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Category: transfusion medicine
My struggle in the community hospital setting is having the appropriate inventory for the patient population I need to serve. When I stocked the refrigerator during my golf club days the oldest inventory went up front and the new product went to the back. Later in graduate school I learned that was the FIFO method of inventory management. Blood Bankers have a unique twist thrown our way in that as blood sits on our shelves certain things happen that make an older unit less desirable than one collected a few days prior. The life span of a red cell is around 100-120 days depending on which literature you cite. Our job as blood bankers is to get the freshest blood to each patient we serve, so inventory management becomes more of an art than science.
Let’s take first the type specific debate. Some will say always transfuse type specific blood; if the patient is type A then the patient receives type A blood. Some will say to give whatever is most fresh; if we have fresh O cells an A person will get O. What I found when I first came to be the supervisor in my blood bank is that we were outdating a lot of type A blood. So instead of just decreasing the amount of type A, I also increased the number of type O I had on my shelf. This allowed me to be more flexible; I would give out more O when my inventory of A was low. Also, the blood I was giving out was always fresher than before I changed the inventory.
Let’s take this another direction. My policy states that any patient with an antibody has to have two red cell units set up so there is no delay if a transfusion is necessary. I would rather have two type O units typed for some antigens, because if the patient with the antibody doesn’t need it, the units are readily available to anyone else. I use the flexibility of type O blood to be more versatile and to make sure that my patients are getting the freshest possible unit. I have searched for literature that says giving type specific blood is better for patient outcomes but I haven’t found it. If anyone has literature on the topic please send it my way.
This really comes down to what type of setting your blood bank serves. If you are in a medium size community hospital you will need to make these type of decisions to be flexible with your inventory. If you are a large medical center and are going through blood as soon as it gets delivered then you may not have to worry as much. The majority of us do not work for large centers, however, so we must look and analyze how we can best use this precious resource.
–Tommy Transfusion is the pseudonym of a blood bank supervisor in the midwest.
Blood Management: The Power of “Why”
There are five established questions that should always be embedded in our quest for knowledge and review within the ever-changing evidence base in medicine: what, who, when, how and why. Of these very important and inclusive queries, the final question wields the most power. For it is the why we do, or should do something that truly empowers us. “Why,” by definition, represents the cause, reason, or purpose for action.
Considering the rapid evolution of the evidence base in transfusion medicine and patient blood management, once again, these critical questions should be included in our appraisal. The why remains, however, the most important. Once we grasp that quality, safe, responsible transfusion practice is the purpose, then the what, who, when and how should more easily move forward.
The Joint Commission has begun evaluating patient blood management elements as part of a possible certification for hospitals. The AABB recently published a draft document of patient blood management standards for potential use by its participating facilities. The Society for the Advancement of Blood Management just announced a hospital affiliation program to align principles of blood management with the Society’s mission. All of these organizations are pushing the mission of evidence-based transfusion practice in order to promote patient safety and improve outcomes.
It is our duty as healthcare providers to constantly and consistently evaluate practices, whether they represent procedures, devices, pharmaceuticals; whether they are new or time-honored. Hemovigilance i.e. blood management, must also be included in this ongoing assessment.
Time and time again, the literature is pointing us in the direction of restrictive transfusion practices; avoiding unnecessary transfusion and utilizing blood products as part of our armamentarium when truly life-saving. This concept, thus exudes the ideals of appropriate patient care, best practices and stewardship of community resources. Our cause, our reason, our purpose is clearly to improve patient outcomes and well -being.
Embrace it! Get on board! It is the WHY!
-Carolyn D. Burns, MD, is the Medical Director of Transfusion Services at Strategic Healthcare Group and Assistant Clinical Professor in the Department of Pathology at the University of Louisville in Louisville, Kentucky. She also blogs for TheBloodyTruth.com.
30 Minutes or Less
How many people have heard of the 30 minute rule for units of returned blood? If you haven’t there is folklore that says once a unit of blood leaves the blood bank it is ok to return it to inventory if they get it back before 30 minutes are up. We even have a place on the documentation that accompanies the unit of blood to write down the time that we can accept a return. It was recommended to us that we get an infrared temperature meter so we could actually take the temperature of units when they are returned. One day I decided to play with my new toy and figure out how long a unit could really be out and still be ok to return. Our policy states a unit can be returned if the temperature is 10 degrees Celsius or colder.
I split my little experiment into two parts. Using an expired unit of blood, I left the unit on the counter and took the temperature every minute for 30 minutes. For the second part, I held an expired unit in my hand (simulating a nurse or transporter carrying the unit) and took the temperature every 2 minutes. In the first experiment the unit of blood reached 10°C in 19 minutes; at 30 minutes I recorded a temperature of 14°C. As expected, holding a unit in my hand sped up the rise in temperature; it took 12 minutes for the unit to reach 10°C. After 30 minutes the same unit was 17°C. In both experiments I mixed the blood before rolling the unit of blood around the thermometer.
This very informal experiment confirmed my suspicion that the temperature of a unit of blood is environment dependent. Put the unit in a warm room and it will warm up faster than if it were in a cold room. When we dispense units we place the unit in a thin plastic bag; the plastic on the blood units themselves is thin as well. There is no insulation from the unit and our warm hands.
So what do you do with this information? If you have a policy or use the 30 minute rule, I recommend suspending it immediately. There is no way of knowing what happens to that blood once it leaves your blood bank. If you do not have an infrared temperature meter, put it on the capital wish list for 2014. They will save you from taking back blood that is not safe and it will put a finite cut off point for taking units back. Once we started using the meter we found that the majority of blood that comes back is not suitable for reissue and ends up being disposed. While we do waste blood, I feel much better knowing that the blood that we do take back is suitable for transfusion and is ultimately better for the patient.
It is performing little experiments like the one outlines above that keeps us all interested in the laboratory field. What other career can you have a question about something, know how to figure out an experiment to find the answer, and then carry it out to see if you were right or not? Now the real question I have is: when I order the pizza for lab week what are the chances it gets here in 30 minutes or less?
–Tommy Transfusion is the pseudonym of a blood bank supervisor in the midwest.
Why Do Two When One Will Do?
Today I attended a great session on transfusion case studies by Carolyn D. Burns, MD, FASCP, and Phillip J. DeChristopher, MD, PhD, FASCP. The speakers were dynamic, personable, and made learning fun. They presented cases on hematology/oncology, transplant recipients, and HLA antibodies, among others. I won’t go over each case—honestly, there was so much great information I’m afraid I won’t do it justice—but I’d like to share tidbits I found interesting.
-A fact that I had forgotten from my blood banking class oh-so-long-ago: the platelets your body makes live for eight to ten days, an autologous platelet transfusion last four days, and a non-autologous transfusion would last three. If a patient has an immune response to a platelet reaction, those platelet might only live a day.
-Fellows and residents in transfusion medicine don’t actually know how to transfuse a unit of blood product. They aren’t aware of what happens in a blood bank or a transfusion center. Laboratory professionals need to be cognizant of this and be open with information. Use teaching moments when they present themselves.
-Eliminate unnecessary transfusions through dialogue with doctor and pathology. Hence the title of this post: “why do two when one will do?” It’s a mantra for the blood banker to live by.
-Don’t be afraid to question orders. Medical technologists might be the first line of defense, so to speak, and are essential when bringing questionable orders to the attention of pathologists. Don’t be afraid to speak up when your instincts are telling you something is off. Hone your critical thinking skills.
-Blood transfusion is like marriage. It should not be entered upon lightly, wantonly or more often than is absolutely necessary.
-This couldn’t be stressed enough: keep the lines of communication open. Ask the doctor and/or nurse questions about the patient; have a open relationship with your medical director; don’t be afraid to ask questions.
Bump in the Night
When is the last time you spent the night in your lab on the 3rd shift–a month, year… maybe a decade? How many supervisors/managers know exactly what happens on their off shifts? I bring this up because most hospitals require certain staffing levels even if they only see 15-20 labs from ER a night. If this is the case in your facility, you’ve been provided with an excellent opportunity to empower your employees while “doing more with less.” Those duties that are essential but not time sensitive—such as analyzer maintenance, quality control, and batch testing—are well-suited for off shift employees. All it takes is a bit of creative thinking.
When I first started working in my current position, the blood bank was prototypical. We ran all QC on first shift, performed morning duties, and tried to process as many pre-admission testing (PAT surgery) specimens as we could with inpatient specimens mixed in. Second shift was responsible for PAT tests and routine in-patent specimens. With productivity measures putting pressure on staffing, I thought about how I could rotate duties to allow one of the three 2nd shift technologists to leave early and only work a half shift. First, I made 1st shift responsible for all PAT testing. Second shift was to pour off the Types and Screens and first shift would do them in the morning. Second, to account for the increased workload created on first shift I made the second shift responsible for tube-testing QC and 3rd shift responsible for Gel testing QC. When things quieted down in the evening one technologist could leave.
This is just one way to look at your daily operations and think what could be done to increase productivity. This rotation of duties required a few things. First I had to teach the off-shifts how to do the QC. This was not a challenge because they were excited to learn something new. Next I had to assure first shift that the other shifts were able to perform these new duties. This aspect was the most difficult even if it meant making their jobs a little easier! Finally, I needed to monitor the workflow to make sure that this change was effective and helped with productivity, which it did.
Working the occasional off-shift has given me insight into what actually goes on in our lab. It is important as managers/supervisors to know the workflow of your lab 24/7. Working a 2nd or 3rd shift is also an opportunity to connect with staff that for the most part you may only see during a shift change. I would encourage all supervisor/managers to be aware of workflow not just during the 8-12 hours you work but for the entire time your lab processes specimens. Try to spend some time on an off shift and see what really goes bump in the night!