Lcsmrz

I got a list of ISBT128 barcodes that my supplier (non-ARC) will be using. I built the products that I wanted (RBC, RBC2, PHPLT, PHPLT2, etc) and entered the supplied ISBT128 barcodes for the corresponding product. It only matters what barcodes your supplier will be using on the units they will be sending you. Rare ones (for our site) were not worth the trouble of building into the product dictionary, nor were products built for which our use is doubtful (i.e., irrad FFP?). I have <10 products in my dictionary, but we're a smalll site; my biggest decision was whether to make irradiated units a separate pcode. (I voted against it.) Our supplier rarely imports units, and I'll deal with them at that time -- although not preferred, you can always use Unit Entry and manually enter the pcode, rather than scan it. Here's an ARC link to their Codabar to ISBT128 translation table to find the current code they are using, but I would not build all of them: http://www.redcross.org/images/pdfs/biomed/trans_tab_codabar.pdf Am I understanding your question correctly?

The Meditech code 'FFP2' will work, since your pcodes are facility-defined. It is associated in the product dictionary with the ISBT barcode for AFFP,second unit. We do the same for RBC2 and PHPLT2.

It sounds like the practice you follow is the same as ours. We only use outdated platelets if no other in-date product is available and if the patient's condition warrants it -- we never extend the outdate for the sole purpose of saving money. Almost all of the products were SPRCA or HLA-matched and were given by noon, with the apropriate approvals and documentation.

We QC each reagent rack, but do not QC every newly-open vial of the same lot. I sleep better at night following manufacturer's product insert recommendations, which must be CLIA- and FDA-approved.

We also use total cells as the denominator. Does this spreadsheet need validating, since we're using it for medical decision-making?

It seems everyone has published transfusion criteria, and while similar, they're not all the same. You really have to look at your patient population and service level. I came from a large AHC to a small rural facility, and the criteria were similar, but not being followed by the medical staff. We found that the criteria were assigned incorrectly for the patient population and are in the process of being modified.

We test the last rinse after bleaching with pH paper to confirm all the bleach was adequately removed. I don't worry about antigen degradation, since we rarely use it any more.

What are the manufacturer's recommendations?

"Necessary" is one of those interesting words in blood banking. It isn't necessary (read: required) to do alot of the things we do, but I can't sleep at night unless we do them ... We run an auto control on full panels (not r-sets for passive Anti-D) and run a DAT only if the auto ctl is positive. We report Anti-IgG and Anti-C3 when doing DATs, and leave it up to the clinician if an eluate is warranted (except post trn rxn). We decided against automation years ago, since our volume is so low. We run manual gel for screens and panels, and tube testing for everything else. But if you already have the automation available, you might as well use it, since it's more consistent. If you are a larger site and have a patient population to support it, you could have 1-2 people on the day shift with expertise to do eluates, more extensive ABID's, etc. A second- or third-shifter could leave the routine tough ones for you, and you could decide how much you want to play with it before forwarding it to a reference lab. Cost becomes a big factor here, since reagent antisera is very expensive, as is more PT Surveys, training, SOPs, etc.

What does the reagent product insert say, and more importantly, what does your SOP say? Mine says we run a cell control whenever the patient is ABpos, regardless of how many times it was tested previously.

Every once in a while, someone presents a poster at the annual meeting about this topic. Their recommendation: do some of it yourself. Biggest decision-maker is whether you use gel for screens; no cell washer is needed if you do, and we rarely use our old one anymore. When I took over my current position, they were sending all positive screens out -- long TAT! At ~$600 per workup, it was a no-brainer that identifying just one antibody ourselves would pay for doing workups in-house. It doesn't take much refrig space for a panel and a few common antisera, and the extra gel cards are stored at RT. The one PT survey is not that expensive. Our techs were quite trainable, and most had experience elsewhere. The big decision I had was how much to do. Sure, we could do alot, but that means more panels, more expensive antisera, a bigger PT survey, and definitely more training. There were 2-3 new SOPs added to the manual. I started by studying the patient population, finding mostly Anti-D, Anti-K, Anti-E, Anti-c and an occasional Anti-Jka dominated our history files (>95%). Pos DATs were almost always warm-auto's reactive with everything, so eluates were out of our league. We have never had a sickle cell patient. Although we do few deliveries, we do Fetal Screens in-house also. So, stocking one panel and the above antisera (without the Anti-c) decreased our TAT on 95% of pos screens to <2 hrs and saved about $50K this year -- no cost analysis needed! Anthing not identifiable with the one panel is sent out, as are eluates. We order Ag-neg units for Anti-c and historical Ab's that are no longer reacting with screen cells. And our techs like the extra intellectual stimulation at our small rural facility. No complaints from the CFO or the medical staff either ... For small facilities that have only one busy tech on-site, you have to make sure that they have the time to perform a panel (or have an on-call person available to help).

I've seen all units in a cooler checked against the patient wristband before draping, then not checked before hanging. But the cooler and patient never leaves the OR suite. Our facility places the patient info on a piece of tape on the forehead, which is used to verify the patient during any procedure done while the draped.

We document the same function checks that you do. The techs are instructed to look at the button before manually adding AHG, and we use the strength of check cells to verify that the washing was sufficient. The CW2 has a built-in resuspend cycle, unlike older models, so button resuspension is never a problem. Since converting to gel, we hardly ever use our cell washer any more, and I worry most about the lines getting contaminated from non-use.

I vaguely remember -- sorry, I vaguely rememeber everything nowadays -- making check cells in my younger years: IgG check cells by adding Anti-D to Rh positive cells, incubate, wash, resuspend in saline for 8 hrs; C3 check cells by using a strong LISS with autologous serum and cells at 4 C, wash, resuspend in saline for 4 hrs. I doubt if I would make my own today, unless I had an adequate QC procedure for the reagent. An very old copy of the Tech Manual or an internet search would be your best bets.

When we went live on C/S v5.54, I had multiple problems in decoding ISBT barcodes, very similar to what you are experiencing, including needing the last 3 chars of the product code. The problem was eliminated when I rebuilt my calculations in the dictionary.

We are rapidly heading to online documentation via the EMR. Once verified that everything is working, we won't be asking for anything back. A report of the information will be audited by the nurses, and we will make sure that everything issued is documented. But it will all be done online.

Most of our central line draws come from PICC lines. We have them stop all infusions (if muliple lumen), push 10mL saline, then waste 10mL in same syringe, then draw samples. We rarely have a problem.

I'm curious why outpatient samples are not being crossmatched on the day of draw. While we occasionally have outpatients drawn one day and transfused the next, we always crossamatch them when we do the T&S, just to get the paperwork ready to go. Outpatient accounts are generally active for one calander day only. If a particular class of patients is causing problems, you could set them up as on recurring account, like we do our dialysis patients.

As with all Ab identification, it is a statistical probability that drives the report. If the patient exhibits the usual "3-pos,3-neg" reactivity and types negative for the antigen, we say we've identified something and infuse antigen-negative, AHG-compatible units (if significant) with good success. It doesn't always means the ID is correct ... If patient already has more than one antibody, the patient could be a hyper-responder, who, with enough exposures, will form every antibody that their genotype will allow.

In most cases, WBCs are considered "contaminants" in donated products. We blood bankers consider them the source of many evil things and jump through alot of hoops trying to get rid of them before transfusion. There are two WBC products of noted worth. One is Granulocytes, which is collected by apheresis and infused into a patient with sepsis, etc. It's use is controversial, and it costs about the same as other apheresis products. A second product is Source Leukocytes, which is the buffy coat from a unit. These are extracted at the blood center during component processing and sold to firms, who use them to make interfereon, etc. Europeans used to be big into Source Leukocytes, and you don't get alot of money for them.

Can't think of any regulation regarding Informed Consent to blood transfusions. You and your legal/risk mgmt team have to decide where the comfort level lies within the facility. My guess is that the "informed consent" current being obtained is pretty poorly done...

We use Meditech, and we ask them to bring a screen-print of the EMR order to transfuse. It positively identifies the patient, plus gives us a copy of the infuse order to verify.

I always had a problem with using bleach in saline bottles, fearing that they would not be rinsed well enough. Currently, we rinse them monthly in DI, then let them dry overnight before refilling them. We change the salline daily.

I vaguely remember reading FDA documents (not sure which ones, though) stating that using the CLIA number is acceptable, if the facility is not registered. The problem would we having the label say it's an FDA registration number, instead of a CLIA number -- unless the FDA considers them equivalent in a non-licensing situation. Is this a good Matt@FDA question?

The issue step in the transfusion process is probably the most critical to patient safety -- once it leaves the Blood Bank, who knows what will actually happen to it! Everything must be verified as correct -- name, MRN, blood types, unit number, product, exp date, compatibility -- and preferably with a second person. May things are FDA-reportable if something gets past this step. It should not be taken lightly by anyone in the facility ... When requesting a change in nursing practice, I send a copy of the standard/regulation/etc and tell them this is why it's important. Occasionally, they come up with something even better!