Has anyone seen the newest CAP Transfusion Checklist dated June 15. There is a long list of new questions regarding Therapeutic Apheresis. An outside agency provides our hospital with the service, and we provide the plasma for the exchange. How much involvement should our pathologist have in this? Currently he isn't consulted, the hematologist docs take care of it all.

Are the questions NA since we don't provide the service? What do you do at your places?

I would say they are NA, since you are not involved in the service (except for the transfusables).

We have an outside company perform them for us but you could write an SOP to say that the Medical Dir of the BB has "oversight" of the program in conjunction with the Hem docs and the provider.

I agree with David, N/A except for the blood products.

We have done exactly that - written a policy stating that the service is under the direction of the provider and their medical director. I agree with the N/A. If you start taking responsibility for one standard it gets very hairy with which ones are legitimately N/A in that same section. It begins to appear that you are just picking and choosing which standards you want to live by.

I haven't seen the new checklist, but from what I remember CAP guidelines infer that anything to do with "transfusion" falls under the purview of the blood bank/medical director - cell saver, re-infusion devices, etc. You might want to contact CAP and get an official ruling. Since you are providing plasma for the procedure, CAP may determine that you are "involved" with that service. We are not involved with those processes at my hospital, but we do have copies of their procedures, comptency assessments, etc. reviewed and signed off on by our medical director. That seems to suffice.

Interestingly enough I just asked this question (last week) of the CAP. We have a similar situation. Outside contract performs the Therapeutic Pheresis, our transfusion sevice's only involvement is in supplying the product.

The official response from CAP. Answer it as N/A because our transfusion service is not doing the procedure. YEAH!

Also, if you are not listing it in your Activity Menu-Scope of Service, it will not print in your Customized Checklist and therefore the inspectors should not even have the questions to ask!

Jan

We received same response from CAP (in september)...I believe they will change or revise the questions.

Interestingly enough I just asked this question (last week) of the CAP. We have a similar situation. Outside contract performs the Therapeutic Pheresis, our transfusion sevice's only involvement is in supplying the product.

The official response from CAP. Answer it as N/A because our transfusion service is not doing the procedure. YEAH!

Also, if you are not listing it in your Activity Menu-Scope of Service, it will not print in your Customized Checklist and therefore the inspectors should not even have the questions to ask!

Jan