Lcsmrz

Personally, I think there is no better monitoring of a person having a transfusion than a physician and at least one nurse standing over the patient surrounded by whatever technology is needed, whether it is in the OR Suite or the Trauma Room. Generally, the documentation of these events is very, very good. Now, try to explain that to an inspector looking for a completed transfusion form ...

We use Meditech and have a "transfuse" order, in addition to the crossmatch order. Both print out in BBK, so we know which ones will be given and which are holds.

Our lab has a generic one, but Blood Bank has never had to use it

We bill for it at one facility at which I work, but not the other hospital. It may be a local carrier thing ...

You should use a cell control suitable to your AHG reagent. At our facility, it's 6% Alb for Anti-IgG and saline for Anti-C3,

There is a difference between a certified thermometer and a calibrated one. The former comes with a certificate of accuracy that states that the thermometer was tested upon manufacture against an NIST-traceable thermometer and has met certain stated limits, typically +1C for BB thermometers. There is usually no expiration date. The latter comes with a calibration report stating at which points the thermometer was tested (usually 2, 3 or 5 points), what the deviation vs the NIST is at each point (usually to two decimal points), and carries an expiration date of usually one year. Then, there's the issue of the validity of test conditions for comparing dissimilar thermometers: total immersion, partial immersion, using a partial immersion LIG thermometer at an immersion level different than the line on the thermometer, and so on. I have the most problem with using the long NIST-calibrated thermometer in tight quarters. We inspect and test our thermometers on receipt and annually thereafter for accuracy against our lab standard, an NIST-calibrated thermometer. Since the cost of recalibrating the thermometer approximates a new one, we buy a new one every two years (use on receipt, then again just before it expires). We do our best at standardizing the test conditions ... Your quality plan should state the level of accuracy requried for thermometers and what the standard will be. For routine BB work, 1C resolution is sufficient. For enzyme work, 0.1C or less resolution may be required. I like John's idea of having the facility provide one NIST-certified thermometer for use by all depts. A big cost savings! And I've been trying to get away from using LIG thermometers for years, without much success.

Traditionally, laboratories are very well managed and run as efficiently as they can -- transfusion services are no different, and most of the "easy pickings" are already implemented. Reagents are usually dictated by buying group contracts and staffing levels are proscribed by the personnel budget. The cost of validation sometimes precludes any changing the little stuff that can add up to something significant. Sure, we can delay some purchases, watch inventory closer, and re-evaluate some costly procedures in the short-term, but we have to have product available when needed. It's usually a trade-off between machines/material and manpower, and with MT availability and reimbursement levels where they're at, the best we can ever hope for is break-even. Your only chance for breakthrough cost savings is process redesign and slaughtering some of your sacred cows, while still being able to sleep at night.

Per the insert, we rinse ours 1mL dispenser weekly with Alcohol and DI water. We test 10 dispenses at 10.0 + 0.5 mL after each cleaning.

I would LOVE to have my supplier eliminate the Rh type on all my cryo! Too many nurses (and techs) get confused easily in Blood Bank. After making the component and freezing it (twice), cryo probably has no intact red cells, but theoretically may have some stroma capable of stimulating Anti-D in that highly-susceptible patient primed and eagerly looking at each infused molecule for something resembling a D antigen. The odds are pretty slim ... My SOP says to issue cryo based on ABO group only and specifically states to "ignore the Rh type, if present." Your blood center got approval from the FDA to label it that way, so there is no compliance issue. You just have to set up your computer to handle all of the different labels that may be sent to you.

Only one thing comes to mind: "What does the SOP say?" If it says two labels, then two labels it is, and if it says no relabeling, then you should reject the specimen. I don't even like correcting labels on instrumented specimens, like CSF. However, changing long-standing practices takes retraining and notification of both nursing and current staff. At a new job, I can remember rejecting a BB specimen once per SOP, so the nurse called my boss, who allowed her to fix the label and told me not to follow that part of the SOP anymore. I quit the next day, but in hindsight, I should have stayed and helped them fix their systems; I'm sure the lab manager had no idea this was happening. Discussing the issue with nursing will be an eye-opener. They draw the cord blood in the midst of an hour of chaotic activity surrounding the birth -- longer, if complications -- and I find just getting one label on a cord blood sample commendable. The infant is not admitted, so no labels are available, and it can be left unlabeled or mom's label marked "baby" or "twin x" can be affixed. Sometime later, toward the end of the chaos and after patients have gone, the "real" label has to be affixed before sending to the lab. We use cord blood only if testing is requested and never for crossmatch purposes. I always wanted to add a disclaimer, like "Cord Blood results; sample identify is questionable."

We pull a segment with each crossmatch, then retain it with the sample for two weeks before discard. Standards say 7 days post transfusion.

A second blood type on a second collection event at a different lab with different techs and reagents lends more confidence than a second blood type from a second collection or from a different tube from the same collection. Still, there is no substitute for a proper collection with a proper patient ID, and if an issue exists, I hope people were terminated -- zero tolerance in the Blood Bank! The best system I ever heard was a fingerstick blood group after the hospital band is attached, and it is written on the band. If the band is removed or the blood group becomes illegible, the fingerstick blood group is repeated after affixing the new band. It is verified at the time of transfusion as part of the bedside checks. It would be difficult to get around this system without alot of effort and creativity. If I had access to a national database keyed on SSN, I would use it, not only for the blood type, but (more importantly) for antibodies, special requirements (irrad, WRBC, etc), and other important comments. A second draw and patient interview is required if the results don't match. Although better than anything else, electronic verification is not foolproof -- as we all found out when nurses started doing POCT.

We are preparing for the worst (no raises & hiring freeze for now), but we've seen no decrease in workload yet. The CFO may be seeing a change in payor mix or maybe just reading too many articles. It makes sense, though, if people are losing their jobs / health insurance, that elective stuff will disappear. If your facility depends on it for their profit, you will expect a revenue decrease and make plans accordingly. Then there's the RePO effect (Reid - Pelosi - Obama), with Daschle as HHS secretary. If they get aggressive after Jan 20th, we could all be civil servants in short order. And why make capital purchases now if the government will pay for it later? Expanded SCHIP is a certainty, and some local companies are already dropping family health coverage for 2009. Less than 10 years to retirement ...

There is no consensus on handling this question yet. While commendable that reducing ID errors in the Blood Bank is getting high profile, I'm not yet convinced that performing a second Veni on a patient without a historical record is the correct answer. I vaguely remember that the chances of getting the same blood type on a random sample is over 50% -- there is no substitute for properly performed ID at the bedside! If I were a patient, and a phleb wanted to restick me after just being drawn an hour ago for the sole purpose of confirming that the first phleb didn't make a mistake, not only would I refuse, but I would make sure everyone in the facility knew of my name and what bed I was in. Pray that I don't become a patient in your facility ... If your patient database is keyed by SSN and contains the patient blood type (antibodies even better!), I can't see a reason for not using it as a second check; if a discrepancy exists, a redraw would be required. But I question whether a patient's SSN would hit a record in such a database, unless the facilities using it were in close geographical proximity or if the patient was part of a national health system , such as the VA or Canada.

The purpose of check cells is to confirm that the AHG reagent was working when the tube test was performed. Inadequate washing is probably the most common culprit nowadays, although in the old days before the green color, missing the tube with a drop was probably more common. If the AHG test is positive already, adding check cells tells you nothing. With an equivocal result under 1+, though, the interpretation becomes a bit fuzzy. Did that tube really get washed as well as the others (esp with an automated washer)? Although green, did it get a full 2 drops of reagent? And so on ... I always add check cells to AHG reaction of less than 1+, just to be sure, but that's not in my procedure manual ...

Doing Spin Cals is an awful, time-consuming process. I would not do more than you have to: if you will never use Albumin, don't calibrate your centrifuges for it.

Plasma storage requires -18 C or lower -- difficult (but not impossible) conditions to maintain in a regular freezer. A regular freezer is designed for about -5 C and has to work pretty hard to keep it cooler than that. I've seen -20 C maintained in regular freezers before, but they get above -18 C with each defrost cycle. It also has to have an alarm and some type of continuous temp monitoring system, such as a chart or electronic system. Most sites also have an liquid-in-glass thermometer inside that is checked once a day against the temp monitor.

For QC of panels to be performed, you would need information that only the manufacturer can provide, such as stability of common antigens in their diluent, age- or process-related appearance of cryptantigens, storage issues with the diluent, and the like. Without this kind of information or other guidance from the company, and without published studies in the literature, any QC performed would be a guess (at best!) and without any scientific merit. We defined "periodic testing" as mentioned in the product insert (IMHO, a CYA ststement!) as required with each use after 30 days. Since we receive our standing order shipment before the 30 days are up, we never have to QC our panels, and inspectors are happy that we have a panel QC procedure in our manual. Performing QC when using expired panels is a whole other topic ...

Our BB band is a specimen identifier, while the hospital band is the patient identifier. We reband the patient with each draw and cut off the old band. BB patients have three identifiers: Name, MRN, BBID. If a sample has these three plus date/time/initials, we accept the sample for BB work, even if the Meditech label says CBC.

We don't put any names on the BB wristband. Our thinking was, whoever is wearing the band is compatible with the unit, as long as the numbers match. The patient identifiers goes with the hospital ID band, which must be present on all draws, including trauma's.

We order only "FDA typed" units from our supplier. Being a small facility, we carry only a minimum inventory of typing sera.

The benefit of having in-house cell salvage depends on volume. The cost of having trained operators from the blood bank on 24/7/365 call is quite expensive, unless your service level is quite high at a large AHC. Besides, he contract for a PRN cell saver usually resides on the OR budget ...

I would look to see what the quality manual say about date formats and whether it was consistently applied inthe documents. In the absence of written guidance, I would not want everyone to choose their own method and would expect to see some unwritten standard in use by everyone.

As with all insignificant antibodies, we ignore them, unless they affect our XM procedure. With Anti-A1, we give Group O RBCs with IS XM.

We have periodic testing of our downtime procedures whenever there is a shortlived, scheduled upgrade to our computer system. We document these occasional episodes as our compliance with this standard.