Russell County Hospital
1610 Dowell Road
Russell Springs, KY 42642
270-866-4141
DEPARTMENT:
Laboratory
POLICY/PROCEDURE TITLE
Ordering, Storage, and Return of Blood Components
POLICY/PROCEDURE NUMBER:
400-PE-BB-133
Issued: Unknown
Revised: 6/30/02, 9/7/02, 4/15/04,7/21/04, 5/1/06
Supercedes:
Prepared by: R. Johnson
Approved:
Reviewed:
Medical Director
Approved:
Reviewed:
Laboratory Director
__________________________________________________________________________________________________
I.
POLICY/PRINCIPLE. Blood components will be ordered from the Central Kentucky Blood Center (blood
supplier) to maintain a minimum routine inventory of uncrossmatched red cells and frozen components that
are adequate to meet the transfusion requirements of the patient population at Russell County. This
inventory level is established by mutual agreement with the blood center, and is reviewed annually and
approved by the Medical Director and the Laboratory Director. Additional special components may be
ordered as needed to satisfy special patient requirements. Upon receipt, our blood bank will accession,
screen, and store the components. A daily report will be sent to CKBC detailing the disposition of the units.
Additionally, some unused units will be returned to CKBC.
II.
EQUIPMENT/MATERIALS.
A.
B.
C.
D.
III.
Blood Component/Accession Disposition Log (RCH).
Daily Blood Inventory/Transfusion Fax Report (CKBC).
Blood Transfer Memo form (CKBC).
CKBC Return Tag.
PROCEDURE.
A.
Ordering blood components.
1.
General information.
a.
Central Kentucky Blood Center is always open. The Product Management Department is open
24 hr a day, seven days a week and orders may be placed with them at any time.
b.
Place orders by FAX to CKBC by speed dialing #1. Numbers are:
1)
2)
3)
Request blood or components: 1-800-775-2522 ext. 221.
Hotline: 1-859-255-9871.
FAX before 11P daily: 1-859-277-3005.
c.
The inventory is done early every morning by the blood bank technologist and the order is
placed as soon as possible to enable the order to be filled and to be shipped later that same
day by the routine courier.
d.
The current courier will usually be the one to transport the blood order to RCH and arrives at
approximately 10A CST weekdays. There is no routine courier on weekends or holidays.
Page 1 of 4
Russell County Hospital
Policy/Procedure Title: Ordering, Storage, and Return of Blood Components
Policy/Procedure Number: 400-PE-BB-133
Issued: Unknown
Revised: 5/1/06
__________________________________________________________________________________________________
e.
If a blood component is needed before the routine courier run, call and communicate clearly to
the CKBC staff who will arrange for a “special courier run”.
1)
Provide the following information to the CKBC staff:
a)
b)
c)
d)
e)
2)
2.
3.
Your name.
Hospital name.
Name and type of each blood component needed.
Reason needed (i.e., for shelf, AM surgery, GI bleed, etc.).
When needed, if time is critical. Be sure to state the current time of day and
emphasize why you need the component.
Product Management personnel will record the order on a Blood Transfer Memo, confirm
the order, and give an expected arrival time.
Routine orders.
a.
Each day fax an Inventory/Transfusion Report to CKBC to report the inventory of blood on
hand and transfusions.
b.
Place orders before 3A on the day the blood is needed, but preferably do this the prior day.
c.
When inventory is low, such as following transfusions, place the order with CKBC as soon as
possible, so the blood will arrive by the next morning.
d.
Orders for deglycerolized and washed RBC’s should be planned for in advance, as these
components have 24 hour expiration dates.
e.
Red Cell orders are routinely filled with leuko-reduced packed cells.
f.
Fresh frozen plasma (FFP) is routinely shipped with the next delivery after the order.
g.
Platelets are ordered as needed for a specific patient.
h.
Cryoprecipitate is routinely shipped with the next delivery after the order.
i.
Other components are ordered as needed for a specific patient.
Emergency orders.
a.
If there is an emergency request for blood that is not available in our inventory, and time
permits, call CKBC immediately with the request. If the type of blood or component is
available at CKBC, request it be sent on a special run.
b.
If time does not permit, contact a nearby hospital that is serviced by CKBC and request blood
products. Complete a CKBC Blood Transfer form listing the blood products being transferred.
Give a copy of the form to the donor facility, forward a second copy to CKBC, and maintain the
third copy in our files. The facilities to contact are:
1)
2)
3)
c.
Westlake Regional Hospital, Columbia, KY.
Lake Cumberland Regional Hospital, Somerset, KY.
Wayne County Hospital, Monticello, KY.
Send a RCH courier to the donor facility to obtain the needed blood products. If a RCH
employee is not available to make the courier run, contact the local police for assistance. If
they cannot do this, contact the state police to make an emergency trip to get the blood
products.
Page 2 of 4
Russell County Hospital
Policy/Procedure Title: Ordering, Storage, and Return of Blood Components
Policy/Procedure Number: 400-PE-BB-133
Issued: Unknown
Revised: 5/1/06
__________________________________________________________________________________________________
B.
C.
d.
Under no circumstances will the Russell County Hospital blood bank draw donor units for
transfusion purposes.
e.
If the needed products cannot be obtained from any source within the needed time frame,
contact the Laboratory Director or the Medical Director. The Medical Director should consult
with the attending physician to discuss and approve an alternative course.
Receiving blood and components.
1.
Upon receipt of the blood unit or component, unpack the product and make a thorough inspection.
Compare the units received to the Blood Transfer Memo form included in the shipment ensuring
the correct units were sent and/or no written error occurred on the paperwork. Sign and fax the
transfer sheet to CKBC.
2.
Check the internal temperature of the blood by placing a thermometer inside the box between two
units. The temperature should be 1-10C for packed cells, 20-25C for platelets, below –18oC for
FFP and cryoprecipate. If the temperature is outside of these ranges, call CKBC and place the unit
in quarantine. Log the temperature in the blood bank logbook.
3.
Enter the unit number, source, type of component, and expiration date of the blood in the LIS.
Also, inspect each unit for any abnormal appearance (i.e., usually color, hemolysis, cloudiness) and
record on the patient blood bank record card.
4.
Pull a segment off of each unit and attach one of the unit stickers around the corresponding
segment. Place the segments in a plain red top tube and write the date on the outside of the tube.
Each RT tube will hold 3-6 segments; use as many RT tubes as needed. Hold the segments for 30
days and then discard.
5.
Perform ABO and Rh grouping on each unit. See Donor Confirmation Typing procedure. If there is
a discrepancy between the results, retype and confirm that the retype matches the labeled type. If
the labeled type is confirmed, store unit in the blood bank refrigerator.
6.
If the confirmatory type does not match the labeled type, repeat with washed donor cells. If
washing does not clear the discrepancy, clip and test another segment from the unit(s) in question.
Record all typing.
7.
If the retype still does not match the labeled type, quarantine the unit until it can be returned to the
supplier. Return the mislabeled unit to the supplier and indicate reason for return on the Return
Tag.
8.
For units that must be returned for reasons other than above, quarantine them in a separate area of
the refrigerator and label them with a Return Tag, indicating the reason for return. Use a Blood
Transfer Memo to document reason for quarantine.
9.
For units accepted into inventory, do not remove unit labels from the back of the unit of blood or
component. One of these unit number labels must be placed on the chart of the patient receiving
blood. If the extra labels from the unit come off, put them back on or return the unit to CKBC for
reissue of additional labels.
Returning units of blood or components to CKBC.
1.
All units should be returned to CKBC approximately five days prior to their expiration dates. Hold
packed cells that are labeled as Directed Donor for the indicated patient until seven days prior to
expiration. Do not release Directed units without approval of the attending physician.
Page 3 of 4
Russell County Hospital
Policy/Procedure Title: Ordering, Storage, and Return of Blood Components
Policy/Procedure Number: 400-PE-BB-133
Issued: Unknown
Revised: 5/1/06
__________________________________________________________________________________________________
2.
Complete the CKBC Blood Transfer Memo form and send it with the units being returned.
Information on the form will include:
a.
b.
c.
d.
Unit number.
Type of unit.
Signature of tech.
Date/time.
3.
Pack the units in a sturdy well-insulated cardboard and/or Styrofoam shipping container supplied by
CKBC.
4.
Place a wet ice in leakproof plastic bag and place on the bottom of the shipping container. This is
to maintain a shipping temperature of 1-10C. DO NOT USE supercooled ice or canned ice or dry
ice for any product other than FFP. The volume of ice should be at least equal to the volume of
blood.
5.
Place a thin layer of newspaper over the bagged ice.
6.
Place the units of blood on top of the newspaper.
7.
Place another layer of newspaper and bagged ice over the blood.
8.
Close the shipping container and seal it with packing tape. Write our hospital’s name and address
on the outside.
9.
Return the blood to CKBC by the courier.
10. Remove units from inventory in the LIS.
11. NOTE: Fresh frozen plasma must be returned packed in dry ice. Request and receive dry ice from
CKBC before returning the FFP. Pack in box as above.
D.
IV.
Final disposition.
1.
We must be able to track and show final disposition of each unit of blood or blood component.
Upon receipt, each unit is logged into the LIS.
2.
On a daily basis, send a final disposition report to CKBC. All units are returned to CKBC within five
days of their expiration dates and units that out-date must be returned to CKBC for final disposition.
REFERENCE.
A.
AABB Technical Manual, 13th edition, 1999.
B.
CKBC Handbook, section VII.
Page 4 of 4