Townsend

Not a thing. This checklist item is - "the temperature of refrigerators is monitored in a manner that will mimic the temperature characteristics of a component stored in the device." We use 10% glycerol solution in a small bottle to mimic a small aliquot of blood. We give syringe aliquots a 4 hour outdate, so that's really not applicable. Stephanie Townsend, MT(ASCP)SBB

As a part of our hospital-wide patient safety initiatives, we have created "Distraction-free zones". These are areas throughout the hospital where the staff member is performing a critical step and should not be interrupted during the process. Applying that to the Transfusion Service, we have placed those signs at all of the workstations where blood products are issued. (the signs are attached) Theoretically, every process from testing to issue could be considered critical, but we decided that this is the one area where catching a mistake would be most crucial. Issuing the blood is the last place where an error could be found. Since this is a hospital-wide effort of which EVERY employee has been trained on, it has actually helped out. Staff will often stop and wait until the process is completed to begin talking. Stephanie Townsend, MT(ASCP)SBB 07-08-10 DFZ Signage PROOF.pdf Distraction Free Zone Blood Issue.ppt

I'm in Ohio - I just confirmed this with my TS Medical Director (also the Medical Director over all of our offsites)..... I'm not sure what you are looking for exactly in terms of policies (testing, issuing, storage and transportation to the offsites, administration, etc.), but two things come to mind. 1 - Are the administering personnel (nurses) employed by your hospital? If so, then the nursing blood administrations would apply the same as inpatients. 2 - The pre-transfusion testing can be performed by your hospital Transfusion Service using existing procedures if you are operating under the same CLIA license as your outpatient labs. Sorry if I'm off-track:p Stephanie Townsend, MT(ASCP)SBB

We do not use a separate armband for blood bank samples collected at our hospital off-sites. Patients are registered through the HIS in the same manner as inpatients. We don't use a separate armband or blood loc for blood bank testing. Stephanie Townsend, MT(ASCP)SBB

I seem to remember a previous thread on this subject - you may want to try a search of the other posts. There was a lot of variation in practice. It is really up to the individual Transfusion Service to come up with their own policies. We use the 3 day expiration (with the day of collect being day 0) unless the practitioner signs a form stating that the patient has not been transfused or pregnant in the last 3 months. If the extension form is signed, we will use the sample up to 30 days. Stephanie Townsend, MT(ASCP)SBB

We have a unique process for BB work review. The techs review the work that was done by the previous shift techs, so that errors are caught as soon as possible. This works for us because we have a total of 11 techs that rotate ONLY in the Transfusion Service (no generalists). New employees do not perform review of other's work until they have been here about 6 months and pass a separate competancy that we created. I still do the review of antibody workups and transfusion reactions. We are a pediatric hospital with about 400 beds - about 6,000 type and screens per year and 13,000 transfusions (lots of aliquots). Stephanie Townsend, MT(ASCP)SBB

We also use the Thermosafe transporters that Kate mentioned and performed a similar validation with a data logger. During validation, we found that the coolers held 1-6 degree temp for 4- 6 hours depending on how many units were in the transporter. So, we only issue the transporter for 4 hours at a time. We also found that when we used the transporter for only one unit of red cells (or a partial unit/aliquot), the unit dipped below one degree C. So when we issue it with only one unit, we remove the bottom freezer pack and only put the two on the sides. I am not familiar with the Transporter-r coolers Kathy.

We have also had problems with our Helmer freezer (which is only about 5 years old). Last year we learned that we had a voltage problem, which was causing the compresser to work overtime. A couple of weeks ago, we replaced the compressor, starter, fluid lines (just about everything inside the freezer!) - the parts were all sent free-of-charge from Helmer due to known reported problems. I am hopeful that they fixed the problem and will be more conscious of having them check the actual voltage coming in the outlet vs. what is needed by the unit. I am not familiar with Follett, but we do have two double-door Jewett refrigerators that we have been happy with.

Sounds like you could have a cold autoantibody. You could try a tube screen with cold (4 degree) incubation. We generally refer to these as "cold autoantibodies" if they react only at the 4 degrees and other antibodies are ruled out in gel (i.e. your negative panel). What did the extended (tube or gel) crossmatch look like? Stephanie Townsend, MT(ASCP)SBB

We are also on Epic electronic medical record, and our orders usually get placed directly into the EMR. However, we still have a couple of areas not live with Epic who use our manual order form. (I've attached a copy.) Page 2 is actually on the back of the form. It is a 2-ply form, the yellow carbon copy gets sent to the blood bank. [ATTACH]498[/ATTACH] Stephanie Townsend, MT(ASCP)SBB LA-3 Physician Order Form.pdf

We do acid elutions on all inpatient positive neonatal DATs (<4 months old). For outpatients, we just add a canned comment that says to contact the TS if further testing is desired. A lot of adult hospitals don't do them if it looks like ABO ab or if the maternal ab is already known. We are a children's hospital (not a delivery hospital), so we don't always get the maternal ab information and don't like to "trust" the information provided by another TS or physician.

We assign patient protocols (CMV neg, Irrad, LR, Sickle neg) based on the patient's diagnosis or procedure. These protocols were approved by the TS Medical Director in conjuction with the medical staff of the appropriate areas (transplant, HemOnc) and the Transfusion Committee when needed. BB staff look at the patient's past and current diagnosis and place them on proper protocol as defined in our SOPs whenever a sample is tested. I tried to attach those charts and special feature SOP, hopefully that worked. Once the patient is on a certian protocol, it is placed in the computer file for future transfusions. Only if the TS Medical Director okays would they be removed from protocol (CN, irrad, etc). This does place a lot of the responsibility on the BB techs, but we are lucky to have dedicated blood bankers rather than generalists. We also find that the ordering physician (who may be a rotating resident) often has no idea what protocol would be required for their patient. (what is irradiation? everyone should get cmv neg, etc) Stephanie Towsend, MT(ASCP)SBB Compat 1.0.doc HO special features.xls OTHER special features2.xls ECMO special features.xls OHSblood.xls

We would also give AB platelets next. If we had to go to a plasma-incompatible product (A or O), we will give one standard-dose of 5ml/kg of group A or O. If more than one dose of the incompatible product were needed, we would volume reduce the product. Stephanie Townsend, MT(ASCP)SBB

We would also give AB platelets next. If we had to go to a plasma-incompatible product (A or O), we will give one standard-dose of 5ml/kg of group A or O. If more than one dose of the incompatible product were needed, we would volume reduce the product. Stephanie Townsend, MT(ASCP)SBB

We discontinued the use of the MSBOS years ago. Each physican/surgeon is responsible for their own blood orders on a case-by-case basis.

Correction to my previous post..... "As for elutions, we perform them on positive DATs if the patient has been transfused within the last month and on all neonatal positive DATs"... That is only for positive INPATIENT neonatal DATs (or for pre-transfusion testing). We don't do elutions on all of our outpatient positive neonatal DATs unless specifically requested by the pediatrician. Now THAT would be a lot of elutions!

As with most of the previous replies, we only do AC with ABID, with pre-transfusion neonatal samples, and of course when ordered by the physician or as part of a transfusion reaction workup. As for elutions, we perform them on positive DATs if the patient has been transfused within the last month and on all neonatal positive DATs. That does mean a lot of elutions on babies (usually just ABO abs or anti-D from RhIg in the eluate). However, we are a pediatric hospital, so mom's sample is not always available. We do try to contact the birth hospital for BB history on mom, but I can think of more than one case where an incorrect history was given from the birth hospital. (maybe they were looking at the wrong patient, who knows) We have even had hospitals call back later to say "oh, wait, that baby was transfused after all - 6 aliquots of Oneg red cells". (no wonder the Apos baby is now typing Oneg!). So, to cover our butts, we do the eluate. The antibody eluted is not always what is seen in the baby's plasma (i.e. ABID). The screen could be negative and antibody is only recovered in the eluate, or could be a different combination. (i.e. anti-D in eluate and anti-K and anti-D in plasma) Anyway, we like to see the whole picture when trying to find compatible red cells for a neonatal transfusion, and this helps especially when mom's sample is not available.

We also use a commercial kit, the same one that is used to screen patients for the trait. It is the Hemoglobin S sickle solubility reagent kit from Nova Century Scientific.

We use barcoded labels that are printed at the patient's bedside at the time of sample collection. (Collection Manager via Sunquest Lab IS) There is no foolproof method, as someone can find a way around every safeguarded method out there if they really want to.... such as the patient wristband bing scanned and labels pre-printed, but our staff is doing their best to train the phlebotomist's the right way from the get-go. We do not use a separate BB armband and always require the patient's name and MR number - NO ACCEPTIONS for pre-transfusion testing! On another note, we have for many years required a second sample (collected at a different time) or a check against a previous blood type on record before we give type-specific blood. This does increase our O red cell usage, so this may not be a realistic option for many institutions. I have heard of other hospitals doing this and taking a more proactive approach to the collection of the second sample to decrease O usage - I believe the articles were in recent editions of AABB's Transfusion.

We also use the sterile connection device to prepare syringes using the Charter Medical syringe/filter sets. They use a standard 150 micron filter. We have not used a smaller microaggregate filter in many years. The only ones we used to have available required the bag to be entered, thus creating an open system with a 24 hour outdate. We also prepare bag aliquots for larger patients that would need to be filtered at the bedside prior to administration. Although the sterile connection device is an absolute must in our Children's Hosp Transfusion Service, I can see the reluctance in having one for only a few aliquots per month. (FYI - if you prepare aliquots you would need to have a relabeling policy as well as being registered with the FDA). One thing you may also want to think about is if you are not pre-filtering in the Transfusion Service, the nursing staff will need approximately 20mL extra of blood product (or saline if you can convince them) to prime the filter. This is one advantage of the pre-filtered syringe of only needing a few extra mLs for tubing (some of our syringes that we prepare are only 10-20mL each!)

I agree with all of the comments about this applying to quantitative testing and the purpose of the initial validation testing. However, that being said, with the new TRM.31450 in the BB CAP checklist, if you are CAP inspected, consider a gel vs tube correlation procedure at least semi-annually. I called CAP for clarification, and I was told that this is exactly what the new checklist item was referring to - gel vs tube (or another method, such as sold-phase). I even tried to stress the fact that the tube testing was only done as supplemental testing and not done instead of gel - but they weren't going for it! Please reply if CAP tells any of you anything differently.... I would love to drop this testing! Stephanie Townsend, MT(ASCP)SBB

Very interesting to see the varying practices on this subject. We do specifically address this in our sample labeling policy. We use Sunquest LIS, and most samples are labeled using the LIS label that is printed at the time of collection. Sometimes the name is too long to print the entire first and last name. We still accept the sample if it has 2 other identifiers, such as hospital number, DOB, SSN, account number. I would think you would be okay as long as you can come to an agreement (Mgr/QA/Med Director) to put a policy in place while having 2 identifiers on the sample label. Good luck! Stephanie Townsend, MT(ASCP)SBB

Coming from another Children's Hospital.... we handle single donor plateletpheresis similar to Elizabeth/sgoertzen/adiescast. However, we refer to a standard dose as 5ml/kg for any patient under 40kg. A patient (including an adult patient) above 40 kg would just get an entire plateletpheresis. We only rarely use random platelet concentrates when no plt pheresis of a specific type are available, so the bacterial testing is done at the blood center by culture. No further bacterial testing on the plateletpheresis is done by us (at least for now). We use the sterile connection device to aliquot the required dose into either a syringe or a bag, so the outdate of the parent plt pheresis is not effected. The only time we would volume reduce a platelet product is after Medical Director approval and for one of the following reasons: -extreme volume restrictions, which does NOT happen often -multiple transfusions of ABO plasma-incompatible platelets (we allow one dose in a 24 hour period without volume reduction). Lately this has been in a few situations when we had to give IgA deficient products or HPA-1a neg platelets which were ABO incompatible. What fun! Stephanie Townsend, MT(ASCP)SBB

You should check your manufacturer's circular to see if it specifies which type of components can be administered through the blood warmer. AABB has also published "Guidelines for the Use of Blood Warming Devices" (2002). It clearly states that a blood warmer should never be used when transfusing platelets, cryo, or granulocytes. We use a Ranger Blood Warmer from Augustine Medical, Inc. and our policy states red blood cells as the only blood product to be infused through the warming device. We couldn't find a consensus on giving plasma through the warmer (the system alarms at under 42 degrees which is warmer than plasma is thawed), so we opted to not use it for plasma. Often the plasma is warm at the time of issue anyway if it has just recently been thawed, so we haven't had any major complaints yet. Stephanie Townsend, MT(ASCP)SBB

I read Suzanne Butch's article last year when the CAP revision came out. When we prepared and went through our CAP mock inspection, I called CAP for explanation to see if this really applied to tube vs gel testing (or other methods). They told me that this is exactly what the checklist item was intending to cover. So whether you're convinced or not (I'm voting no), the inspectors will be looking for this when they come out to your BB next time. We created a very general comparison SOP for our gel and tube (antibody screens and direct coombs) to run every 6 months. We currently do manual gel testing with LISS tube as a backup. Stephanie Townsend, MT (ASCP)SBB