1.7 - Blood Bank General Information

IMMUNOHEMATOLOGY (BLOOD BANK)
TRANSFUSION MEDICINE

Technical Director of Blood Bank

Hongbo Yu, MD

857-203-5898

BACL Blood Bank Supervisor

West Roxbury

Kirsten Torkelson

857-203-5968

Laboratory Telephones

West Roxbury

857-203-5966

GENERAL
 
Blood Bank Medical Center Policy MCP 113-02 SAC Blood Transfusion Program gives a detailed statement of the Laboratory Service policy for the transfusion of blood and blood products.  A summary of the policy is given below.
 
BLOOD BANK SPECIMEN COLLECTION
 
Most blood bank tests, i.e., type and screen, type and cross require a 6 ml plastic EDTA (plasma) pink top tube.  For transfusion reaction work-ups, a post-transfusion 6 ml plastic EDTA (plasma) pink top tube is needed plus urine specimen.  Direct antiglobulin tests (DAT) are done on 6 ml plastic EDTA (plasma) pink top tubes.  4 ml Lavender top EDTA tubes are also accepted for referral ABO/RH and DAT testing.  All specimens must be free of hemolysis.   Incorrectly or incompletely labeled specimens will be discarded.
 
Blood Bank specimen requirements are stricter than most clinical laboratory departments.  Blood bank specimens may be drawn by individuals who are in the following categories: employed by the VA, in VA training programs, or are VA contracted employees working within a VA facility.  Blood bank specimens cannot be collected by individuals at non-VA staffed drawing stations (e.g. Quincy lab, Quest Framingham Drawing Station).  

Note: We have a signed MOU with Bedford so that patients requiring transfusion as part of the treatment they receive at VA Boston (Hemo/Onc and Dialysis at JP) can be drawn at Bedford.  An e-Consult will be sent to hem/onc requesting the transfusion so orders can be placed in VA Boston CPRS system.  Samples ordered as T&S (BED) will be reaccessioned once received by VA Boston Blood Bank so blood products can be assigned to the patient in the Blood Bank computer package. 

Note: The homecare setting and Lowell CBOC do not require wristbands to be worn by patients prior to Blood Bank Samples being drawn if the procedures of two unique identifiers outlined in MCP-113-002-SAC, Blood Transfusion Program, are followed and as outlined on the collection form and in the VHA Directive 1106, Pathology and Laboratory Medicine Service (per AABB standards).

BLOOD BANK SPECIMEN IDENTIFICATION

Procedure for verifying patient identity is mandatory, failure to verify patient identity may result in the incorrect person's specimen being drawn and raises the likelihood of a fatal hemolytic transfusion reaction.
1. Ask the person to state their name and social security number, if they are unable to respond you must ask a nurse or physician to positively identify the person.  The nurse or physician then will cosign the specimen tube.
2. Verify the patient's complete name, complete social security number with information on the tube label/orders/blood bank specimen collection form/patient’s wrist band*.  In the event of discrepancy do not draw the patient.  A staff member is to be notified and the discrepancy is to be resolved.  If the error is on the wristband a new wristband with the correction needs to be placed on the patient before the specimen is drawn.
*NOTE: Wristband not required for outpatients. Verification of patient identifiers on outpatient wristband only required if outpatient has a wristband.

3. All specimens must be promptly labeled, in the presence of the patient being drawn.  Do not leave the patient you have positively identified without labeling the specimen.  The specimen must bear complete Social Security #; First and Last Name; date drawn; and the full signature of the person who drew the specimen and verified the patient identity.
4. Once the specimen is labeled, recheck that you have placed the correct label on the tube.  Check the tube label against the wristband*.
5. The blood specimen with the blood bank specimen collection form will be forwarded directly to the Blood Bank without delay. 
6. Blood products are ordered by entering an order in CPRS GUI.


PRE-TRANSFUSION TESTING

Grouping, typing, antibody screening and compatibility testing will be performed in accordance with established procedures.


EMERGENCY TRANSFUSIONS

In life threatening situations where time does not permit complete pre-transfusion testing, blood may be released from the Blood Bank if the requesting physician assumes full responsibility and signs an emergency release form.  He should be fully aware that the patient is receiving blood that is uncrossmatched and/or before the patient is tested for the presence of irregular antibodies.  If the requesting physician is unable to leave the patient a verbal order can be documented on the VA Boston Healthcare System Blood Bank Massive Transfusion Protocol (MTP) Activation/Emergency Release Check List and the requesting physician can sign the Emergency Release Form once the emergency is over. The blood bank will complete the work as soon as possible.

ISSUING AND RECEIVING OF BLOOD

1. In all instances involving the issue of a unit of blood for transfusion from Laboratory Service, a member of the Laboratory Service staff shall see that the special CAUTION TAG (VA Form 10 2084) is securely attached to the unit and the Blood Transfusion Record Form(BTRF) is placed in the same biobag or cooler as the unit before it leaves the Laboratory Service.  Only authorized personnel may issue blood units from the Blood Bank and only to authorized personnel.  The date and time of issue and the name of the person taking the blood shall be recorded.  Only one unit of red cells will be released at a time, except in emergencies, and/or for the OR, SICU, MICU and CCU.  Only red cells on one patient may be picked up by the same person at the same time except for the OR and SICU.
2. Blood administration will begin within 30 minutes from the time it is released from the Blood Bank.  Blood may not be stored in refrigerators outside the Blood Bank.  Ward refrigerators do not have adequate temperature controls/monitors and must not be used for storage of blood.  Any unit that has been issued from the Blood Bank that is returned with a temperature has exceeded 10 degrees Celsius cannot be accepted for reissue.  Blood transfusion time must not exceed 4 hours.
3. Following the completion of the transfusion, blood transfusion record form (BTRF) must be returned to the Blood Bank.  The blood bag is not to be returned to the blood Bank except in cases of suspected transfusion reactions.

CANCELLATION OF CROSSMATCH

1. The Lab should be informed of canceled crossmatches as soon as possible.
2. Samples used for compatibility testing must be drawn within 3 days of the transfusion. Day 0 is the day of draw. Example, specimen drawn on Monday is valid to use for any transfusion on Monday, Tuesday, Wednesday or Thursday.
3. Patients without a prior sample tested by the VA Boston Blood Bank will require a 2nd T&S sample drawn at least 5 minutes after the first sample to confirm the patients ABO/Rh.  Each sample will need its own order number and collection form.  Patient identification needs to be performed for each phlebotomy.
4. Cross-matched units may be held and considered available for transfusion up to the end of the specimen's life span.  However, units may be released into the general inventory at the discretion of the Blood Bank and hence the units may be unavailable for the patient.  Some events which necessitate units being released include:
a. Change in patient transfusion requirements.
b. Patient's surgery is rescheduled or canceled.
c. Inventory management.
Once units reserved for a particular patient are released, a new order for blood products must be implemented (consult Blood Bank for specimen requirements). Usually, units set up on surgical patients will be held until the day after surgery unless notified by the care team that the unit is not longer needed. 

TRANSFUSION PROCEDURES

1. The physician will assume the responsibility for providing close supervision of the patient until the transfusion is finished.  
2. Following the completion of the transfusion, blood transfusion record form (BTRF) must be returned to the Blood Bank. 
3. Do not return the blood bag to Blood Bank unless a transfusion reaction is suspected.  
4. Remember to complete the Pretransfusion Data and Transfusion Data section of the blood transfusion record form. 

TRANSFUSION REACTIONS

A. If transfusion difficulties occur, the physician administering the blood will immediately discontinue the transfusion.  He will promptly notify the Blood Bank and will also complete the Transfusion Reaction Data section of the blood transfusion record form (BTRF).  The suspected blood bag unit, the required specimens and the BTRF must be returned to the Blood Bank to initiate the work-up. A Suspected Transfusion Reaction consult and a TRW will be entered using CPRS GUI.
B. The Laboratory Service will investigate the reported transfusion reaction following the procedures prescribed by the American Association of Blood Banks.  In order to investigate the transfusion reaction.  It will be necessary to obtain a post transfusion 6 ml plastic EDTA (plasma) pink top tube and urine specimen.
C. The Blood Bank Pathologist will administratively complete the Suspected Transfusion Reaction consult.  No further red cell products may be issued until completion of the transfusion reaction work-up.  If blood is needed for life threatening conditions prior to completion of the transfusion reaction work-up, units will be issued only after an emergency release form is signed by the physician or house officer.

BLOOD BANK INVENTORY

The Blood Bank inventory consists of leukoreduced packed red cells, leukoreduced Irradiated CMV negative packed red cells, frozen plasma, pooled cryoprecipitate, and a small standing order of platelet apheresis units. For patient safety we try to always keep one unit of platelets in the Blood Bank.  If our standing order platelet apheresis unit has been transfused a replacement unit will be ordered from the American Red Cross. Platelet apheresis units have a short shelf life and cannot be returned to the American Red Cross if not used, so only order if transfusion is definite.
   

Blood Bank Notification	Time Required
Leukoreduced Packed RBC	X-match Turnaround Times: STAT  45 minutes ASAP/Routine 1-2 hours 15 minutes if typed and screened specimen available on a patient without antibody problems
Washed RBC	24 Hour notice Approval required
Fresh Frozen Plasma	45 minutes before use: Notify Blood Bank to implement “Request to Thaw”
Platelets	Small standing order inhouse for emergencies. If more than 1 units is needed for a procedure or transfusion event additional product will need to  be ordered from Red Cross Dedham once the platelet order is received by the Blood Bank. Short expiration time and cannot be returned to ARC
Irradiated or CMV tested products	Small stock keep in the Blood Bank for emergencies.  Additional units must be ordered from the American Red Cross.  Allow a minimum of three hours for orders of more than two units.

BLOOD PRODUCTS
 

Product		Shelf Life	Volume	Indications for Use
Red Blood Cells, Leukocytes Reduced		42 Days	250 mL	Increase Oxygen carrying to tissue Red Cell replacement
Deglycerolized Red Blood Cells		24 Hours	230 mL	Red Cell Replacement when: Rare blood is needed Patient has antibodies Leukodepleted product needed No residual plasma for IgA deficient recipient
Washed Red Blood Cells		24 Hours	200 mL	Repeated febrile Transfusion reactions Repeated, severe hypersensitivity reaction to plasma proteins
Apheresis Platelets Leukocytes Reduced		5 Days or less	200-400 mL	Platelet replacement in patients (Platelet Pheresis) with low counts or dysfunctional platelets
Pheresis Platelets Leukocytes Reduced PAS (Platelet Additive Solution)		5 Days or less	200-400 mL
Frozen Plasma		24 Hours (once thawed)	200 mL	Replacement of clotting factors
Pooled Cryoprecipitate AHF		6 Hours (once thawed)	25 - 100 mL	• Von Willebrands Disease • Replacement of Factor VIII or fibrinogen in hemophilia, surgical patients with coagulopathy, DIC

Blood Bank