We are a multi-hospital conglomerate-driven by CAP standards.

Is there any regulation that demands alarm checks on the plasma thawed?  Other than CAP saying it should be thawed below 37 degrees?

 

Several inspections ago I was cited by CAP for not performing alarm checks on my water bath. I asked if facilities with water baths that do not have an alarm get cited for this. I still received the citation but I challenged it stating that a water bath was not a blood storage device and my citation was expunged. Just in case, I implemented the alarm check anyway

We check them quarterly on our water bath thawer; recommended by the manufacturer.  We don't have a way to check our microwave so we take the temp of every plasma we thaw to make sure it's not overcooked.

Yeah, unfortunately you have to follow the manufacturer's instructions. Our manufacturer also has quarterly checks built into its schedule so we're obligated to perform them.

According to AABB Standards, FFP must be thawed between 30 and 37 or on a FDA-cleared device. We check ours at both 30 and 37 quarterly.

I check my high alarm 2x/yr.

 

I only check the high temp as I do not keep my bath full but only add H2O when I'm going to use it  (sometimes go for months with no plasma orders).  Since I use "warm" water I know in advance I am not going to be below 30C.  We document the temp when we thaw.

Edited November 4, 20159 yr by David Saikin

I check the high alarm on the thawer as per manufacturer's recommendation, keeping CAP and CLIA inspectors happy. Its also something that FDA inspectors asked to see in the past, long ago, when I was FDA inspected.