are not responsible for training and competency of the testing staff at our small hospitals so would not accept responsibility for their work. We share a computer system so historic blood types count toward electronic crossmatches but we would want the patient ID to be for this facility for the specimen of record. Many of our transferred patients are emergencies and the logistics of getting a blood bank specimen transferred here in time to be of use for the patient make it pretty much impossible. We also don't want nurses to start thinking that it is okay if ID numbers etc. on patient bands don't matter in cases like this so they end up ignoring them on other cases when there is an error. We do allow pre-ops to be drawn at any system draw site because have a consistent phlebotomy competency program across all sites.

Ortho provides a template DAT procedure for gel you might want to look at. We now do our cord DATs in gel, on the Vision mostly. We have long done only IgG DATs on cord blood so use the IgG cards for this.

So what do all of your hospitals do for plasma, stock thawed, liquid or only frozen plasma?

If a unit is issued at, say, 2210 and the specimen (not the unit) will expire at MN, do they have to stop the transfusion at MN or is it okay to finish giving the unit if it isn't quite done by MN? We use MN on day 3 as our crossmatch/specimen expiration (not exactly 72 hours) so theoretically a specimen even in normal circumstances could be over 90 hours hours old at the time of a transfusion if it was drawn very early in the morning. I am convinced that medically it won't "turn into a pumpkin" at MN but what do you think inspectors would say? Do you have a hard and fast policy for this or leave it up to judgment? Is it okay to issue a unit on an expiring specimen as long as issuing occurs before the specimen expires, the infusion will start by the time the specimen expires, or only if the entire infusion can be completed by the time the specimen expires?

As stated above, we use IS XM for ABO compatibility check only when the computer is down. We have passed several TJC and AABB inspections since starting this. Here is a quote from my crossmatch procedure: Whereas: Sensitivity: Immediate Spin crossmatch will not detect 100% of ABO incompatible units due to low titer of antibodies or weak expression of the antigens. Specificity: Immediate Spin crossmatch gives some false positive results (cold agglutinins, rouleaux etc.). Cold antibodies can cause false positives with immediate spin crossmatches, presenting a quandary on how to manage a unit that is incompatible at IS and compatible at AHG. Warming the sample to avoid the cold antibody might reduce the reactivity of the ABO antibodies as well. This false positive could happen even with an O unit when ABO incompatibility is not even possible. The BBIS contains algorithms that verify the ABO compatibility of all products selected and our validation shows this to have 100% sensitivity for detecting ABO incompatible units and 100% specificity for avoiding false positive results—both an improvement over immediate spin testing.

How are Critical Access Hospitals dealing with the need for plasma in MTPs? Do you use liquid plasma? Keep thawed 5 day units on hand or thaw on demand and have to come from behind on keeping a 1:1 ratio? If you have a specific protocol that covers use of TXA or cryo at these locations to make up for not having platelets & thawed plasma available, I would love to see your procedure.