Recently the JCAHO inspector strongly implied that there was a requirement for placing issued units in a secondary bag for transport to the patient. At the time we had no such requirement.Of course our Infection Control nurse who was present blurts out that 'of course we use a secondary bag!" Now they want to write our policy to make this a requirement.

Can anyone tell me which regulation would require a secondary bag for blood units?

All I can find is documentation that would seem to dispute this:

AABB Technical Manual

"Blood transported short distances within a facility, eg, to the patient care area for transfusion, requires no special packaging other than that dictated by perceived safety concerns and institutional preferences."

CFR 1910.1030(g)(1)(i)©

"Containers of blood, blood components, or blood products that are labeled as to their contents and have been released for transfusion or other clinical use are exempted from the labeling requirements of paragraph (g).

(Paragraph (g) is the one that requires biohazard warning labels.)

Any opinions would be appreciated.

I always ask the inspector to see the requirement, so I can "best assess our compliance with it." There are alot of inspectors that are only ciomfortable doing things their way ...

At our facility, all patient specimens (any body fluid and blood bags) are transported in a biohazard bag, more out of tradition than anything else.

I do not know of any compliance issue on this subject. BUT, I have personally seen a nurse drop a unit in an elevator and cause quite a commotion with decontamination with our infection control team. One of our main employee elevators was out of us for several hours! I think it is a good preventative measure to prevent any large biohazard spill.

Is it a JACHO requirement?

I don't think it is a JCAHO requirement. We use bags that don't close and they haven't add a problem with them. And my previous place of employment didn't use them at all.

The only reason we use the bag is so the people picking up the blood don't get all squeamish and want to wear gloves while wandering through the hospital.

We actually transport blood and blood specimens in a red puncture proof container, but the policy is more of an internal one than in response to a standard.

You are correct in that there is no regulation stipulating such secondary containers. We use a cheap zip-seal bag here as institutional policy. We can't be sure how clean the transporter's hands are. The bags are not only fragile, they are also porous - two reasons to use a secondary container.

we also use zip-lock bags

In the UK our blood is supplied by the transfusion service in a secondary bag, the main purpose is to reduce the bio-burden on the component.

We do not use a secondary bag. If the nursing staff picking up the unit of blood requests, we place the unit in a biohazard bag. Again, I do not know of any regs requiring this secondary bag. I have experienced a broken unit of RC and it is a major mess to clean up. Also, have experienced broken RC in boxes received via airlines from the blood supplier. Talk about a HUGE MESS this is it! My take on this is, why fight it, it's not worth the aggravation, just bag it.

When using the pneumatic tube for transport we use plain old ziploc bags. When a unit is being transported by hand we just use little brown paper bags for the squeamish visitors. We don't use biohazardous bags. If the two nurses came in to check my armband, like we know they always do, and the unit was still in a bag labeled as biohazardous I'm not sure I'd want it infused into me (even though I am fully aware of the potential risks and benefits). Perhaps the bags are discarded prior to the unit being at the bedside, but we didn't know at what point the blood would be removed from the bag and didn't want to take a chance that it would scare or worry the patient.

Update:  This was not cited by TJC but inspector really wanted to. We prevailed when we asked to read the requirement.

Makes sense to me that blood products are carried around the hospital in a clear sealed bag to keep tags, labels etc. attached, in good condition and contain the mess in case it is dropped and breaks. Because it is not regulated does not mean it is not a good idea, just my opinion. 

10 hours ago, Ensis01 said:

Makes sense to me that blood products are carried around the hospital in a clear sealed bag to keep tags, labels etc. attached, in good condition and contain the mess in case it is dropped and breaks. Because it is not regulated does not mean it is not a good idea, just my opinion. 

I largely agree, but not necessarily about the plastic bags being clear.  Some people cannot stand the sight of blood (haemophobia), and seeing a unit of blood can cause them to become faint, resulting in them falling over and, potentially, injure themselves.

4 hours ago, Malcolm Needs said:

I largely agree, but not necessarily about the plastic bags being clear.  Some people cannot stand the sight of blood (haemophobia), and seeing a unit of blood can cause them to become faint, resulting in them falling over and, potentially, injure themselves.

Agreed, though by clear I was trying to infer NOT a biohazard bag as that would, in my opinion, really send the wrong message about blood products about to be infused. 

We tried clear plastic bags for awhile and the RNs complained about one more piece of plastic to have to throw away (amid an already huge plastic waste burden of trash from the hospital).  Materials Management didn't want to buy the paper bags - too expensive they said - and we could not find a contracted source of colored plastic bags (to hide the unit).

I hate to waste even more single use plastic trash, but even the packed cells occasionally break if they happen to hit wrong and they are a huge mess to clean up.  With Whole Blood coming back in some of the Trauma protocols, look out - they always break!

Ours go to the floor in a bag that is zipped closed and locked with a FinalCheck lock. The bag has a biohazard symbol on it. The empty bag/infusion set goes back in the bag for disposal.

Before we used the lock system, our units went to the floor w/o a bag.  I do like the idea of a closed bag because of the potential mess if a bag is dropped and broken.

Another thing I'm waiting to be questioned/cited for is having patient identifiers visible on the bag as it goes to the floor. I encourage staff to turn the patient ID tag to face the unit. Anyone had issues with that?

We use clear zip lock bags and we fold the product ID tag around the unit so that none of the information on the tag is visible.  We used to use Biohazard bags, but someone pointed out that the patient or patient's family might think that we are giving them units with positive viral markers.

When we release multiple units at one time, they go in a validated thermal container.

Either way the unit and patient information are out of sight during transport.